The impact of integrated care on direct nursing home care

Available online at www.sciencedirect.com

Health Policy 85 (2008) 45–59

The impact of integrated care on direct nursing home care Aggie T.G. Paulus ∗ , Arno J.A. van Raak 1 University of Maastricht, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Department of Health Organization, Policy and Economics (HOPE), P.O. Box 616, 6200 MD Maastricht, The Netherlands

Abstract Background/aim: The introduction of integrated nursing home care is an important policy goal in many countries and is expected to affect the type, frequency and duration of activities delivered to nursing home residents. The exact impact however is unknown. The aim of this paper is to reduce this information gap in order to provide decision supporting information to policy makers and managers. Design/methods/ethical issues: At three measurement points between 1999 and 2003, caregivers belonging to 18 functions registered activities delivered to somatic and psycho-geriatric nursing home residents in The Netherlands. Residents either received traditional care, integrated care or care that contained elements of traditional and integrated care (hybrid care). Thirtysix thousand and seventy-one registration lists were used for data analysis. Data analysis included determining, comparing and linking the (total) average frequency and duration of each activity per care type, measurement point and type of resident. Results: The (total) average frequency and total duration of most activities were higher for integrated care than for traditional and hybrid care. The average duration per activity was generally higher for traditional care. The (total) average frequency of most direct care activities at most measurement points and the total average duration per resident per day were higher for somatic care than for psycho-geriatric care. Conclusions: The introduction of integrated nursing home care affects the total average duration and frequency of direct care activities. However, there is no noticeable impact on individual activities or on differences in activities received by somatic and psycho-geriatric residents and the degree to which the occurrence of an activity is related to the duration of that activity. This is because a large proportion of care delivery represents patterned behaviour (routines). Because existing routines are difficult to get rid of, we should not have too high expectations about the effect of integrated care on service delivery. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Integrated care; Traditional care; Nursing home care; Time spent on residents; Activities; Routines; Somatic care; Psycho-geriatric care

1. Background ∗ Corresponding author. Tel.: +31 43 3881706; fax: +31 43 3670960. E-mail addresses: [email protected] (A.T.G. Paulus), [email protected] (A.J.A. van Raak). 1 Tel.: +31 43 3881699; fax: +31 43 3670960.

In many countries, health care policy is increasingly aimed at replacing traditional nursing home care with integrated care [1,2]. In its general use, the term integrated care refers to “. . .a coherent and co-ordinated set

0168-8510/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2007.05.014

46

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

of services which are planned, managed and delivered to individual service users across a range of organizations and by a range of co-operating professionals and informal carers. It covers the full spectrum of health and health care-related social care” [3]. Applied to nursing home care, integrated care refers to a demand-oriented delivery of services (i.e. the demand of residents dictates what is delivered, when, how often, how long and by whom) by caregivers with different disciplinary backgrounds. Caregivers have to cooperate and coordinate the provision of services in order to meet the demand of residents in an environment in which specific features of the home situation (e.g. residents being engaged in daily activities such as cooking and cleaning or joining social group activities) are copied in nursing home care [4,5]. Traditional nursing home care, on the contrary, is supply oriented (i.e. caregivers dictate what is delivered, when, how often, how long, etc.), mono-disciplinary and requires no integrated – thus cooperative or coordinated – actions from caregivers or adaptations of service delivery to a home-like environment. Due to the differences between traditional and integrated care, a transition process will generally precede the formation of integrated care. During this process, nursing homes offer hybrid care, i.e. nursing home care which contains elements of both traditional and integrated care [5,6]. The process of care delivery clearly differs between traditional and integrated care. Compared to traditional nursing home care, the process of integrated care delivery is tailor-made and thus directly aimed at the individual needs and wants of residents [3,7]. The part of the service delivery that is primarily related to activities directly conducted for individual residents is known as direct care. Well-known examples are morning care, toileting and medication. Direct care is often considered a desired goal in nursing care [8]. Due to its focus on activities desired by individual residents, it can be expected that integrated care will affect direct care delivery [9]. However, studies on nursing home care activities are limited [10]. Available research shows that the duration of many direct care activities (which are often irregular) seems to depend on the type of patients (e.g. patients with psycho-geriatric or somatic needs) or resident case mix levels [11–13]. Research also suggests that the frequency of individual nursing activities is often related to the total amount of time spent on (i.e. the duration of) these activities [10,14].

