Abstract
Background
The Norwegian teaching nursing home (TNH) programme was launched in 1997 to address the continued challenges and threats to quality in long-term care. They included high turnover, inadequate recruitment of qualified staff, poor image and inadequate learning opportunities in long-term care for students, and lack of opportunities for knowledge and skill development for staff. Research into the particular challenges and needs in long-term care was very limited. The aim of the programmes was to establish partnerships between selected nursing homes, universities and university colleges. Together the institutions would address the challenges by developing quality development programmes, initiating research and improving teaching in collaboration. During the first project period (1997–2003), the TNHs proved to be efficient in launching quality-improvement programmes, improving teaching of students and staff and supporting relevant research. Following a formal evaluation, the programme was established on a permanent basis in 2004. Since then the programme has gone through a number of changes, including growing in numbers, being widened to include home care services, and changing focus from local developments to also being vehicles for national quality initiatives.
Aim
This paper describes the current programme of teaching nursing homes in relation to its goals, organisation and responsibilities.
Results
The strong learning network among the institutions contributes to the robustness of the programme which focuses on developing and implementing evidence-based care and creative learning environments for students and staff.
Conclusions
The programme has altered since its inception to ensure it remains a sustainable innovation for improving the care of older people.
Introduction
This paper describes the current status and main characteristics of the Norwegian teaching nursing home (TNH) programme (renamed ‘development centres for nursing homes and home care services’ in 2011). The programme was initiated in 1997 to improve the care of older people and was established on a permanent basis from 2003. It has gone through a number of changes over time, but is still supported by the national government through yearly financial support over the national budget. The early developments of the Norwegian TNH programme were described in Kirkevold (2008). The major focus in this paper will be on a presentation and discussion of the current goals and responsibilities of the developmental centres for nursing homes and home care services, as well as how they are organised and run. The recent developments will be discussed in relation to the current needs for quality and competence development in the nursing home and home care services.
Background
TNHs, or academic nursing homes, have been introduced in many different countries around the world in order to address the persistent challenges in providing high-quality care for older people in need of extensive and continuous health and personal care. The first programmes were established in the US in the 1980s (Mezey et al., 1989; Schneider et al., 1985). Subsequently, similar programmes have been/are being initiated in Canada, Australia, the Netherlands, Sweden and the UK, though with somewhat different aims and goals, focus and organisational arrangements (Barnett et al., 2011; Hockley et al., 2016). The different TNH initiatives have remarkably similar rationales, despite the distance in time, geographical location and contextual conditions in the societies and healthcare systems of which they are a part. This highlights the profound challenges that many countries around the world have in terms of providing adequate and humane care to an ever-increasing number of frail and vulnerable older people.
The Norwegian TNH programme was initiated at a time of significant challenges in terms of providing high-quality care to nursing home residents due to difficulties in recruiting qualified staff. Due to demographic and social changes, as well as a restructuring of the healthcare system with more complex care provided in the community, Norway still faces challenges in terms of providing high-quality care to frail, older people (White Paper 26, 2014–2015). A recent study indicates that the competence of the nursing home and home care staff is inadequate to meet the complex needs of older people in the community (Bing-Jonsson et al., 2016). The current developmental centres for nursing homes and home care services are charged with the responsibility of contributing to solve these challenges.
The original TNH program
The original TNH programme in Norway was launched in 1997 as a 4-year project. The idea was to explore whether it would be possible to develop selected nursing homes into TNH facilities through formal collaboration with local universities and university colleges. Initially, four nursing homes were included in the programme. Later, one more was added with particular responsibility for providing and developing services to the indigenous populations of the Sami people in Northern Norway.
The rationale for establishing the programme was the persistent critique of the quality of care provided in the nursing home sector, as well as difficulties recruiting sufficient numbers of qualified staff and high turnover (Kirkevold and Kårikstad, 1999). These problems were considered to be ‘shared problems’ by the nursing home sector and the education and research sectors. The assumption was that by establishing formal collaboration with the research and education sectors, the nursing homes would gain access to qualified researchers and teachers with interest and commitment to contribute to the development of the nursing home sector. By developing stimulating clinical practice arenas for nursing and other health professional students, the nursing homes would be able to improve their recruitment of qualified staff. Furthermore, the idea was to collaborate on quality-improvement projects by bringing the different experiences and qualifications of the clinicians and teachers/researchers together to develop new ways of providing services. The universities and university colleges involved would benefit from the collaboration by gaining access to nursing homes committed to providing rich learning experiences for students, as well as being prepared to collaborate on research projects relevant to the nursing home sector (Kirkevold, 2008).
