Factors that influence patient involvement in nursing homes: staff experiences

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Sykepleievitenskap . Omvårdnadsforskning . Nursing Science

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Introduction

The aim of the present study was to identify the staff ’s experience with factors influencing patient involvement. This article presents results from three focus group interviews following the completion of a one-year systematic competence-building project where staff in a Norwegian nursing home (NH) participated.

It is usually assumed that educated staff members know the best way of satisfying a patient’s needs. However, current legislation, ethics, and public recommendations stress the importance of involving patients and the next of kin in decision making processes that frequently occur in a patient’s daily life. This is also supported by the principle of human rights (1-3).

Recommendations for patient involvement are part of a philosophy of human dignity, which is based on the principles of human rights (4). Recognition of the inherent dignity, equality and inalienable rights of all human beings is the fundamental tenet of human rights (4).

Human dignity requires equal and fundamental rights, and that everyone has the right to life, liberty, and personal security (3, 4).

The terminology describing the role of patients in planning and implementing their own treatment includes both the concepts of involvement and participation. These concepts are often used interchange- able as exemplified in a literature study by Levasseur’, Richard’, Gauvin’ and Raymond’ (5) that includes a content analysis of the definition of social participation in older adults.

Patients have a right to freedom and autonomy (1, 4), but they may not be able to exercise their rights to involvement in decision making in every given situation. There are various reasons for this. First, the level of patient involvement is determined by a patient’s ability to participate.

This study illustrates that the level of cognitive impairment decides the possibility of patient involvement (6). According to Penney & Wellard (7), patients do not want to make decisions in every situation, while Zoffmann et al. (8) emphasize the importance that patients attach to shared decision making. In any event, a number of studies have shown that adequate patient involvement is a necessary requirement for high- quality services and that it contributes to the well-being of patients

living in nursing homes (7-11). It is also evident that person-centred care require staff members who consider patients as human beings rather than limiting their focus to their conditions (12-14).

Good attitudes among the staff are also vital to succeed (6) (13-15).

Accordingly, the studies referred to, demonstrated the importance of good attitudes and the ability to understand patients as people, which in turn represents a prerequisite for involvement. Rokeach (16, p.132) defines an attitude as «...a relatively enduring organization of interre- lated beliefs that describe, evaluate, and advocate action with respect to an object or situation, with each belief having cognitive, affective and behavioural components.» An attitude is a state that is internal and not directly observable. However, the evaluative responses towards the attitude object or situation are observable. A cognitive response includes an intellectual evaluation of the current situation; an emotional response is often spontaneous without prior evaluation, and a behavioural response represents evaluated action (17). This conceptualiza- tion of an attitude has been applied in our study. Hence, knowledge is an integral part of the attitude definition, in the same way as emotions and actions. This means that increased knowledge has an impact on attitudes, and can contribute to attitude changes.

Halvorsrud et al (18) stress the importance of environmental conditions that combine external factors which are important to the quality of life of older people. The authors suggest that the environment is never experienced as unitary or monolithic, but rather as a series of settings where older adults experience day-to-day living. We share this view and believe that external factors may affect the patient's ability to participate.

In order to succeed with person-centred care when the patient for instance has cognitive impairment cooperation with the next of kin could be useful. Studies have shown that this kind of cooperation should be planned and structured (19, 20). Expanding the understanding of quality to include a family perspective is essential in ensuring the optimal value of nursing care, while interdisciplinary cooperation is also a key factor (21, 22).

Despite the expectation of patient involvement, studies show that the traditional nursing culture is dominated by routines and tasks rat-

Factors that influence patient involvement in nursing homes:

staff experiences

Anne Norheim, RN, Associate professor, Anne Guttormsen Vinsnes, RN, PhD. Professor ABSTRACT

Aim:The aim of this study was to identify the staff’s experience with factors influencing patient involvement.

Background: The focus of this study was care for frail, elderly patients in Norwegian nursing homes (NHSs). The background was an earlier quality development project where staff participated in a one-year systematic competence-building programme. Recommendations for patient involvement are part of the current legislation and ethical norms in Norway, but patients may not be able or have the opportunity to exercise their rights on every occasion.

Method: Focus group interviews were conducted with a multidisciplinary team of professionals. Three groups were selected from different wards in one nursing home. Data were systematized and categorized before further analysis.