However, we observed that it is still largely unknown whether this is true for various types of nursing home care or different types of nursing home residents and will change as a result of the introduction of integrated care [6,15,16]. Given this lack of knowledge, we therefore investigated the following questions: 1. Compared to traditional and hybrid nursing home care, what is the impact of integrated care on how frequently (somatic and psycho-geriatric) residents receive direct care activities? 2. Compared to traditional and hybrid nursing home care, what is the impact of integrated care on the duration of direct care activities? 3. Compared to traditional and hybrid nursing home care, what is the impact of integrated care on the relationship between the frequency and duration of direct care activities? From a policy point of view, providing answers to these questions is relevant for different reasons. First, duration and frequency are generally considered as important cost-drivers in the delivery of services [17,18]. If integrated care leads to changes in the duration and/or frequency of direct care activities, our analysis may indicate whether this type of care has a cost-saving potential. Secondly, if integrated care leads to a totally different pattern of direct care delivery, policy makers and managers need to know these differences in order to efficiently allocate nursing time and make decisions with respect to manpower planning, resource utilization and improvements in the quality and productivity of work and the quality of care [16,19–21]. Finally, even if integrated care does not lead to a different pattern of direct care delivery in comparison to traditional care, our analysis may indicate that this is because of the perseverance of certain ‘routines’ in the delivery of nursing home care. These repetitive, recognizable patterns of interdependent actions performed by multiple agents [22,23] could indicate that different types of care for different types of residents are not altogether that different. As we will show in our discussion, if routines are present, this has important consequences for the implementation of integrated care, which to date are underexposed. The paper starts with a brief summary of our theoretical and methodological framework. Then, the results are shown. The result section is divided into three parts, each dedicated to one of the research questions. Finally,

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

the main conclusions are shown, followed by a discussion of the findings and limitations of the study. 1.1. Theory on direct care Direct care refers to ‘nursing activities that are patient-centred and that take place in the presence of the patient and/or family’ [9,24]. Direct care is one of the four groups of nursing activities, which also include indirect care, unit-related care and personal activities [9,24]. Direct care consists of different activities to which caregivers (depending on their roles and responsibilities) have to allocate their time during working hours [25,26]. Since time is a scarce resource, the delivery of each activity has opportunity costs: time spent on one activity is time not spent on another activity. The time spent on one activity depends on how long it takes to deliver that particular activity and how often that specific activity has to be provided during a particular time unit. Ceteris paribus, an activity which lasts longer and takes place more frequently within a restricted timeunit is more time-consuming than an activity with a shorter duration and a lower frequency. The duration and frequency of direct care activities can be considered from the perspective of the provider (i.e. the organization or caregiver) and/or the consumer (i.e. the patient, client or resident). In the first perspective, task analysis in terms of how long and how often a particular caregiver delivers a specific activity is the main underlying goal [10]. In the second perspective, the delivery process is reviewed in order to determine how much direct care a consumer receives per time-unit and how often [27,28]. Most studies (e.g. time and motion studies and work-sampling studies [29,30]) focus on the first perspective and generally neglect the second one [31]. In this study we analysed duration from both perspectives and frequency from the perspective of the resident. Studies indicate that the frequency and duration of (direct) nursing care activities are closely correlated [10,14] and influenced by such factors as the methods of care provision [32], caregiver characteristics [33,34], patient characteristics [11–13] and the organizational structure [35]. A study by Lundgren and Segesten [9] with respect to a medical-surgical ward, for instance, showed that changing the staffing pattern through the introduction of a patient focused system

47

of nursing delivery increased the time used for direct care. However, the same study also showed that it took time for caregivers to change their routines with respect to direct care delivery [9]. Authors agree that it is difficult to change routines [36] because they are bound by rules [37]. This may imply that, for change in routines to occur, these rules are a stumbling block and they should be changed [36]. The concept of routines is relevant for health care and nursing in particular, because a large part of the care providers’ work is performed through routines [20,37–39]. When a nursing home intents to introduce the concept of integrated care (i.e. a new routine) this will require change of existing routines.