Following the 4-year feasibility period, an external evaluation was carried out. The evaluation panel concluded that the programme had been a success; it had led to enthusiasm among leaders and staff in the participating nursing homes with regard to staff development and participation in quality development projects. It had also contributed to improved services on specific issues, which varied among the nursing homes due to different priorities with regard to which issues to address. The student placements had improved both in quality and numbers, and students were more satisfied with their clinical learning experiences than before (Kirkevold, 2008).
The evaluation panel was, however, critical of the bottom-up approach that had been employed (inspired by a participatory action research approach) (Bradbury-Huang, 2015) and recommended that the national health and care authorities assume a more directive approach. They also recommended that a clearer leadership structure be established as they considered the collaborative model established between the nursing homes, universities and/or university colleges to be vulnerable in terms of lines of responsibility.
Following the evaluation, the Department of Health in 2003 decided to continue the programme and established the TNH programme on a permanent basis with dedicated financing over the national budget (Kirkevold, 2008). The Directorate of Health was assigned the responsibility for leading and running the programme. The responsibility for ensuring collaboration with local universities, university colleges and other relevant institutions was delegated to the TNHs. Furthermore, each TNH was assigned a particular responsibility for supporting other nursing homes in their region by developing and testing transferable models for quality improvement and by collaborating with and supervising other nursing homes that wanted to initiate quality-improvement projects. The number of TNHs gradually increased and the goal of one TNH in each of Norway’s 20 counties was reached in 2008. During the 1990s and 2000s, home care services became more and more important in providing care for older people as the municipalities across Norway established home care services around the clock and the national policy increasingly maintained that people should live at home for as long as possible (White Paper 50, 1996–1997; White Paper 28, 1999–2000). The home care services were faced with many of the same challenges as the nursing homes. Consequently, in 2009 one teaching home care service was established in each county.
From TNHs to development centres for institutional and home care
The Norwegian TNH programme underwent several changes between 2004 and 2009. The main idea of being centres responsible for contributing to the quality improvement of nursing home services and providing rich learning experiences for students continued. However, the idea that the TNHs should conduct research was downplayed. The reasons for this were primarily caused by scepticism regarding the ability to ensure high-quality research in the nursing homes due to limited academic training among the staff. One idea of the original TNH programme was never institutionalised – the creation of faculty-practice positions, which were meant to ensure academic staff in the nursing homes. Instead, the Directorate of Health decided that the TNHs should facilitate research initiated and conducted by the universities and university colleges.
In 2011 a new strategic plan was developed. The TNHs changed their names to developmental centres for nursing homes and home care services to reflect the fact that their major responsibility was to contribute to the continued development of the services. This implied both conducting quality-improvement projects and continuing to facilitate learning among staff and students from a broad range of fields and at different levels. Each developmental centre now had a major responsibility for serving the whole county and putting more emphasis on collaboration across institutions and home care services to improve services and facilitate knowledge sharing.
The current programme
In 2017, based on a thorough external evaluation, the developmental centres for nursing homes and the developmental centres for home care services in each county were merged. The number of centres was thereby reduced from 38 to 20 across Norway (two had already merged previously). The rationale was to ensure larger and more robust centres, and to facilitate collaboration across institutional and community-based care. Typically, the centres have about four to six core permanent staff, although the size varies depending on whether they are able to secure additional support for specific activities.
The major responsibilities of the development centres in the years to come are to contribute to increased quality of care through promoting evidence-based practice, and provide methods and tools to support the development of learning cultures in institutional and home-based care services. Furthermore, they are expected to be resources for local professionals and service providers who want to initiate development and implementation work, and contribute to the active involvement of users and their relatives in these processes (www.utviklingssenter.no). It is specified that their work should be guided by local and national prioritised strategic areas. Developmental centres are expected to carry out their work in close collaboration with educational institutions, the municipalities (who are responsible for primary care in Norway), national authorities and the county officer’s office, who oversees the quality of services in its jurisdiction. The development centres are not expected to conduct research, but to facilitate research into the care services.
Current vision for the developmental centres for nursing homes and home care services.
