Clinical observation of deteriorating frail older patients: Improving the competence of homecare professionals

Abstract

Introduction:

Homecare services are providing care to an increasing number of frail older patients with complex care needs. These patients are in a vulnerable state and have an increased risk of deterioration, and the early detection of changes in their clinical condition is highlighted as a means of preventing adverse health outcomes. Clinical observation is an essential prerequisite in identifying deteriorating patients. In homecare, clinical observation is currently insufficient, and little is known about homecare professionals’ detection of deteriorating patients. Therefore, the overall aim of this PhD project is to gain knowledge of clinical observation in homecare and to understand how a competence improvement programme can change homecare professionals’ clinical observation. Consequently, theories on competence and improvement in healthcare have been applied in the thesis.

Methodology:

This thesis adopted a multi-method qualitative, sequential design consisting of three phases: (1) before the implementation of a competence improvement programme (study 1), (2) during the implementation of the programme (study 2), and (3) after the implementation of the competence improvement programme (study 3), focusing on two homecare districts (homecare A, homecare B) in Norway. The programme was designed to improve homecare professionals’ competence and skills in recognising and responding to deteriorating frail older patients. The first study developed knowledge of homecare professionals’ observational competence in the early recognition of deterioration in frail older patients. Homecare professionals, including nurses, skilled health workers, and assistants were observed during their home visits to patients and interviewed in focus groups. The second study described and analysed the implementation of a competence improvement programme for the systematic observation of frail older patients. Participant observation was used during the implementation activities, and focus group and individual interviews were conducted to describe the experiences of the homecare professionals, managers, and development nurses with the implementation of the competence improvement programme. The third study described the outcomes of the competence improvement programme for the systematic observation of frail older patients. Homecare professionals were observed during their home visits to patients and interviewed in focus groups, while managers and development nurses were interviewed individually.

Results:

The studies included in this thesis contribute to longitudinal research on a competence improvement programme for the systematic observation of frail older patients in homecare and demonstrate that clinical observation is multifaceted and the improvement of this competence is challenging.

In study 1, the homecare professionals’ observational competence before the competence improvement programme was characterised by a focus on patient-situated assessment of changed clinical conditions and how the organisational environment impacted the homecare professionals’ performance of clinical observation. Patients’ physical and mental conditions formed a vital basis for detecting clinical deterioration. Communicating with the patient was highlighted, together with precise nursing documentation. Basic understanding and use of vital sign measurements as part of clinical observation were insufficient in the two homecare districts. Pre-planned workplans organised the homecare professionals’ practice, but actions to follow up on patients’ changed conditions were not reflected in these plans. Collaboration with colleagues was seen as supportive of homecare professionals’ observational competence.

In study 2, the homecare professionals perceived the competence improvement programme as important, as the programme would improve their observational competence and confidence in situations with deteriorating patients. However, the competence improvement programme consisted of several learning resources with complex content and was applied differently in the two homecare districts. The homecare professionals described the implementation process of the competence improvement programme as demanding and time-consuming. The homecare professionals were unfamiliar with simulation-based learning and found it more challenging than they had expected.

Study 3 reported that two years after the implementation of the competence improvement programme, the frequency of vital signs measurements for the systematic observation of frail older patients varied between the two homecare districts. Although measurements of vital signs had increased for new patients and in the case of patient falls, situation awareness related to the clinical deterioration of patients remained insufficient. However, the homecare professionals reported improved coping with deteriorating patient situations. Regular programme activities integrated into the homecare professionals’ daily work routines sustained the competence improvement programme. Organisational issues affecting the sustainability of the competence improvement programme varied between the two homecare districts. Organisational needs were prioritised by homecare A, but sick leave, personnel turnover, busy work plans, and a change in managers in homecare B affected the maintenance of the programme.

Conclusions:

This thesis provides knowledge and understanding of homecare professionals’ clinical observation and how a competence improvement programme can change such observational competence. Clinical observation had a low priority before the competence improvement programme, and vital signs were rarely used to detect early deterioration in patients. The competence improvement programme changed clinical observation in defined situations; nevertheless, homecare professionals’ situation awareness of patients’ deterioration was insufficient. The PhD project demonstrates that the implementation of a competence improvement programme is influenced by factors regarding the programme itself, the professionals, the organisation and the external context.