2. Methods 2.1. Design Since the introduction of integrated nursing home care is unmistakably present in The Netherlands [27], we have chosen this country for our analysis. Our study took place between September 1999 and February 2003. To be able to uncover possible differences between various types of care and in order to obtain a spread which is indicative for nursing home care in The Netherlands, we selected three nursing homes. They offered either traditional care (A), ‘hybrid’ care (B) or integrated care (C). ‘Hybrid’ care refers to nursing home care which contains elements of both traditional and integrated care. The differences between traditional and integrated nursing home care were related to the presence of the following five dimensions in the latter type of care: • a demand-oriented supply structure; • a home-like environment in the nursing home (e.g. wards that were furnished and decorated to make them comparable with a home-setting and engaging residents in daily activities such as doing the laundry); • a limited number of residents per ward (to mimic the home situation, the number of residents per ward was limited to a maximum of 12); • social group activities for residents (both in- and outside the nursing home);

48

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

• a coordinated care delivery by co-operating caregivers with different disciplinary backgrounds. Selection of the nursing homes took place on the basis of criteria that included comparability of size, a stable working environment, motivation to contribute to the research and being indicative for that specific type of nursing home care in The Netherlands. In addition, different types of residents had to be present. In The Netherlands, these types generally include somatic residents (i.e. people with mainly physical/physiological problems) and psycho-geriatric residents [27]. We purposefully chose three nursing homes that fulfilled all criteria. One nursing home, with 121 beds and 2 somatic care wards and 2 psycho-geriatric care wards, was selected as the ‘A’-setting. This setting represents a nursing home that delivered traditional nursing home care during the entire research period. Another nursing home (with 141 beds and 3 somatic care wards and 2 psycho-geriatric care wards), which delivered comparable traditional care at the beginning of the research, was selected as the ‘B’-setting’. This nursing home delivered ‘hybrid’ care. Here, integrated nursing home care (with the five dimensions indicated above) was gradually implemented during the research period. Finally, a nursing home (with 88 beds and 3 participating wards (with 28 beds; 2 somatic care wards and 1 psycho-geriatric care ward) was selected as the ‘C’setting. This nursing home delivered integrated nursing home care since March 1998. 2.2. Data collection During the period 1999–2003, for all types of nursing home care, data were collected once (May/June 2000) before implementation and twice afterwards (6 and 14 months after implementation, which took place in the ‘B’-setting in March 2001). Approval to conduct the study was obtained from the relevant ethics committees in the nursing homes. Data were obtained from formal caregivers, who recorded the direct care activities employed for individual residents. Caregivers recorded activities on forms that listed 14 different activities (e.g. evening care; meal activities), which were customary for nursing home care in The Netherlands. The selection of these activities was based on a literature study, interviews with caregivers in nursing homes throughout the country and observations

in nursing homes that offered traditional or integrated care. Table 1 gives an overview of the activities and the number of times they were registered. During each of the 3 measurement points, each lasting 14 consecutive days (14 × 24 h), caregivers recorded the type of activity performed for residents and the frequency and duration of each activity. In total, 36071 forms were subjected to data analysis (see Table 1 for further details). All somatic (som) and psycho-geriatric (pg) residents had average dependency scores between 7 and 9.5 (on a scale from 1 to 12). The higher the dependency score, the more help the resident needed from carers. In the A-setting, at each measurement period, activities were registered for 84; 89 and 98 residents, respectively. In the B- and C-setting, these numbers were 101; 91; 97 and 25; 23 and 26, respectively. Caregivers in the nursing homes belonged to 18 functions. These categories ranged from various types of nurses to household assistants and aids. Volunteers were also included as caregivers. Table 2 specifies all functions. 2.3. Data analysis All data were put into a SPSS 10.0 data file. The basic units of analysis were the frequency and duration of the direct care activities mentioned in Table 1. Frequency was considered from the consumer’s point of view. From this point of view, frequency refers to the average number of times a nursing home resident obtained a particular activity per day. This frequency was calculated as follows. First, the total number of times a particular activity was registered during a specific measurement point for a specific type of resident was determined (e.g. suppose medication was registered 300 times for somatic residents at the first measurement point). Then, the average number of times that activity was registered per day was calculated. Since each measurement took 14 days, the average was the total number divided by 14 (thus 300/14 = 21.42). This number indicates that medication on average was delivered more than 21 times a day. Then, per measurement point, the number of residents was determined (e.g. 10 somatic residents). With 10 residents and an activity that is delivered more than 21 times a day, this means that each somatic resident on average received this activity more than twice a day

Table 1 Registered direct care activities Activity

Morning care

Coffee/tea-activities Medication

Afternoon care

Extra care

Evening care Meal activities Medical Care General activities Social group activities Transfer/transport