Approaches to quality development and learning projects
The development centres have a long tradition of supporting smaller, locally initiated projects, and this is still an explicit responsibility, as expressed in the current vision (see Box 1). In recent years, they have also increasingly assumed the responsibility of contributing to the implementation of larger, national initiatives. In this section, I will highlight two examples of development projects that illustrate how the development centres work in order to contribute towards improving care. In addition, I will provide examples of how the development centres facilitate student and workforce learning.
Example 1: Agder living lab
The first example is a nationally supported project within the area of eHealth and welfare technology. The project is ongoing and is supported by the Norwegian Directorate for Health. It is a collaborative effort between the University of Agder, the Center for eHealth and Care Technology, a development centre for nursing homes and home care services and Grimstad municipality in Aust-Agder, Southern Norway, in collaboration with different businesses involved with developing welfare technology solutions (Aslaksen, 2017; https://video.uia.no/media/t/0_stvikg4i/35281).
The focus of this project is to engage the users in the development and testing of different welfare solutions from crude ideas through to the finished product, by testing the innovations in different environments. The uniqueness of the project is the involvement of users, such as patients and family members, in the testing and evaluation of the equipment. The technology varies widely, from tracking systems to ‘smart’ napkins/diapers to dressing-assistance devices.
The project applies a participatory action-oriented stepped approach, which is common in technology development projects (Bradbury-Huang, 2015). Initially, the focus of such an approach is on defining the need for a new technological solution; next, initial technological testing of early versions of the new technology is carried out; this is then followed by user tests in a welfare technology laboratory at the university. When the technology appears ready, the new device or technology is tested at home by real users (patients, family and/or staff as relevant). Finally, the testing continues when the new technology is implemented in the healthcare services. Through this thorough development and testing process, with different stakeholders, new technological solutions can be designed to meet the needs of the users, their different helpers and the service providers. Experiences so far suggest that a number of user-related problems may be discovered this way, thereby preventing the launching of products that will not work properly for the user groups they are intended for (Martinez et al., 2016).
The role of the development centre for nursing homes and home care services in the project is to contribute to user-friendly, relevant and quality-ensured welfare technology that may be used in a range of settings. This modelling approach may assure easier access to relevant technological tools for a wider audience. As the project evolves, one might expect that the spreading of the technology and new practices will be an important focus of the local development centre, as well as other centres in the national network.
Example 2: developing learning networks within and across municipalities to improve patient security and quality of care of frail, older nursing home residents
A major task of the development centres is to facilitate student and staff learning by creating good learning environments and by initiating projects to address specific learning needs. The development centre in Hordaland (located in the city of Bergen) has led a number of different projects aimed at facilitating workforce development. In these projects they have applied the ‘learning network methodology’ (White et al., 2011). This is an approach where multi-professional local teams are established to work on a particular quality issue. This approach builds on the idea that learning and quality improvement go ‘hand in hand’, and that bringing staff from different institutions together to work on the same issue will facilitate learning by sharing experiences as well as practical tools and methods. Several local teams from different units/municipalities comprise the learning network. The teams work partly on the issue locally in their own units or departments, but meet regularly in network meetings to share experiences and discuss common problems across settings in terms of addressing the selected issue. An important element of the methodology is the use of systematic registration and the evaluation of data, which is presented and discussed in the network meetings. The systematic use of empirical data to document the process of change is found to stimulate progress and motivate the participants to keep addressing the issue.
The first learning network initiative was related to the quality of medication management in nursing homes. This continues to be a major quality issue in Norwegian nursing homes, as well as in home care services, and is related to polypharmacy among frail and chronically ill older people (Handler et al., 2006). Polypharmacy, with its associated problems of interactions and side effects, may seriously threaten the functioning and well-being of vulnerable patients. This problem is also reported in other countries (Handler et al., 2006). In order to address this problem, ‘The National Security Campaign’, a national initiative run by the National Knowledge Center on behalf of the National Directorate of Health, initiated a programme to reduce medication problems in Norwegian nursing homes. They introduced the concept of ‘medication rounds’ – a systematic review of all patients’ medication lists in a multi-professional group consisting of the patient’s physician, the primary nurse, other relevant healthcare professionals, and a clinical pharmacist if available. The approach entails the systematic assessment and review of the patient’s medical, physical and psychosocial situation and treatment plan, including the total list of drugs. A major goal is to reduce the number of drugs, adjust the medication and dosage, and adjust the drug regime to the current situation. This systematic, multi-professional approach has been found to improve the treatment and care of frail, older people internationally (Patterson et al., 2010).
