Esther Cloutier1, Hélène David2, Élise Ledoux1, François Ouellet2, Isabelle Gagnon2, Madeleine Bourdouxhe1, Catherine Teiger3
1 Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST)505 boulevard de Maisonneuve ouest, Montréal (Québec) H3A 3C2
- 2 GRASP, Université de Montréal C. P. 6128 succ. Centre Ville, Montréal (Québec) H3C 3J7
- 3 CNAM et CNRS,
41 rue Gay Lussac, 75005 Paris, France
An interdisciplinary study in four home-care services in Québec is using a convergent approach. The analysis reveals the importance of case discussions that take place in multidisciplinary care teams. In fact, the topics dealt with are very diverse. These discussions not only have a positive effect on the quality of care, but also numerous impacts on the health and safety of personnel by mainly allowing: the personnel to be valued; the sharing of information on the users, which increases the knowledge about the case, which is identified as a central aspect of prevention; training and exchanges on the different protective work strategies used by the personnel; the improvement of intervention coordination and planning, which reduces time constraints; the implementation of organizational means for solving certain problems; the creation of a strong interprofessional work group. This study allows organizational development suggestions to be formulated in order to maintain and promote multidisciplinary team functioning which is threatened by the current intensification of the work in Québec.
Work organization, protective work strategies, health sector, interprofessional exchanges, work group
In home care, the jobs of visiting home-support and social aid workers and nurses are the most numerous in terms of manpower but they also present significant occupational health and safety (OHS) risks. In Québec, home care services are provided by the local community service centres (CLSC). When CLSCs were created in the early 1970’s, they proposed an innovative service provision model based on collaboration between the professionals from various disciplines (D’Amour et al., 1999). At the present time in Québec, the demand for services is significantly
increasing, which is related to the shift to ambulatory care. This increase is combined with major budgetary restrictions in the health sector. To attempt to respond with insufficient manpower to the growing demand for services, managers are attempting to modify certain organizational aspects, which at first glimpse may be considered as a waste of time. Therefore, in some CLSCs, multidisciplinary team meetings and case discussions have been eliminated or their frequency reduced. In this text, we will illustrate the impact of these organizational choices on the occupational health and safety of the care-giving personnel.
A study has been undertaken to investigate the role of work organization in home-care services as support: 1) in the development of protective work strategies for experienced visiting home-support and social aid workers and nurses; 2) in the development of these strategies by novices; 3) in the use of these strategies during the real work activity, particularly for hazardous situations. The aim of this study is to propose avenues of organizational development to provide support for personnel, thus ensuring the quality of care as well as better risk prevention for workers.
This interdisciplinary study is based on four embedded case studies (Yin, 2004) in home care services of CLSCs with different organizational characteristics. To demonstrate this complex problem, the collected data come from different sources:
- individual interviews with managers (management, team leader, OHS manager, etc.) and personnel representatives;
- group interviews with visiting homesupport and social aid workers (3 interviews) and nurses (3 interviews) of different ages and experience in order to understand their work;
- observation of the work activity of 11 visiting homesupport and social aid workers and 11 nurses throughout their workday, and time analysis of this activity;
- observation of various types of work meetings: multidisciplinary, professional, case discussions, debriefing and solutionfinding;
- group interviews (7 visiting homesupport and social aid workers) and individual interviews (6 interviews) with visiting homesupport and social aid workers who have had accidents or have had workrelated health problems;
- administrative documents dealing with work organization;
- data on manpower, occupational injuries and absences for health problems in the last three years;
- questionnaire on musculoskeletal health and psychological health.
THE MAIN RESULTS
The main results that emerge overall from analysis of the data collected in the four home care services are that:
- the workers are aging and insufficient in number to meet the demand for services, thus requiring them to have to deal with a heavier work load;
- the risk indicators show that the professions of visiting homesupport and social
aid workers and nurses could involve occupational injuries and work-related health problems;
- the experienced personnel develop many work strategies that have a positive impact on the quality of services and on personnel protection;
- the relationship with the client is a central aspect of the work activity that cannot be disregarded in the work analysis;
- this relationship is most often masked at all levels (actual workload, satisfaction, working time, quality of care, etc.);
- a significant part of the work of the visiting homesupport and social aid workers and nurses is based on relational and affective aspects, which, while being invisible, are an integral aspect of the job;
- there is a great variability in the work of the visiting homesupport and social aid workers and nurses that is mainly due to the different types of clients as well as the fluctuations in their health status; to the diversity of the activities to be carried out; to the variation in routes and schedules; to the unexpected events and incidents that require daily reorganization; to the importance of the relational support and screening work; and to the different office tasks;
- several aspects of work organization affect the work activity and OHS of the visiting homesupport and social aid workers and nurses.