Results: The results reveal the staff’s descriptions of the attitudes and the environmental conditions that contribute to patient involvement. The competence-building programme raised consciousness among staff and contributed to a change in staff attitudes. Furthermore, the results also emphasize the importance of teamwork, continuity, structural conditions, time pressure, and cooperation with the next of kin when evaluating patient involvement.

Conclusion: The findings of this study have the potential of contributing to the improvement of clinical practice in nursing homes.

KEY WORDS: attitudes, environmental conditions, focus groups, patient-centred care

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The NH referred to in the present study organized a one-year systematic competence-building programme in order to improve the staff ’s understanding of patient involvement. The programme included the following: (i) Education for all staff members and the patients’ relatives. The education included the topics legal regulations (two hours), human rights (two hours), ethics (two hours) and patient involvement (two hours), and was organized in three sessions in order to reach all staff members. (ii) A one-day seminar for key staff (staff members selected by the head nurse) that was based on a bottom-up perspective.

Thirty staff members were invited to participate. The seminar used role play to illustrate stories from daily life, which were followed by group discussions and plenary reflections. The competence-building programme was a source of inspiration to the study.

On this background we planned and conducted a focus group study to explore the experiences from the competence-building programme and in this way identify the staff ’s experience with factors influencing patient involvement in NHs. The following research areas were inve- stigated: Staff descriptions of factors contributing to patient involvement in nursing homes; a, descriptions of their attitudes to patient involvement, b, descriptions of factors influencing their attitudes, and c, descriptions of the environmental conditions influencing the possibilities for patient involvement.

Method

A qualitative focus group design was used to acquire a broad sample of views from the staff members with regard to factors contributing to patient involvement in nursing homes. As others have pointed out, this might have been more difficult in a one-to-one interview situation (27, 28). The potential value of the focus group reflected the interaction in the group that creates new perspectives and improves the discussion (29, 30).

Participants

Purposive sampling was used to recruit participants to the focus group study. The staff received information about the project from the head nurse. A multidisciplinary team of staff members from different wards in one nursing home was invited to participate and announced their interest. They had all taken part in the education offered in the competence-building programme. The team consisted of nurses, nursing assistants, physiotherapists and one occupational therapist. The sample included three focus groups of which two groups had six members and one had four participants, altogether 16 participants. Two of the groups had participants from long-term care wards (where patients live on a permanent basis), while the third group had participants from a short-term care ward (rehabilitation ward).

Focus group interviews

Each focus group met once. The interviews lasted between one and one and a half hours. Each interview took place at the nursing home about half a year after the completion of the competence-building programme.

An interview guide was used and the staff was asked to use examples from their professional lives to illustrate factors contributing to patient involvement, their attitudes to patient involvement, factors influencing these attitudes, and which environmental conditions they think influence their possibilities. One researcher moderated all the interviews, which included keeping the discussion focused, ensuring that everyone took part and balancing participant contributions.

Transcription procedure and analysis

The interviews were recorded and transcribed verbatim, retaining fre- quent repetitions, pauses, and emotional expressions (31). The transcripts were initially read through to gain a contextual understanding of respondents’ descriptions. Transcripts were read in their entirety several times to obtain an overview of themes and a general impression of what the respondents expressed. The analysis then moved on to the coding process. Codes and sub-codes were subsequently categorized

theoretical perspectives (32). Two main factors emerged from the analysis; attitudes and environmental conditions. Two researchers analy- zed the text independently, and this was regarded as a cross-validation of the coding process to ensure the reliability of the analysis.

Further interpretation was made on the basis of the following perspectives (32).

1. Self-understanding – as described by the professionals them - selves.

2. Critical understanding – based on qualitative analysis by the researchers.

3. Theoretical understanding – earlier studies contributing to clarification of the findings.

Ethical considerations

All members were given complete oral and written instructions. It was emphasized that the study was based on voluntary participation and that the participants could leave the programme at any time. Informa- tion was handled confidentially and a written informed consent was obtained before the participants were recruited. The Norwegian Social Science Data Services (NSD) approved the study.

Results

In the following analysis, the three focus group interviews are presen- ted as a whole. However, there were differences between the staff experiences in the short-term and long-term wards. Comments on these differences are given at the relevant points in the following text.

Table 1 shows a schematic overview of the attitudes and the environmental conditions contributing to patient involvement, relative to their respective sub-factors. However, it must be stressed that attitudes in turn affect how the external conditions are exploited.