The goal of the Norwegian project was to implement and evaluate the effect of this approach more systematically and model an approach that could be copied by others. In this way, the aim was to contribute to staff development across the whole sector.
This initial project was carried out first in all nursing homes and residential centres in the city of Bergen (39 institutions). Subsequently, the other municipalities in the county of Hordaland were invited to participate. Local teams from the municipalities met regularly (three times over a period of approximately 9 months). An evaluation of the project documented significant improvements in terms of the number of patients who were subjected to a medicine round and the number of patients who had prescriptions with a clear diagnostic rationale. In terms of reduction in the number of drugs prescribed, the results were more varied. Subsequently, the development centre in Hordaland has launched similar learning network projects to address falls and pressure ulcers, and also to accommodate national initiatives from the ‘National Patient Safety Campaign’ (https://www.bergen.kommune.no/omkommunen/avdelinger/utviklingssenteret-for-sykehjem-og-hjemmetjenester/ 9641/article-114450).
Example 3: creating rich learning environments for students
Facilitating student learning continues to be an important responsibility for the developmental centres. A recent example of an ongoing project that addresses student learning is being carried out by the developmental centre in South Trøndelag (in the city of Trondheim). They are conducting a project to develop and test multi-professional supervisory teams to enhance the competence of supervisors and improve the clinical studies of diverse healthcare students in nursing homes. In particular, the aim is to contribute to improved multi-professional collaborative competence among the students. The project is being evaluated through process evaluation research (http://www.utviklingssenter.no/prosjekt-tverrprofesjonelle-veilederteam.5936807-179690.html).
Another example is the work at the development centre in Oslo to facilitate clinical learning experiences for students in the newly established Master's in Geriatric Nursing, established at the University of Oslo in 2011. This advanced practice nursing programme, which builds on the international nurse practitioner training programmes, required a whole new approach to clinical practice studies for the students. The development centre in Oslo has worked closely with teachers at the university to create models for clinical practice in close collaboration with several nursing homes on a wide range of subjects, such as pharmacology, physical assessment, care of complex older patients and health promotion.
Discussion
The Norwegian TNH programme has been in existence since 1997. Over the years the programme has changed substantially, yet still retains the main characteristic of working to improve the care of older people in close collaboration with leaders and staff of participating nursing homes and home care services. Compared to similar programmes, such as the early national programmes in the US (Mezey et al., 1989, 2008; Schneider et al., 1985), the Norwegian programme has been remarkably sustainable. There are several possible explanations for this.
One important factor that has contributed to the sustainability of the programme is the continued support of shifting national governments. One reason for this is that the Norwegian TNH programme has proved to be a robust and cost-effective vehicle for continued focus on quality development at the local level. Despite limited economic support (amounting to two to four positions at each site, supplemented by external funding secured to increase the quality improvement activities), these centres have been able to motivate and support local initiatives through supervision, low economic funding and practical resources. Due to the local initiative the projects have had a clear and immediate relevance, which has sustained the initiative and motivation. The local projects, therefore, have been important in maintaining support from the staff and local leaders who have experienced that their initiatives to improve care have been recognised and supported. This is in line with the recommendations of Mezey et al. (2008), who understood that TNHs should address quality concerns of the leadership and staff at the nursing homes, as well as concerns among the residents and their relatives.
Another possible explanation of the continued success of the Norwegian TNH programme is the long-term networks established between the regional TNH/development centres and other nursing homes/home care services in the region. These networks facilitate initiation of new quality-improvement projects and research projects. A recent publication by Davies et al. (2014) highlights the challenges of developing sustainable care home networks for research in care homes, and the need for long-term commitment on the part of both research institutions and care homes. Furthermore, they found that the managers in care homes emphasised that the research had to be relevant for residents and staff in order to succeed. The authors recommend that networks are established, and measures put in place to maintain them, in order to promote sustainable culture change in the nursing homes.
A third factor contributing to the success of the Norwegian programme is the fact that the Norwegian government has been able to use the developmental centres as a ‘vehicle’ for implementing national policies and guidelines. In this way, the developmental centres have contributed to national quality improvement within specific areas, such as medical treatment of older patients, fall prevention, and nutritional and palliative care. Because the development centres have had the ability and capacity to work locally to implement national initiatives, the health authorities have seen them as effective policy implementers. This has maintained their position as essential actors to improve care nationally, which has ensured continued national support. This is in line with Mezey et al. (2008), who consider the implementation of evidence-based guidelines to be one of the responsibilities that TNHs are uniquely equipped to take.