Incidental care

Additional direct Activities

Residents receiving help with getting out of bed, bathing, dressing, shaving, getting their hair combed in the morning Residents receiving activities related to the making and pouring out coffee and tea, doing the dishes, cleaning up Residents receiving activities related to medication (e.g. help with medication) Residents receiving help if they need to go to the bathroom, a change incontinence slips, or help with emptying catheters Residents receiving help with getting in or out of bed, getting (un)dressed, getting their hair combed in the afternoon Getting extra attention through conversations, walking or shopping, extra pedicure or hair treatment, ‘snooze activities’ (“snoezelen”: activating and stimulating primary senses such as hearing, smelling, taste) Residents receiving help with getting to bed, bathing, cleaning teeth and dentures in the evening Helping residents with eating, doing the dishes, setting the table Taking care of wounds, catheterise, medical treatments, etc. Activities such as pottering, singing, playing games and cleaning up afterwards Preparing and doing social activities in groups (e.g. a choir or bridge-club) Helping residents to or back from a particular social activities meeting ward or room for general activities or appointments Taking care of residents in case of extra-ordinary events (e.g. a sudden change in health, aggressive behaviour towards other residents or staff) Activities other than those mentioned above such as: Caregivers buying extra food or clothing or doing the Laundry for a particular resident

Care type AT1a (4012b )

AT2 (4898)

AT3 (5591)

BT1 (5988)

BT2 (5798)

BT3 (4535)

1299c

1265

1488

1422

1443

1396

374

389

396

288

278

414

537

535

449

168

182

218

907

1032

1320

2330

1849

1145

898

590

938

1594

1716

2095

1869

1959

1368

1114

946

996

160

182

224

722

799

606

179

263

245

265

559

702

457

699

407

133

323

440

1337

1435

1489

1398

1384

1236

319

339

418

942

1411

1585

2841

2991

2072

912

975

1114

628

509

953

736

462

259

191

222

163

173

279

172

88

46

103

128

56

64

0

4

4

0

4

3

6

8

4

846

1497

1851

1304

1332

1222

309

203

228

45

65

86

125

231

134

55

124

113

243

262

240

513

284

279

155

158

230

CT1 (1769)

CT2 (1623)

CT3 (1857)

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

Toileting

Description

Source: data in table from original research by authors; presentation of data and translated terms partly based on Paulus et al. (2003; 2006). a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point. b # number of registration lists filled in by caregivers (in total 36071 lists). c The numbers in the table refer to the absolute number of times that a particularly activity was registered by caregivers at the specific measurement point (e.g. at the first measurement point, the activity ‘morning care’ was registered 1299 times in traditional home care). 49

50

Table 2 Function categories: description and absolute number of participants Regular term in The Netherlands

Nature of the work

Licensed practical nurse

Ziekenverzorgende Niveau 3

Geriatric nurse

Bejaardenverzorgende Niveau 2

Registered nurse

Verpleegkundige niveau 4

(Ward) assistant

Afdelingsassistent niveau 1

Evening/night/weekend manager

ANW-hoofd

Night duty watcher

Zwerfwacht

Recreational activities supervisor

Activiteitenbegeleider

Nutrition assistant

Voedingsassistent

Household assistant Living room assistant

Huishoud(elijk) assistant Huiskamerassistent

Hostess

Gastvrouw

Student nurse

Leerling

Trainee

Stagiaire

Volunteer

Vrijwilliger

Nursing assistant

Zorgassistent

Nursing care coordinator

Zorgco¨ordinator

Aid

Helpende

Kitchen assistant

Keukenassistent

Basic bedside care, monitoring and changing catheters, treat bedsores, etc. Household work, physical care, assisting with meals, bathing, administering medicine, consultation with registered nurse, etc. Direct patient care (treatment, observing and recording symptoms and progress in patients); administering medications; supervising student nurses, trainees, etc. Administrative activities other than those performed by the registered nurse Supervises nursing personnel, is responsible for treatments and, if necessary, also employs nursing activities Is on duty during night-shifts and, on call, performs nursing and supervisory activities Offers and employs a variety of activities (games, art, craft, music) for nursing home residents Takes care of food and drinks, serves meals, helps residents with meals and consults with dietician Supports and assists in household activities Provides extra care to residents (e.g. through reading with or talking to residents) Assists activities in nursing home restaurants (e.g. receiving guests, setting the table, etc.) To gain job experience, supports or assists registered or licensed practical nurse Students who during their internship support certain activities (e.g. those by the recreational supervisor) Unpaid persons who assist in meals, having coffee/tea, shopping, recreational activities) Supports in basic bedside care under supervision of a licensed nurse Coordinates, administrates and manages activities including planning of personnel and also performs nursing activities Perform tasks under the supervision of nursing staff; serving meals, making beds, take temperatures, etc. Assists in preparing meals and transports meals to wards or restaurant

