1 Introduction
1.1 Quality and safety in primary care
The increasing demands from an ageing population, patients’ more complex needs, and the desire to have patients remain at home have put pressure on healthcare services in western countries (Dixon-Woods et al., 2012; Jha et al., 2010; Lang et al., 2008; Lindblad et al., 2018;
Vaughn et al. 2019; Vincent & Amalberti, 2016; Strømme et al., 2020).
The World Health Organization (WHO) indicates that globally, as many as four out of ten patients are harmed while receiving healthcare in primary and ambulatory care settings. The most serious errors are related to diagnosis, prescription and the use of medicines (WHO, 2018). Other preventable types of harm include pressure ulcers, falls, venous thromboembolism and catheters causing urinary tract infections (Vincent
& Amalberti, 2015).
Patient safety risks and adverse events in primary care are less known than in specialised healthcare settings (Guise et al., 2014; Henriksen et al., 2009; McDonald et al., 2013). At the same time, homecare is rapidly
growing and there is a need to identify the type and patterns of safety concerns for users, family members and caregivers (Larsson et al., 2018;
Lang et al., 2008). Caregivers in homecare travel alone to patients and it can be difficult to access medical supplies without the support of colleagues (Lang et al., 2008). This can also be seen with earlier discharge from hospital and the increasing number of patients receiving homecare, lack of resources for continuing competence development and the isolated nature of homecare environment (Gautun & Syse 2017; Lang et al., 2008; Schildmeijer et al., 2018). Homecare services are struggling with fragmentation of care, discontinuity and multiple care givers that lack overview of patient status and an unregulated environment (Glette et al., 2018; Lang et al., 2008). In homecare, performing clean or sterile procedures may be almost impossible and there is a risk that homecare staff transferring infection from one home to another (McDonald, 2013).
All forms of homecare need to be negotiated to a much greater extent than other settings due to patient preferences and these values will often take priority over medical guidelines (Stajduhar, 2002; Vincent &
Amalberti 2016). Employees in homecare services are working alone in decision making with patients and the increased pressure on homecare services has created a disparity between demands for competence and workers’ actual competence (Bing-Jonsson et al., 2016; Bjerkan et al.
2020; Genet et al., 2011; Haltbakk et al., 2019; Maybin et al. 2016).
In nursing homes, frail and vulnerable patients often have extensive needs for nursing care. A minor adverse event can cause serious injury (Andersson et al., 2018). Norwegian research by Glette et al. (2018) shows that managers and employees experience patients in nursing homes as sicker and more complex and patient care as becoming more time consuming. Most serious adverse events are caused by medication errors, falls, delayed or inappropriate intervention and missed nursing care (Andersson et al., 2015; Andersson et al., 2018; Panesar et al., 2016). The most common contributing factors were lack of competence, incomplete documentation, teamwork failure, inadequate
communication (Andersson et al., 2018), heavy workload and time pressure (Al-Jumali & Docette, 2017) and distances in the ward and the storing of information in different places (Odberg et al., 2020).
Medication errors by nurses are often attributed to medication packaging, poor communication, unclear medication orders, and to workload and staff rotation (Hammoudi et al., 2017). A qualitative observational study in nursing homes found that interruptions during medication administration can be characterised as passive, active or technological interruptions such as background noise, discussions or use of mobile applications (Odberg et al., 2017). Nursing homes also have the risk of infection being spread among residents (FHI, 2020). This is linked to the shortage of registered nurses and part-time jobs that require many workers to work in several locations (Kirkevold et al., 2020).
The implementation of information and communication technologies in healthcare settings, in both nursing homes and homecare, has the potential to improve the quality and safety of services, but it may also introduce new potential risks to patients (Bates & Gawande, 2003;
Battles & Keyes, 2002; Guise et al., 2014; Johannesen et al., 2019b;
Lyngstad et al., 2014). Medical and technical advances have enabled patients to undergo the advanced treatment of complex and long-term illnesses at home. But, as care becomes more complex, interaction among professionals from home healthcare, nursing homes, general practitioners, specialist care and social care can impose risk (Lang et al., 2008). Electronic patient journal systems that do not document and communicate patient information internally and between departments is also a potential safety risk in primary care settings (Bjerkan et al., 2020;
Sogstad & Skinner, 2020; Vassbotn et al., 2018). To summarise, minor incidents, discontinuity, and multiple care providers with limited overview of patient status and development may have cumulative negative effects in primary care (Vincent & Amalberti, 2016).
