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Community Health as Focus: Strengths and Weaknesses

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Development of Harbour Landing Community (HLC) subdivision in Regina began in 2007 . To develop community nursing skills, community engagement, and to support organization strengths, student nurses have been placed at Harbour Landing Village (HLV) for community clinical practicums. HLV, established in 2016, is located at 4000 James Hill Road, Regina, Saskatchewan and is a private intergenerational care facility which is comprised of independent living suites, assisted living housing, supportive living housing, and respite care as well as a childcare facility for children ages 6 months to 12 years.

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Levels of care and services offered at HLV vary based on resident needs and may include: meals prepared by the on-site restaurant, home-care services, free and fee-for-service activities developed by an in-house coordinator, transportation services to medical appointments, respite care, child-minding, and before-and-after school childcare. This paper comprises community analysis, identification of HLV community strengths and weaknesses, and a tentative plan of action to facilitate the provision of quality care according to HLV mission and values through documentation policy development and holistic health-oriented education.

A windshield walking survey was completed in May, 2019, to gather data about HLV and the surrounding community. Appendix A is a comprehensive table that outlines primary data from student observation, data analysis from secondary sources and interpretation of information. The survey serves to synthesize student observation and resident accounts/interview responses from a 1km radius around HLV as well as available public information about community services. Overall, HLC and HLV depict a modern lifestyle and zeitgeist with homogenous housing, smaller yards and lots, large green spaces for community use, and walk/bike paths to promote physical fitness. Services such as grocery stores, health care clinics, and general shopping needs are present however they are at the periphery, or outside of the 1km radius. As a new community, roads and sidewalks are in good condition, devoid of cracks or rubble. Undeveloped lots, however, sit collecting debris with wires and pipes jutting from the ground, a visual discord from the affluence observed in the new, well-kept homes.

City of Regina statistics and demographics are available for public reference, however, detailed census data for HLC is unavailable, therefore increased emphasis is placed on primary data collected through observation about HLC demographics, diversity, and economy. Strengths and weaknesses particular to HLV were identified by residents, staff, as well as student nurses during the assessment period.

HLV strives for resident engagement through active participation in activities and encourages the residents to voice any concerns or suggestions for improvement. Biweekly activity calendars outline diverse recreational activities throughout the week and daily agendas are posted outside each elevator. The activity coordinator, together with other staff, use word of mouth and reminders to engage with residents individually to incite interest and participation in larger activities such as the Soc Hop on May 8th. Residents, staff, and management find that method of information delivery provides sufficient community engagement, yielding high turn-out. Intergenerational programming, diverse activities, physical activity, and opportunities for socializing reduces feelings of isolation, depression, thereby increasing overall quality of life.

The management team attends monthly resident council meetings for the residents to share their opinions, suggest activities, and menu revisions. Changes are implemented quickly post-meeting; however, some residents are wary of speaking out in a large group. As a result, HLV is implementing a suggestion box on each floor so residents and their families can provide anonymous feedback, another demonstration of quick change based on resident needs. Overall, HLV succeeds at listening to residents and fostering intergenerational relationships through activities which improve resident’s quality of daily living.

As HLV grows, management seeks to expand services to include home care for independent residents. Home care staff confided that documentation policy is scarce and home care charts do not exist which results in an inability to provide consistent care and a lack of accountability. According to home care clients, lack of consistent assistance into their mobility braces has led to decreased range of motion, increased pain, and decreased satisfaction of care provided. Furthermore, Donna explained that she feels guilty asking for help if aspects of care are forgotten. Uncertainty and absence of charting and policy/procedure was the result of organization overhaul and rapid staff turnover in 2018.

Through observation, student nurses in the Winter 2019 semester noted hand-hygiene practices that did not fall within Saskatchewan Health Authority standards learned through school and clinical practice and sought to improve hand hygiene through in-service education as a way to prevent infection transmission. This weakness persists as staff can be seen providing care to different residents without engaging in hand hygiene, and there are only 10 rubbing alcohol stations on the assisted care units to provide service for 37 residents. Hand washing is the most important, cost-effective way to prevent disease transmission. However, because hand-hygiene compliance is related to accessibility of hand-washing stations, the placement of stations at HLV does not set the staff up for success.

To conceptualize HLV sectors and populations, HLV can be divided into subsystems of staff and residents, and categorized by the amount of care the resident requires and the job description of the care staff. Windshield walking data illustrates that HLV home care division is an area of particular vulnerability. Home care residents and home care staff subgroups interact, and therefore, a systems approach must analyze both to determine an appropriate intervention.