This article discusses multidisciplinary teamwork and information transmission as key aspects of the OHS of the care-giving personnel.
Multidisciplinary teamwork in the four CLSCs studied
The four home care services studied are different: the first (CLSC #1) has no multidisciplinary team, the second (CLSC #2) functions partially as a multidisciplinary team, while the two others (CLSCs #3 and #4) implemented this method of operation several years ago and are attempting to retain it. Since CLSC #2 uses a hybrid method, we mainly use the data collected from it to explain our statements.
CLSC #2 and CLSC #4 are of comparable size in terms of manpower, users and interventions. The risk levels, calculated using the frequency rate1 for the visiting home-support and social aid workers and for the nurses (Table 1), are advantageous for CLSC #4. Several organizational factors differentiate these two CLSCs and may explain this difference, one factor being whether it has a multidisciplinary team or not.
Table 1 -OHS problem frequency rate (%) for visiting home-support and social aid workers and nurses from two CLSCs
Visiting home-support and social aid workers
1 The frequency rate corresponds to the number of injuries divided by the number of individuals considered as a full-time equivalent. The injuries compensated by the CSST (organization that handles the compensation of occupational injuries in Québec), cases of temporary assignment, and absences compensated by employee personal salary insurance, which are potentially work-related (musculoskeletal disorders and mental health problems), have been considered.
In contrast to the other CLSCs studied, CLSC #2 is the result of a merger in 2000 of two CLSCs of different sizes and cultures. Several differences existed between these two organizations, mainly in the approach to care, record keeping, and work schedules. These differences slowly disappeared over the years, except that the planning of care-giving work teams is still done by respecting the former territorial division of the two organizations, and that part of the care-giving team, associated with a former geographical sector, has retained a multidisciplinary operation. The second part of the care-giving team, which serves the other geographical sector, does not use this method of operation. In terms of OHS, the toll is heavier on the staff in the sector lacking a multidisciplinary team, as shown by the specific analysis below.
A particular OHS issue: the case of the “woman with stockings”
At the time of the study, seven accidents involving visiting home-support and social aid workers resulted in upper limb injuries under similar circumstances within a period of a few months in the home of one client. At the request of the CLSC’s managers, we focused our analysis on these events in order to identify the solution scenarios. The complex problem reveals the fact that there are many relationships between organizational parameters and OHS.
The client was 78 years of age, lived alone and suffered from gigantism in her legs. On the doctor’s prescription, the woman had to wear compression stockings with a pressure of 70 mm Hg. The visiting home-support and social aid workers visited her home daily to put on and remove the stockings. Hygiene care in the bath was provided once a week. The donning and removal of the support stockings was painful for the woman. Also, from the comments gathered, the visiting home-support and social aid workers who provided the care had relational type difficulties with the woman (depressive, aggressive, manipulative, giving orders, etc.), as well as major physical and time constraints when the service was provided.
The history of this OHS problem with the visiting home-support and social aid workers revealed that the home care services had considered several things to correct it, particularly regarding the physical work environment in the client’s home, finding adapted equipment, and work organization. For this, the means implemented mainly involve:
- training of personnel in different techniques for donning support stockings,
- consultation of the visiting homesupport and social aid workers, and case discussions with the social worker and occupational therapist responsible for this client after several accidents had occurred,
- implementing teamwork for donning stockings,
- rotating three and four teams to ensure that the visiting homesupport and social aid workers recover,
- the introduction of a man into the work team,
- firmly establishing with the client the tasks authorized by the CLSC, and the signing of a service contract,
- the meeting of the caregiving team, doctor and the director of the home care services.
Analysis of the circumstances of these accidents reveals many problems in information
sharing within the care-giving team. First, major gaps were identified in the transmission of information between the visiting home-support and social aid workers. In fact, work organization does not encourage meetings between them. As a result, few exchanges can take place on the difficulties encountered in the home or on the protection strategies developed from experience. For example, during the group interview, the visiting home-support and social aid workers discovered at the same time as the researchers that there are several ways of working in pairs to put on the stockings. Second, the lack of case discussions between the team’s visiting home- support and social aid workers was such that they were unable to develop common positions on different problem subjects. Therefore, no consensus emerged about the behaviours to adopt with this client, based on what is acceptable and what is not; everyone had to cope in his own way. Also, this results in a lack of sharing of information, particularly on the actual state of health, which often leads to erroneous information. Third, the impact of the lack of interdisciplinary work is the lack of a work group2, which could consist of the people involved with the user. This weakens even further the movement of information. Analysis of the meetings between the social worker, occupational therapist and some visiting home-support and social aid workers when the situation was of major concern shows that the exchanges were somewhat unidirectional. First, the visiting home-support and social aid workers talk to the professionals, who wanted to understand the problem; then the professionals informed the visiting home-support and social aid workers of the decisions taken by the organization. At another level, the exchanges between the managers, professionals and the physician were also relatively unidirectional. They were delayed as well, which had a negative impact on the rapid and efficient resolution of the problem, considering the little feedback of information. Finally, without a multidisciplinary team, the experience and knowledge of all of the care-giving team cannot be accessed.