The role of managers in quality and safety
Management involvement and commitment in activities are crucial in the development of cultures and systems to improve quality and safety (Birken et al., 2012; Clegg et al., 2005; Husabø et al., 2018; Jha &
Epstein, 2010; Leape et al., 2009; Oldenhof et al., 2013; Oldenhof et al., 2016). Managers at different organisational level are important in the effort to improve quality and safety in healthcare. Middle managers have a role in bridging information gaps and their boundary-spanning role allows them to influence senior management and front-line staff (Birken et al., 2012; Clegg et al., 2005; Oldenhof et al., 2013; Oldenhof et al., 2016). Middle managers can be described as coordinators, communicators, campaigners and conflict managers, with responsibility for translating and conveying information into day-to-day activities for front-line staff (Birken et al. 2012; Zjadewicz et al., 2016). Effective communication is key for clinical leaders to influence and empower staff to share and learn from each other (McSherry et al., 2016). Parand et al.
(2014) found that senior hospital managers’ activities related to quality and safety were undertaken in relation to strategy, use of data, and organisational culture. Leadership is the foremost requirement of any quality improvement effort (WHO, 2018). In Norway, managers in nursing homes and homecare services need to balance external and internal factors such as type of service, infrastructure, staffing, competence, commitment, culture of improvement and user orientation (Forås & Andreassen et al., 2020). There is a knowledge gap in how this operates in practice and how managers work with quality and safety over time and with different tools. This thesis reduces this knowledge gap by exploring the role of managers in quality and safety work.
Research-based tools in quality and safety work
It has always been challenging to translate research into practice and to bridge the gap between research and the complexities of practice (Dopsen et al., 2009; Greenhalgh, 2018). Translating research into
practice involves many processes, systems, and interactions between the researchers and knowledge users. Research-based tools such as clinical practical guidelines are designed to facilitate evidence-based decision making (Brouwers et al., 2013; Greenhalgh, 2018). However, the development of these knowledge tools requires active involvement and collaboration between researcher and knowledge users. Several knowledge translation frameworks acknowledge the social nature of knowledge implementation (Rycroft-Malone & Bucknall, 2010; Stetler et al., 2009). They help researchers and practitioners who implement quality and safety improvement initiatives and identify contextual factors for better use of knowledge. However, the research evidence from specific use of tools and frameworks in the nursing home and homecare setting is limited. There has also been a call for implementation of research-based tools for managers in Norway and sound evaluation of factors in and barriers to success (Meld. St. 29 2012–2013; Meld. St. 26 2014-2015; NOU, 2015). This PhD thesis helps to close this knowledge and practice gap.
The role of context in quality and safety work
Context can be conceptualised as a set of events or factors that surround improvement efforts (Damschroder et al., 2009; McDonald, 2013). The context can be the internal (structure of the organisation, the work culture, competence) or the external (laws, external policies, funding) setting of the organisation. Therefore, organisational change processes are context-dependent, and the processes are likely to differ among healthcare organisations (Ferlie & Dopsen, 2009). Efforts to improve healthcare quality and safety occur in many situations, and improvements may be suitable for some organisations but not others (Ferlie & Dopsen, 2009). Moreover, the contextual factors should be taken into account in research and interventions in healthcare services (Batalden & Davidoff, 2007; Coles et al., 2017; Dixon-Woods et al., 2012; Kaplan et al., 2012). The settings that nursing homes and homecare services work within vary greatly, and there are few studies on how
contextual factors affect their quality and safety work. Furthermore, the way in which managers handle contextual factors as part of their quality and safety work has been insufficiently investigated (Kaplan et al., 2010;
Wiig et al., 2019). The thesis therefore contributes to understand how contextual factors influence nursing home and homecare managers’
work in improving quality and safety.