Clinical practice guidelines to improve shared decision-making about assistive device use in home care: a pilot intervention study

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Abstract

This study examines whether clinical practice guidelines (CPG) for the introduction of assistive devices (ADs) in home care improve shared decision-making about AD use and modify its social-cognitive correlates. Data were collected in an intervention study with quasi-experimental design. Questionnaires were obtained from 116 home nurses and home care workers and their 140 clients with disabilities. Significant differences between intervention and control group revealed that implementation of CPG improved home nurses’ and home care workers’ self-reported practice: the number of intervention methods they applied increased, and the methods were applied with increased intensity. Nurses’ attitudes towards introducing ADs in a shared decision-making process decreased in both intervention group and control group over time. Clients’ reports about caregivers’ practice showed a minor concurrence with the reports of the caregivers themselves. The complexity of the CPG and a substantial time investment were reported as the main barriers to involving clients in shared decision-making through the experimental CPG. Nevertheless, CPG hold promise for shared decision-making between formal caregivers and community-dwelling persons with disabilities concerning AD use. The findings suggest that these CPG can structure communication between caregiver and client, and can support caregivers in facilitating clients’ self-determination concerning coping with their disabilities.

Introduction

Use of assistive devices (ADs) for mobility and self-care is one of the strategies for coping with functional disabilities in activities of daily living (ADL) that are associated with the ageing process. Research during the last decade revealed that a significant proportion of older, community-dwelling persons already use ADs [1], [2], [3], [4]. This is due to the potential of ADs to promote a person’s autonomy, to optimise self-care and to improve quality-of-life (for an overview, see [5]). However, some community-dwelling elderly do not use ADs that could enhance their autonomy and safety, and therefore their quality-of-life [6], [7]. Even community-dwelling persons with well-documented physical disabilities show room for improvement of AD use [8].

To introduce ADs, insight into the decision-making process is required. Decision-making regarding AD use has been studied from a social-cognitive point of view. This has revealed that although AD use is determined by the functional status of the older person (the objective need), personal factors are also to some extent involved in the decision to use ADs [9], [10], [11], [12], [13]. Awareness of the existing ADs, attitudes towards AD use, self-efficacy regarding AD use, and perceived expectations of the social environment (subjective norm) were factors recently identified [4], [14], [15] in studies based upon the theory of planned behaviour [16]. Besides personal factors, the effects of context variables on the process of informing, advising, acquisition and use have been studied. Family variables have a direct impact, as they make informal care an option or not. The presence of formal caregivers and their characteristics equally affect AD use. Several studies have suggested that inadequate instruction by occupational therapists during hospitalisation may be a reason for a patient to abandon the AD or to use it infrequently upon returning home [17], [18], [19]. Home nurses’ knowledge of available ADs and their need for clear procedures have been mentioned as factors in service delivery [20]. Variables related to the more remote social context are legislation, industry and supply [21], [22]. We conclude that introduction of ADs might be optimised when formal caregivers take personal factors of older clients with disabilities into consideration, as these personal factors are direct determinants of their AD use.

In this respect, a mutual relationship and shared decision-making between client and formal caregiver is required. The client with disabilities then can be actively involved in decision-making about coping with disabilities and care, including the use of ADs. This focus on the relationship between a person with disabilities and the formal caregiver fits into the participatory model of service delivery [23], also called the consumer-driven model [24]. The consumer-driven model is characterised by a professional educating the consumer about various options and facilitating decision-making by the client [24]. Inspired by Sprague and Hayes’ description of mutual relationships [25], the relationship between formal caregiver and client in the context of optimising autonomy in the elderly through AD use could have the following characteristics: both actors actively participate in the process of coping with disabilities; both contribute from their knowledge and experience; and the perspectives, needs, and abilities of both are taken into consideration. The formal caregiver’s behaviour determines to a large extent whether or not this mutual relationship will develop. Caregivers can then facilitate self-determination in clients for coping with disabilities by helping them to explore relevant cognitions regarding AD use and by involving them in the decision process.

The question is whether or not professional caregivers are willing to share decision-making with clients. Roelands et al. [26] described the intention of home nurses and home care workers to introduce ADs with the close co-operation and active involvement of clients. They found that nurses and home care workers have a rather strong intention to introduce ADs, and they have a positive attitude and rather high self-efficacy and subjective norm towards it. In the literature on the education of occupational therapists and rehabilitation professionals, authors propose to involve clients in assessments [27], [28], [29]. Because several groups of formal caregivers are willing to share decision-making with clients regarding AD use, and many educators and researchers support this development, instruments to facilitate it are welcome.

The use of person-centred interventions has been suggested in order to facilitate shared decision-making about AD use. Levine and Gitlin [29] developed an educational program for occupational therapy students that emphasised the importance of assessing a client’s life-style during a collaborative problem-solving process. Sax [27] developed an elaborate online education model for rehabilitation professionals that included increasing awareness of personal factors influencing the access and use of ADs, and developing competencies in conducting person-centred assessments.