A concrete example convinced us of the gaps in the movement of information with this client. A hydraulic bench had been installed in her home to reduce the risk of back injuries during the assisted transfer of the user to the bath. However, it was four years later that one of the home-support and social aid workers visiting the home reported to the occupational therapist that the woman refused to use this equipment: the visiting home-support and social aid workers partially supported this heavyset client, thus making their work hazardous. Once this was known, a new transfer procedure to the bath was introduced. This clearly illustrates the impossibility of the CLSC to prevent all hazardous situations because, in this case, the expected problems involved back efforts. Given the lack of updating of the file, it was practically impossible to see what would happen and to prevent the upper limb injuries.
A similar complex issue was observed within a multidisciplinary team from CLSC #3. This problem was eliminated by an in-depth case discussion that included all of the caregivers involved. Also, debriefing/solution-finding sessions helped solve this problem by allowing the care-giving personnel to: 1- state their experiences and express their feelings; 2- develop a common understanding of the problem; 3- reframe the mandate of home care services and its personnel; 4- develop common intervention strategies. In this CLSC, no cases of occupational accidents occurred.
Below is a more specific analysis of the qualitative contributions of multidisciplinary
2 The existence of a work group can be recognized by the presence of informal work rules that the members of the group establish for themselves and that allow technical, logistical and affective support to be provided in the work.
work in order to attempt to understand why these meetings are important for OHS.
As already stated, CLSC #2 has two methods of operation. In one sector, there are weekly multidisciplinary meetings, bringing together all the professionals available in the sector. In the other geographical sectors served by the home care services, there are “sector meetings”, but these are completely different. The professionals are available in their offices to receive the visiting home-support and social aid workers and other caregivers; these meetings are in fact a succession of visits in which only two people talk at a time. A one-hour time slot is provided per week for these meetings.
Multidisciplinary team meetings
During the three multidisciplinary team meetings observed, 37 case discussions took place, or an average of 12 per meeting. Overall, 65% of these case discussions (24) were requested by the visiting home-support and social aid workers, five by the occupational therapist, and four by the nurses and social workers, respectively. Also, for the 13 case discussions initiated by the professionals, the visiting home-support and social aid workers were the main providers of information.
During the multidisciplinary meetings, 4.5 minutes on average were devoted to each case discussion. The analysis reveals that 67.6% of the meetings (25) involved three or more direct speakers, not counting the other participants who witnessed the discussion and benefited from the exchanged information. Also, of the total 37 client situations dealt with, only three could not be corrected because the professionals in charge were absent. These meetings, with an average of less than 5 minutes per case, can be considered effective because they not only solve the problem cases because a position is taken, but allow many members of the care-giving team to benefit from updated information.
The topics addressed during these case discussions are very diverse. They involve the client, his network, his physical and psychological health and his physical and psychosocial environment, the worker in her task and her health, the care provided and the intervention undertaken with the client, and the relationship between the worker and the client. Also on the agenda are the equipment and work methods, coordination with the care-giving team, the reassessment of cases, the planning of services, as well as work organization.
These discussions also produce many results. Among others, they allow:
- updating of the information in the files of the professionals responsible for the clients regarding the situation at home. The information can either be about the change in the user’s or helper’s physical health and psychological health, or about the medication and its effects, or about the physical environment (architectural barriers and equipment);
- communication tools to be implemented for the other caregivers who visit the home;
- training in the use of the equipment, an exchange on the personnel’s different work practices and methods;
- improvement in coordination (between the different professionals as well as
with the casual help) and in the planning of visits and follow-up to be done to the file;
- a common position by the entire team on certain more complex and difficult files;
- valorization of the homecare professionals and particularly the enhancement of the role of the visiting homesupport and social aid workers, thus giving value to their work;
- implementation of organizational means to stop certain problems before they become too complex or serious (updating of service plans and user profiles, policy on cigarettes, etc.).
