ïSCOPE: Safer care for older persons (in residential) environments: A study protocol

Lisa A Cranley 0 Peter G Norton 1 Greta G Cummings 0 Debbie Barnard 0 Carole A Estabrooks 0 0 Faculty of Nursing, University of Alberta , Edmonton, Alberta , Canada 1 Department of Family Medicine, University of Calgary , Calgary, Alberta , Canada Background: The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life. Aims: Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life. Methods/design: The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking. Discussion: There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector. - Background Approximately 70% of people with dementia will die in a residential long-term care (LTC) facility [1], commonly referred to as a nursing home. Almost one-half of Canadians in LTC facilities are frail elderly over 80 years of age [2,3]. Furthermore, present prevalence estimates indicate that the number of people with dementia in Canada will almost triple by 2038 to 1.25 million [4]. People with dementia have complex care needs and a high dependency on their providers, particularly during end-stage dementia. High resident acuity can result in increased staff workload and decreased quality of work life [5]. Several reports at international [6], national [7], and provincial levels [8] describe the sub-optimal quality of care in nursing homes. With people living longer and with the growing numbers of those living with dementia, the need for quality LTC for the elderly will continue to increase dramatically [9]. Threats to quality and safety in care in nursing homes Over the past decade, we have seen increasing efforts to develop and test methods to address quality of care and safety [10-13]. The Canadian Patient Safety Institute comprehensive plan focuses on strategies that will continually improve cultures of safety in healthcare to establish the safest health system for all Canadians [13]. Quality of work life in healthcare settings affects both patient outcomes and crucial staff outcomes such as retention [14,15]. The growing number of residents in nursing homes with dementia increases job strain [16] and job-related stress [17] of healthcare providers, leading to reduced job satisfaction [17] and ultimately staff turnover. High turnover has been linked to poor resident outcomes, such as decreased functional ability and pressure ulcers [18]. Staff turnover in nursing homes is higher than in many other types of organizations [19]. Healthcare aides (HCAs), who provide 70 to 80% of direct resident care, often leave nursing homes within months of employment [19]. Several studies have demonstrated that staff satisfaction and engagement are related to quality of care for residents of nursing homes [20-22]. Staff engagement is the involvement and commitment of staff [20,23] and a heightened emotional and intellectual connection that an employee has for his/her job, organization, manager, or co-workers that, in turn, influences him/her to apply additional discretionary effort to his/her work [21]. There is evidence that teamwork contributes to performance by reducing errors and improving the quality of patient care [24]. Team performance has been associated with improved patient outcomes [25] and improved quality of care in LTC [26]. Yeatts et al. [26] reported that certified nursing assistant empowered work teams had modest positive effects on (improved) empowerment and performance, coordination and cooperation with nurses, and on residents care. Others have suggested that improving communication and leadership among staff in nursing homes can facilitate team cohesion [27] and improve quality of care [28]. Interdisciplinary team functioning is particularly important in caring for frail elderly because of their complex needs, requiring effective coordination of resources [27]. Others have found that teams with a champion perceived themselves to be more effective [29]. Study purpose and objectives The purpose of the study, which is called Safer Care for Older Persons [in residential] Environments (SCOPE), is to evaluate the feasibility of an intervention designed to engage front line staff (primarily HCAs) in using quality improvement (QI) methods to integrate evidence-based (best) practices into resident care. The overall goals of this study are: to support HCAs in learning and using QI methods to improve safety and quality of care for the elderly living in nursing homes; and, through the resulting empowerment, improve the quality of work life for staff providing direct care in these nursing homes. Theoretical framing The SCOPE study is guided by the Model for Improvement developed by Associates in Process Improvement [30]. The model has two parts: 1. Three fundamental questions, which can be addressed in any order: 2. Changes are tested using the Plan-Do-Study-Act (PDSA) cycle of rapid change in real work settings [31]. The PDSA cycle guides the test of a change to determine if the change is an improvement [32]. The fundamental premise is that front line healthcare providers know their processes of care and can, using this simple change management system, improve these processes. The model enables staff to bring evidencebased care to the bedside. Design This study is a two-year (2010 to 2012) proof of principle pilot that has resea (...truncated)