Linking the Context of Home Care Work Environments, the Documentation of Best Practices and Client Outcomes

Purpose:
The purpose of the study was to investigate the relationship between the documentation of evidence-based interventions and client outcomes, and to identify factors that influence evidence-based practice in home care nursing settings.

Background/Significance:
The study was guided by the Client Care Delivery Model based on open systems theory. It depicts inputs (e.g.client and nurse characteristics, context of homecare work environment) and throughputs (e.g. number of visits, documentation of evidence-based interventions) that are expected to influence outcomes, specifically pain, dyspnea, pressure ulcers and falls. This study begins to address the knowledge gap about the relationship between the use of best practice guidelines and client outcomes.

Methods:
A longitudinal mixed methods design was used to collect data using questionnaires completed by 348 home care nurses, data from corporate databases and audits of nursing documentation of 978 cases at 4 organizations. The Maslach Burnout Inventory and the Problem Solving Inventory were components of the nurse questionnaire. Client outcomes included pain, dyspnea, pressure ulcers and falls, each of which was assessed by visiting nurses on admission and on discharge, using a standardized tool. The Registered Nurses' Association of Ontario has developed a Best Practice Guideline for each of these outcomes. Data analysis included descriptive, content and multivariate analyses.

Results:
Organizational culture predicted documentation of falls-prevention interventions. 76.7% of nurses agreed or strongly agreed that they had adequate orientation to their job. Nurses documented assessment-related recommendations more often than evidence-based interventions. Non-pharmacological interventions were rarely documented. Clients who received more frequent visits were more likely to experience improved pain outcomes. Documentation of best practices for dyspnea was linked to improved outcomes. For each additional year of nurses' employment, there was a 24.1% decrease in the likelihood of having any evidence-based interventions documented among client who had COPD or dyspnea.

Conclusions and Implications for Practice:
Nurses need resources to recall less-frequent interventions. Over 75% of nurses “would use research more often if they could,” presenting an opportunity for employers. The results can assist in the design of delivery models that benefit clients by integrating best practices into care planning tools.