A meeting called the “sector meeting” at the home care services was observed. As already stated, these meetings consist of successive visits of the visiting home-support and social aid workers to the offices of the professionals in charge of the files when there is something to discuss. One hour per week is available. In fact, the observed visiting home-support and social aid worker remained only 30 minutes at the CLSC because he had a client to visit afterwards. During his visit to the CLSC, he had:
- two case discussions during informal hallway meetings with a nurse and a social worker;
- two case discussions with a nurse in her office;
- one case discussion with a social worker in her office;
- three missed visits because the social workers were not in their offices. He therefore had to plan for another meeting, which would take place when he picked up his schedule.
The visiting home-support and social aid worker was able to discuss three of the six situations that he had planned to discuss, or half of them. Furthermore, two informal meetings with a nurse and a social worker also took place. Each discussion lasted an average of 6 minutes, which is more than the average time spent on each client with the multidisciplinary team.
Based on an analysis of a meeting with a nurse about a difficult situation with a client, this type of case discussion can be compared with those observed in the multidisciplinary team. Following an observation made by the nurse concerning the questionable cleanliness of some of the client’s clothes, the visiting home-support and social aid worker provided a lot of information about his health, diet, the services offered, and told the nurse about the high rotation of visiting home-support and social aid workers with this client. Finally, the visiting home-support and social aid worker provided information on his way of working with this man, and the methods that enable him to successfully change his dirty clothing. He shared his tricks and strategies and together they drew up an intervention plan. This clearly demonstrates the advantages that a multidisciplinary meeting would have from several viewpoints: the sharing of information on a particular case for the different caregivers; the exchange of work strategies; the implementation of a service plan that would better meet the client’s needs and the many objectives of the caregivers, including the visiting home- support and social aid workers.
DISCUSSION AND CONCLUSION
In the current context of an increase in clientele with increasingly complex health requirements, and chronic problems that may include important socioeconomic aspects, a single professional can no longer grasp the situations encountered in the home. Contrary to the current trend, interdisciplinary collaboration must be encouraged, as underlined by D’Amour et al. (1999). These authors mainly reveal the importance of promoting what they call “interiorization”, which consists of improving the professionals’ knowledge of each other, the sharing of each discipline’s territories, and the use of an interprofessional reference framework. Analysis of the observed multidisciplinary meetings shows how these meetings promote this interprofessional interiorization work.
In several respects, our study shows the OHS issues underlying this multidisciplinary work. In fact, the example of the many accidents that several visiting home-support and social aid workers had with the same client shows the OHS-related cost of a lack of articulation, coordination and support of the work group. On this subject, our results agree with those of the Seifert and Messing study (2004) on the effects of discontinuous schedules on the work activity of nurses in a short-term hospital. We also show that OHS is supported in different ways by professional exchanges. Among other things, these exchanges promote the recognition and valorization of the work that the different caregivers do in homes. Furthermore, this recognition and valorization are particularly important for mental health, as shown by several studies on hospital personnel (Carpentier-Roy 1991; Bourbonnais et al., 1998; Bourbonnais, Mondor, 2001; Cognet, 2002). Moreover, we also show that interprofessional exchanges encourage coordination between the different caregivers that reduces the time constraints, and consequently has an impact on the health of the personnel, as demonstrated by many ergonomic studies and investigations on working conditions (e.g., Cloutier, 1994; Gaudart, Laville, 1995; Gollac, Volkoff, 2000; Puéyo, 2001).
This study is particularly detailed regarding the contributions of intradisciplinary and interdisciplinary exchanges as well as the development of protective work strategies between caregivers. The ergonomic process integrates into its methodology a collective result-restitution phase which always allows extremely fruitful exchanges to be created in terms of professional know-how, which are useful in maintaining health (Guérin et al., 1991; Teiger et al., 1998). However, to our knowledge, very little work has considered this question from the multidisciplinary standpoint, as we have done.
Also, work with a living person, which is specific to service jobs, benefits from the protective role of the interdisciplinary group because it allows personnel to develop common rules and to set limits to the care provided (Cognet, 2002).
Finally, we want to emphasize the fact that our study shows that work organization plays a determinant role in the OHS of care-giving personnel because it may or may not promote interdisciplinary work. The possibility of contrasting two different methods of operation in the same CLSC has provided many lessons on this subject.
The current trend in the health sector towards the increasing merger of different institutions in order to facilitate the continuity of services introduces enormous management challenges that may have major repercussions on OHS. In fact, the increase in the size of establishments may threaten interdisciplinary operation, which is more difficult for large teams. Creative scenarios will have to be conceived. Reflection will be needed on the types of case discussions in large or small groups in order to maximize the use of working time at the CLSC. It will also be needed on the division
of the territory covered by the home care services into several subsectors that would allow teams to be created whose size would promote multidisciplinary exchanges.
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