Home care residents associate increased pain and worsened physical health to inconsistent casual care staff who neglect to apply support braces . When prompted, Donna explained that she is reluctant to call for extra assistance for fear of being “a burden”. Terry, a new home care client, echoed Donna’s sentiment and stated that inconsistancy care has prompted him to be independent, causing him to fall and become injured (bruises to his weakened right side), but won’t speak up out of fear of being mistreated. The elderly home care population is vulnerable without a voice to advocate for quality of care.

Home care Continuing Care Aides Marnie Goldstone and Boomie Adeoti, explained that casual home care staff make medication errors and do not complete components of resident care, and are worried that errors made by casual staff reflect poorly on them. Because they feel that their previous concerns about resident safety have not been heard and investigated by management and, they have stopped speaking out against poor care, thereby also making them a vulnerable population susceptible to legal repercussions for unsafe care.

Both home care residents and staff are confronted with care inconsistencies and uncertainties as a result of scarce documentation policy and documentation paperwork. As a result, a socio-environmental approach to health promotion through public policy development is necessary to promote individual accountability, provide safe practice and quality care. An overarching theme in HLV is inadequate staff accountability and responsibility, which results in weaknesses such as improper hand hygiene techniques and inconsistent provision of quality care.

As a core competency of quality community eldercare, documentation helps identify whether a resident is appropriately aligned with services and serves to measure whether the resident’s social needs are being met. Furthermore, documentation facilitates the evaluation of the quality of care services provided by staff and is, therefore, a measurement of quality improvement.

Bing-Johnson et al., 2016, postulate that that unregistered staff struggle with documentation due to a lack of standards against which to judge their competence. Care providers perceive the absence of communication and documentation as a barrier to the quality of care they wish to provide and are frustrated that changes they implement are not maintained by other care personnel. Therefore, to provide efficient safe care and substantiate care provided, it is paramount to foster individual competence and accountability.

Two distinct goals were established to develop staff accountability and responsibility using the population health promotion model which include: a focus on developing the sector (who) working conditions (what) through building healthy public policy and strengthening community action (how) and; a focus on the individual (who) and the health services they provide (what) by developing personal skills.

A socioeconomic approach to facilitate community mobilization within the HLV home care populations is ideal as it serves to empower the community and develop the confidence to their voice concerns, make changes, and ultimately, find nursing interventions satisfying and successful. To develop sustainable interventions surrounding policy development the vulnerable population was actively engaged in “identifying health issues, planning and initiating interventions specific to their community”.

Prior to designing and implementing an intervention is important to build trust and rapport with stakeholders and to assess population perceptions and readiness for change. Initially, staff were wary of nursing students as the title was marred when the previous nursing students overlooked their needs acted as “experts”. This compounded existing disempowerment which was caused by limited resources, service cutbacks and perceived absence of managerial support. As a result, a third Population Health promotion Model goal was leveraged to ensure the provision of quality care to homecare residents by supporting the healthcare staff (who) which begins by creating a supportive environment within the community (how) thereby improving communication and working conditions.

Capacity building and community mobilization occur when community members are actively involved throughout planning change that is relevant to their needs and desires to increases their “skills, knowledge, and willingness to take action”). Therefore, involving informal and formal leaders at all phases of the change strengthens community action through community mobilization as and builds individual capacity, ultimately, strengthening community action to develop healthy public policy. Overall the individuals will develop proficiency in the new format and become models for their peers . Furthermore, the client remains the expert regarding their needs, and, because care decisions have direct consequences on their health, their participation is instrumental to the process of planning effective interventions. As a result, the staff and residents were actively involved throughout the process of developing charting forms and documentation: they identified weaknesses and strengths, then brought forward ideas for improvement. Residents suggested using colorful symbols in lieu of long-hand notes to describe care needs and proposed placing a care plan where it is visible to them so that they can explain it to casual staff, while care staff was excited to modify existing documents from another ward so that the flow sheet charting was succinct and specialized for home care tasks, activities, and perspectives and supported with long-hand notes.

To improve documentation procedures and sustain documentation standards, employees must have formal training in documentation procedures. However, Tworek et al., 2019, suggest that repeating simple interventions, such as informal education sessions, are cost-effective and improve success rates of intervention uptake. Therefore, supporting individuals through formal education about documentation and frequent refreshers develops personal skills and increases the health services they provide.

Establishing respectful, trusting therapeutic relationships allows community members to collaborate with student nurses when exploring and identifying health concerns and strengths and determining how to employ strengths and to improve weaknesses. Due to the temporary nature of student nurse involvement at HLV, it is vital to cultivate independence and self-management through mutual decision-making and power-sharing to facilitate confidence in their own strengths. Through empowerment the community action is strengthened and public policy is developed.  

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