Staff attitudes

The participants relied on an approach that emphasized the preserva- tion of patient identity. Attitudes seemed to be based on values under- lining the importance of individual well-being, thereby ensuring that patients thrived and felt well. As one said:

We try to see the person behind, … speak with them, use their names, … have pictures on the wall … You can sit down to chat a bit, then problems that you are able to handle emerge.

Further, the staff did not regard patient involvement as realistic for everyone. Some patients were too sick or frail, while others did not want to get involved in decision making. However, some patients needed some encouragement to get involved, while others wanted to make their own decisions. This quotation underlines the consequences of individual care:

Every patient is a unique human being. If I ask them about their wishes or expectations, some answer very clearly about their needs in all situations, while others say that «I» know what the best is … Then it is more difficult to get them involved.

The staff described the conflict between the patients’ right to autonomy and self-determination, their right to be treated with respect and dignity and the demands of professional judgement, such as knowledgeable pri- oritization, full effort and skilled performance. They explained that there were situations where a patient’s right to autonomy could represent a challenge to responsible professional judgement. For example, the staff were uncertain about the extent to which they might allow themselves to persuade patients to participate in social activities. They frequently observed that patients flourished after participating in social activities and «gentle persuasion» was often all it took to get them involved. The staff were aware of their own attitudes and did not want to pass a moral

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judgement on a patient’s right to decide for him-/herself. They emphasized the necessity of advanced skills in evaluation in order to determine whether participation was in the best interests of a patient. This issue was highlighted in one of the focus groups representing the long-term ward.

There was no conflict of opinion and the group members seemed to agree. The following quotation illustrates this discussion:

One must have the appropriate expertise (knowledge and skills) to ask the right questions. For example, does the patient have the insight required to make judgements? … We have legal obligations and that is what is difficult. I’m afraid autonomy may be an excuse for doing nothing …

There was agreement among the staff that there had been a change in the attitudes following the completion of the competence-building programme. They described a shift in the culture towards a more patient-centred focus and that they were more engaged during communication with patients in each focus group interview. Examples were provided to show that they did not take full advantage of the possibility of mutual conversation with patients prior to the training programme. The following quote illustrates this raising of awareness:

I feel I have become more conscious about how to find the best way to deal with a challenge … it is easier to take time to sit down and have a talk (with the patient) than it was before … there has been a change (other staff nodded their approval).

Some of the informants claimed that they were more aware and focused following the competence-building programme. They regarded education as a condition for understanding the complex interaction between the separate parts and the totality of a patient’s care needs, and seemed to be aware of their obligation to offer patients the information required for participation in the decision making process.

According to one informant:

After the programme, I became more conscious about giving infor- mation to the patients. I had previously (before the education pro- gramme) not thought that I had a duty to provide this information.

In addition, the importance of role models or enthusiasts was emphasized during the dialog as a source of knowledge in the words of one of the informants:

Enthusiasts are important in the daily work and during training in seminars. It is important to learn from each other. I believe in good role models who ensure that knowledge does not get lost.

A role model implies a staff member with a set of positive personal characteristics and an ability to take care of patients in a good manner.

But a role model cannot act alone. The importance of cooperation was emphasized as an essential requirement for success in ensuring patient-centred care. Success is not an individual achievement:

If only one person always tries to inspire I think that person would be exhausted after a few weeks.

The staff also needed a profound understanding of each profession’s area of responsibility during interdisciplinary team cooperation. Still, it was important to clarify attitudes and understand the cultures of different professional traditions. A clearer understanding of the attitudes would make it easier to understand each other. This dialogue took place in the group representing the short-term ward where nurses, physiotherapists and occupational therapists are working close together. As one staff member expressed it:

… to stay together … just focus on what is necessary to ensure per- son-centred care … and clear up matters in accordance with the staffs’ attitudes and workplace culture.

Environmental conditions

The external factors listed in Table 1 in different ways affected the success of patient involvement. According to the staff, external factors often appeared as a hindrance to succeed with patient involvement.

The staff considered interdisciplinary teamwork as an opportunity to ensure patient-centred care, as a collective assessment benefited the decision-making perspectives. They also stressed the importance of an interdisciplinary approach in meeting patient needs and that careful planning was necessary to ensure the success of interdisciplinary col- laborative work. The three focus groups agreed on this statement:

We just have to be focused in the morning to plan the day’s activity.

