Assessment of patients' needs and resources as a basis in supervision for individualised nursing care in nursing home wards : evaluation of an intervention study

Abstract

The study in this thesis was conducted as an intervention project in three nursing home wards in Sweden, in a big city as well as in rural areas, one year in each ward. The intervention consisted of supervision for individualised and documented nursing care with a multidimensional assessment instrument, the Resident Assessment Instrument (RAI/MDS), used as a basis. The main aim was to evaluate the intervention in the wards.

Study I aimed at reviewing nursing documentation in the wards before and after the intervention. Quantitative content analysis was used to review the total number of nursing documentation (n = 58 + 57). The greatest change seen after intervention was the writing of care plans for the individual patients. Daily notes increased in length and number but reflected mostly occasional situations, as before. Computer-triggered Resident Assessment Protocol (RAP) items, obtained from the RAI/MDS assessments and regarded as a means of quality assurance, was used to compare items in the nursing care plans.

The aim of study II was to compare patients' life stories and current situations as told by carers (n = 30 + 30). Qualitative content analysis was used to disclose changes and to enable descriptions of patterns in the text. After the intervention the patient was more seen as a unique person with resources and abilities despite limitations, and the nurses' awareness of their own professional approach increased.

In study III a phenomenological-hermeneutic approach was used to illuminate nurses' video recorded interactions in morning care sessions involving patients, in one ward, suffering from severe dementia. In order to disclose any changes in the nurses' interactions the video recordings were conducted before, during and after the intervention (n = 24). The meaning in the interactions between the nurse and the patient were communicated through the balancing in actions and reactions, verbal- as well as non- verbal, and was about confirmation and the lack of it. This could fluctuate at times and be present within the whole complex of nursing care situations. The intervention contributed to developing a relationship of intersubjectivity and thus a greater emphasis on confirming nursing care.

In study IV stimulated recall interviews were used in connection with the video recordings in order to illuminate the significance of nurses' reflections on their interactions with the patients (n = 12). Another aim was to find out if any changes in their reflections took place across the intervention. A phenomenological-hermeneutic approach revealed that nurses improved their ability to verbalise their reflections and to be aware of their own influence on care quality. The meaning in nurses' reflections was about efforts to maintain a sense of dignity for the patients as well as for themselves.

In study V the Cognitive Performance Scale (CPS) included in the RAI/MDS was used to demonstrate the cognitive performance in elderly persons on different levels of care (n = 1276). Cognitive impairments in different stages were found for all levels of care investigated. In nurses' views (n = 50) of using the RAI/MDS (V) a majority thought that the instrument could contribute to improved care quality, even if some of them were hesitant. As the instrument made nurses more aware of the need for information, they thought that information as well as knowledge about the patient increased. They stated in their comments that the assessment covered all areas, and that they sought information they had not paid attention to or bothered about before the intervention, and further, that more of the patients' capacity and interests were considered.

The importance of continuing education and supervision was confirmed by the study. It seemed as if the supervision and the use of a comprehensive and detailed assessment tool contributed to increased knowledge about the patients and to efforts to see them as real persons even behind a dementia surface.