A fourth criterion that may have contributed to the success of the TNH programme has been its flexibility. The network of TNHs and subsequently home care services, in close interaction with the Directorate of Health, the local municipalities and selected institutions and units, has been able to adjust to meet changing needs over time. The national–local inter-level organisational structure seems to have been efficient in being able to both allow for changes and for maintaining a relative stability of the vision and focus of the centres over time. Because the development centres have remained rather small, staffed with a few key committed actors, they are flexible units that can quickly adjust their activities and focus when needed. Yet even if all of the development centres are rather small, the strong network between them has made them robust. National meetings, a common vision and shared goals have created a strong network that has facilitated the implementation of national initiatives. As such, they may exemplify how it might be possible to achieve the goals promoted by Davies et al. (2014).
Some of the changes and current characteristics of the Norwegian TNH programme might also have introduced potential threats. A major change for some of the development centres is that they are no longer located in a nursing home/home care service. Rather, they have been relocated outside a specific institution/home care service. Often they are located together with the central health and care leadership/management in the municipality or other quality, teaching or research support services. The rationale for this decision has been that the development centres are to serve all the nursing homes/home care services/districts in a municipality/region and that being located in one particular nursing home/home care service may reduce the access for other nursing homes/home care services. Furthermore, easy access to the leadership in the municipality and/or other similar units may ensure support from the leadership and collaboration with other relevant units. However, a potential threat is that the increased distance of the development centres from the staff, and the daily workings and challenges in the nursing homes/home care services, might reduce their legitimacy among the local management and staff, and thereby threaten their ability to facilitate positive change and learning cultures in the nursing home/home care services. Mezey et al. (2008) maintain that a key aspect of TNHs is that the teaching, quality improvement and research activities are integrated activities of the institutions designated TNHs. This might be more challenging to maintain when the designated TNH staff move out of the nursing homes/home care services, because they will be less visible and integrated in the daily working of the institutions.
The original plan of the Norwegian TNH programme was to address the challenges in the nursing home sector through multi-professional collaboration. The inclusion of the physicians and medical students was seen as an important element; unfortunately, this proved to be difficult. The major reason for this was a great lack of qualified geriatricians with substantial impetus to educate geriatricians for the geriatric departments in the hospitals. Moving some of the medical education to the nursing homes proved difficult due to curricular constraints and lack of qualified supervisors in the nursing homes. General practitioners (GPs) were mostly serving the nursing homes part-time in addition to their GP practice. This limited their capacity to participate in education efforts, supervision and quality-improvement projects. The lack of participation of physicians and medical students poses a threat in terms of the capability of the development centres to contribute towards improving the medical care of nursing home residents. In recent years, more nursing homes have increased physicians’ hours, and some have hired physicians in full-time positions. These are important developments that may increase the likelihood of developing educational practice models for medical students and increase the commitments of physicians in improving care. The recent establishment of national research schools for general practice and municipal health and care services are other initiatives that might support this.
Conclusion
The Norwegian TNH programme has become an integrated part of the municipal health and care services in Norway. The main aim continues to be quality improvement through locally and nationally initiated quality development projects. Close collaboration with the education and research sectors continues to be an essential part of this, facilitating good learning experiences for students and the initiation of relevant research to underpin the care provided. Development centres are key actors in the implementation of new research-based guidelines and approaches across the continuum of care.
Key points for policy, practice and/or research
The Norwegian TNH programme, initiated in 1997, has proved to be a sustainable national programme for improving the quality of care of older people in long-term care. The programme has gone through substantial changes over time in order to adjust to changing needs and challenges. The flexible nature of the programme has contributed to its success. The programme was widened to include home care services in 2009, and the TNHs and home care services were renamed ‘development centres for nursing homes and home care’ in 2011. The sustainability of the programme may be related to several criteria, including continued support from the Norwegian government, a national network, and a combined focus on local development initiatives and national quality initiatives.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethics statement
This paper does not report on an empirical study rather a long-term service evaluation. The work underpinning it did not require ethical approval however we adhered to the ethical principles of research involving human subjects used in other Norwegian settings.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.