If we manage to do that, then everything flows, and if we do not, there is no progress. It’s all about communication.

A reliable information flow through communication was important to ensure care based on patient involvement. The informants seemed to rely on a philosophy that allowed the patients to optimize their resour- ces. They needed to cooperate in order to provide continuity of care in accordance with the patients’ needs. Shifts of personnel created problems as neither oral nor written reports were sufficient.

The importance of being a reflective practitioner was also emphasized. The staff in the short-term ward was not able to achieve as much interdisciplinary reflection as they felt they required:

We have an interdisciplinary meeting once a week where we can exchange experiences … We could have had interdisciplinary meetings every day. … We talk about concrete situations. We want, yes, but … For example, structural barriers meant that different professional groups were separated from each other and this was viewed as an obstacle to communication across disciplines. The short-term care staff in particular considered these external factors a hindrance to maximizing the potential for interdisciplinary collaboration.

We are placed in our offices far away from the nursing staff’s duty room. It is not natural for us to join them.

Cooperation with the next of kin was not always described as satisfac- tory. The staff sometimes felt there was a discrepancy between a patient’s individual desire and what their relatives decided on their behalf.

I feel we have a problem because some of the patients don’t partici- pate in any activity because their families reach decisions (on their behalf).

Although the staff wanted to maximize patient involvement in the decision making process, cooperation with the next of kin was regarded as essential for successful participation when patients were unable to express their needs. Family members were seen as an essential communication link between the staff and the residents, as they possessed a unique ability to interpret the patients’ needs and wishes.

Table 1 Overview of the attitudes and the environmental conditions contributing to patient involvement

Staff attitudes

• Values

• Staff assessment abilities

• Consciousness raising

• Knowledge enhancement

• Role models

• Clarification of responsibilities

Patient involvement

• Team work

• Continuity

• Structural conditions

• Cooperation with the next of kin

• Time pressure

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that risked generating low-quality care. The amount of available time varied between staff members and the feeling of having sufficient time did not always correspond with the actual situation. The lack of sufficient time meant that some staff members admitted that they often felt they had to ignore an important task in order to give priority to an even more important task. This challenge of making priorities forced them to depart from a previously planned schedule. One of the staff members expressed, «you do not have a chance». Sufficient staffing was seen as a condition for patient involvement, as this is a time-consu- ming strategy.

Discussion

Methodological considerations

This study was planned and conducted after a competence-building programme. We wanted to explore the staff ’s experiences from the programme. Interviews before the programme would have given us the opportunity to compare experiences before and after the programme, but this did not happen in our case. Still, we were able to receive valuable information from the staff.

One researcher moderated all the interviews, but an observer might have increased the credibility of the results. Nevertheless, the researcher had experience with focus group interviews from earlier studies (6, 15). Focus group discussion tends to reveal levels of consensus but also contrasting views among the participants (30). During the group discussions no such contrasting views were evident, but the participants described in detail their experiences from their daily practice.

Possibilities as well as challenges regarding patient involvement were discussed.

Each focus group met once. In order to increase the trustworthiness of the study, a re-interview might have offered new perspectives. For practical reasons this was not done.

Attitudes

The informants highlighted positive attitudes such as the patient’s right to self-determination and to be treated with respect and dignity.

These examples are in line with the human rights principles (4). They wanted to focus on the individual as a person and expressed a positive attitude towards patients (4). As indicated in other studies, our informants also stressed the importance of involving the patient (7-10, 12), and using life stories to help practitioners in viewing patients as human beings (12).

The importance of the cognitive, affective and behavioural aspects in their attitudes (16) was obvious throughout the interviews. The behavi- our and emotions occurring in daily situations are influenced by knowledge. Increasing knowledge subsequently represents an important way of changing attitudes in order to improve the quality of care. The staff members were conscious about the importance of viewing the patient as a unique individual, and this helped to promote an intellectual evaluation of the relevant situation or person. Attitudes are intended to describe, evaluate and defend our action in situations we encounter (17), and are subsequently essential in borderline cases where respondents experience a conflict between the right to autonomy and demands for professional responsibility (6). The results in our study emphasize the importance of shared decision making with the patients, which is in accordance with the conclusions of Zoffmann et al.(8).