The use of protocolled clinical practice guidelines (CPG) for formal caregivers is a second strategy. These are defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” [30]. CPG are promoted with a variety of objectives: to improve quality of care, reduce costs of healthcare, transfer the results of research from literature to clinicians, or protect against malpractice litigation [31], [32]. Scherer and Cushman [28] determined the content of an interactive training programme and interpretative guidelines “to better guide professionals in incorporating MPT (Matching Person and Technology) assessment components into their evaluation procedures to ensure that consumer preferences and environmental constraints are accommodated prior to the selection of a particular assistive technology.” Daniëls et al. [33] developed CPG, an extensive course and an algorithm regarding the introduction of ADs by nurses and home care workers.

To be effective, CPG should be able to guide and change a formal caregiver’s behaviour. In general, only limited effects of CPG on changing caregiver practice have been found [34], [35], [36]; and reviewing the literature, Keffer [32] points to caregiver behaviour as the most likely obstacle to greater impact of CPG on a variety of outcomes. We are not aware of CPG or protocols concerning AD use that have been evaluated. It is not known whether CPG can change formal caregivers’ practice regarding introducing ADs in clients and determinants of this practice. Barriers to the use of CPG and shared decision-making in this area need to be investigated.

This study aims at investigating whether existing CPG can be adapted to comply with recent research findings and theoretical knowledge, and whether these CPG improve practice and strengthen social-cognitive factors related to shared decision-making about AD use in formal caregivers.

The study focuses on two groups of formal caregivers: nurses—who are involved in medically oriented care, and home care workers—who primarily concentrate on home care tasks (cooking, cleaning, and shopping) and on personal assistance. They were analysed separately, as their education and professional roles differ substantially.

This article describes the development of theory-driven, evidence-based CPG and algorithm to introduce ADs. Further, two hypotheses were tested:

  • The implementation of these CPG improves the shared decision-making between nurses and home care workers on the one hand, and their clients on the other hand;

  • These guidelines increase nurses’ and home care workers’ attitude, self-efficacy, and subjective norm regarding shared decision-making.

Barriers to involving clients in shared decision-making through CPG, as reported by nurses and home care workers, are described.

Section snippets

CPG “Introducing ADs”: adaptation to theory

The CPG “Introducing ADs” are an adaptation of Daniëls et al. [33] training programme, decision tree and guidelines for home nurses and home care workers regarding ADs. We agree with Browman [37] that replication of efforts in this field should be avoided in favour of co-operative strategies. The solution is adapting the original material to the new context to preserve useful central points and strategies. This adaptation was based on recent research and guided by the Intervention Mapping Model

Design, participants and intervention

The hypotheses were tested in an intervention study with pre-test/post-test design in intervention group and control group. Participants were nurses and home care workers, and their clients. In many countries, they are among the most important formal caregivers for community-dwelling elderly persons with long-term disabilities. Their daily responsibility for the well being of clients confronts them with their clients’ needs and use concerning ADs. In many countries, occupational therapists and

Caregivers

Fifty-eight departments co-operated in the study: 25 departments of home care workers (13 intervention groups and 12 control groups) and 33 departments of home nurses (19 intervention groups and 14 control groups).

One-hundred-and-sixteen formal caregivers participated in the pre-test: 26 home care workers in the intervention group and 26 in the control group; 35 home nurses in the intervention group and 29 in the control group. The mean age of the caregivers was 35 years (S.D.=9 years); 95%

Discussion and conclusions

Existing CPG were adapted in this study, taking into account new evidence about the involvement of personal factors in AD use in older persons, as well as in introducing ADs in formal caregivers. Afterwards, these CPG were evaluated regarding their efficacy to change formal caregivers’ practice. Despite the short training course, the complexity of the instrument (decision tree and questionnaire) and the rather high number of ADs that clients possessed at pre-test, the CPG shows an ability to

References (39)

  • S.D. Pell et al.

    Use of technology by people with physical disabilities in Australia

    Disabil. Rehabil

    (1999)
  • L.N. Gitlin et al.

    Emerging concerns of older stroke patients about assistive device use

    Gerontologist

    (1998)
  • T.L.-B. Pape et al.

    The shaping of individual meanings assigned to assistive technology: a review of personal factors

    Disabil. Rehabil

    (2002)
  • J.C. Rogers et al.

    Assistive technology device use in patients with rheumatic disease: a literature review

    Am. J. Occup. Ther

    (1992)
  • Scherer M, McKee B. But will the assistive technology device be used? In: Proceedings of the 12th Annual Conference on...
  • L.H. Kraskowsky et al.

    Factors affecting older adults’ use of adaptive equipment: review of the literature

    Am. J. Occup. Ther

    (2001)
  • F. Aminzadeh et al.

    Factors associated with cane use among community dwelling older adults

    Publ. Health Nurs

    (2000)
  • H.S. Bynum et al.

    The use and effectiveness of assistive devices possessed by patients seen in home care

    Occup. Ther. J. Res

    (1987)
  • D.J. Caudrey et al.

    Rehabilitation engineering service evaluation. A follow-up survey of device effectiveness and patient acceptance

    Rehab. Lit

    (1983)
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