Our informants stressed that competence building had changed their attitudes and work methods. They gave examples describing a new way of looking at the patients that resulted in a more person-centred care. Increased knowledge was an important factor in changing the attitudes, and there was an emphasis on the importance of cognitive aspects as a part of the attitudes. Professional education was regarded as a condition for understanding the complex interconnec- tion between the parts and the totality of a patient’s care needs and for judging a patient’s capacity for self-determination or participation in decision making.

from a bottom-up perspective, the informants also experienced a change in their attitudes and work methods. All staff members were involved in the competence building programme. The importance of involving all the staff members is also stressed by other studies (33). The staff participated in workshops that involved role play followed by reflections. The ability to reflect on the current practice and theoretical perspectives has also been highlighted as important by Vatne et al. (34).

Previous studies state that interdisciplinary cooperation is necessary in order to succeed in person-centred care (22). Our study provides several examples of external factors that limit the possibility of success. Thus, a willingness to engage in interdisciplinary cooperation is insufficient, as external conditions are of equal importance.

Earlier research (35) has emphasized the importance of exchange and communication regarding patient information and how the quality of information transfer may affect patient safety. It is also argued that routines and delivery processes affect how care and treatment are conducted after the shift handover.

This problem is clearly demonstrated in our study. It was evident that staff rotation created problems with continuity. The system of reporting and documentation was not good enough. This situation prevented the patient from adequate participation. The interdisciplinary aspect also represented was a challenge due to the lack of contact be - tween different professions.

Other studies stress the importance of planned and structured cooperation with the next of kin (19, 20). Our study highlighted the need to improve the communication of knowledge with next of kin in a positive manner and not in the context of a power struggle.

Norwegian welfare policy emphasizes the importance of autonomy and choice. This study provides several examples of demands for cut- backs and efficiency that make it difficult to find sufficient time or opportunity to implement the necessary practices, something which has also been emphasized in earlier studies (7, 26).

In line with the findings of Halvorsrud et al (18), the current study underlines the importance of environmental conditions as a combina- tion of external factors that are important for patient involvement in nursing homes. Further, the attitudes of the staff significantly affect how external conditions are implemented.

Limitations

One nursing home is included in this study. A broader sample taken from different nursing homes might have given other variations in the data material. Focus group interviews may not explore issues as deeply as one-on-one interviews, nor do they tend to expose sensitive or potentially embarrassing information (36). However, Morgan (30) suggests that focus groups may strengthen the discussion by generating more contrasts. The participants in this study shared a positive attitude towards patient involvement when possible, and we did not experience any contrasting opinions or controversies regarding this issue during the interviews. A purposive sampling was used, which might have prevented a more heterogeneous result, though it is difficult to conclude if this is the case. It is a matter of discussion if three focus-groups consisting of 16 participants are sufficient. However, the participants were involved in the same programme, and they are repre- sentative of the target group.

Conclusions

This paper presents staff descriptions stressing the importance of attitudes that focus on patient-centred care. These attitudes are a contribu- tory factor to succeed with different levels of patient involvement. The competence building programme raised consciousness among staff and influenced a change in staff attitudes.

Furthermore, good teamwork and the contributions of enthusiasts motivated patient involvement. However, several structural challenges

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were identified as obstacles to possible patient participation. Time pressure as a result of efficiency requirements was described as a key limiting factor. It is important that politicians respond to this information, although the current study has a limited scope.

The findings of this study have the potential of contributing to the improvement of clinical practice in nursing homes. This is because the study identifies important factors contributing to patient involvement and factors that prevent this kind of involvement.

Further research with a focus on cooperation and communication will shed further light on the themes explored in this study. A new project with a focus on how the next of kin perceive themselves as resour- ces for family members in nursing homes is in progress.

Acknowledgements

The authors would like to thank our colleagues Helene Hanssen and Rita Sommerseth for their helpful comments.

Accepted for publication 6.09.2012

Corresponding author: Anne Norheim, RN, Associate professor in Nursing Science, Department of Health Studies, Faculty of Social Sciences, University of Stavanger, NO-4036 Stavanger.

Email address: anne.norheim@uis.no, phone: +47 51 83 42 67, fax. +47 51 83 41 50, cell phone: +47 928 37 215

Anne Guttormsen Vinsnes, RN, PhD. Professor, Sør-Trøndelag University College, Faculty of Nursing, NO-7004 Trondheim.

Email address: anne.g.vinsnes@hist.no, phone: +47 958 06 707 References

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