Total

AT1a

AT2

AT3

BT1

BT2

BT3

CT1

CT2

CT3

79

73

68

93

79

72

20

21

28

1

–

10

11

12

13

11

9

7

–

1

–

1

1

–

3

1

1

–

3

1

16

17

20

–

–

–

8

7

10

10

10

9

3

8

5

–

–

–

4

5

3

–

–

–

6

5

7

7

6

7

2

2

2

3

4

1

16

14

19

6

5

6

– –

– 3

– 7

14 2

16 5

15 4

5 –

5 –

5 –

–

–

–

–

–

1

–

–

–

11

7

7

3

3

13

2

3

1

–

7

–

1

6

1

–

1

1

24

26

27

58

49

59

11

10

11

–

–

1

–

–

–

3

7

6

16

12

8

–

–

–

–

–

–

2

7

7

–

–

–

–

–

–

5

7

9

–

–

–

–

–

–

155

154

163

236

223

236

66

72

73

Source: data in table from original research by authors; presentation of data and translated terms partly based on Paulus et al. (2003; 2006). a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point.

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

English term

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

(21.42: 10 = 2.14). The latter number indicates the average frequency, which is summarized for all types of residents and types of nursing home care in Table 3. The duration indicates how long, in terms of minutes, a particular activity on average lasted. Duration was considered first from the provider’s point of view. For each registration, caregivers had to indicate how many minutes the activity took place per resident. The total number of minutes registered (e.g. 1500) was divided by the number of times that activity was registered (e.g. 300) in order to determine the average duration per activity (5 min for medication for somatic residents). These averages are summarized in Table 4. The last row of this table, however, considers duration from the resident’s perspective and indicates the total average duration of direct care received per resident per day (e.g. 80 min/day). This average was calculated as the summation of the total duration of direct care per resident per day during the registration period (e.g. 1120 min) divided by the number of registration days (e.g. 14 days). The analysis then proceeded in different steps. First, per measurement point, per type of nursing home care and per type of resident (somatic and psycho-geriatric), the average frequency and duration were determined. Per activity (e.g. morning care) and per set of activities per measurement point (e.g. all activities in A at the first measurement point) also standard deviations (S.D.) were determined (see Tables 3 and 4). Then, the duration, frequency and activities were compared per type of nursing home care, per measurement point and per type of resident. A one-sample t-test (α = 5%) was performed (see Tables 3 and 4), using SPSS 10.0. Finally, the relationship between the frequency and duration of activities was determined and compared for the different types of nursing home care and residents. On the basis of all comparisons, the most important similarities and differences between all care types as well as the impact of integrated care on direct care delivery were determined.

3. Results

51

Fig. 1. Average frequency direct care activities. Legend—Som: somatic residents; PG: psycho-geriatric residents; T1: first measurement point; T2: second measurement point; T3: third measurement point.

ing home resident obtained a particular activity per day. A score of 1 for instance indicates that this particular activity on average is received once per day. A score of 0.50 indicates that a resident obtained that activity once per 2 days. 3.1.1. Activities The table shows that meal activities, toileting, medication, morning- and evening care and transfer/transport had the highest average frequency. A resident, for instance, on average received between 0.614 and 3.531 activities related to toileting per day. Social group activities were part of the activities with the lowest frequency. On average, a nursing home resident obtained between 5.8 and 16.3 direct care activities in total per day. 3.1.2. Changes over time Over time, the average frequency showed significant changes mainly for extra care, general activities, medication, meal activities and additional direct activities. Most of these changes occurred between the first and third measurement point (T1 and T3, respectively). Except for general activities, afternoon care and evening care, the average frequency of activities significantly increased over time.

3.1. Frequency Table 3 indicates the average frequency of the direct care activities, i.e. the average number of times a nurs-

3.1.3. Differences between care types Fig. 1 shows the average frequency of the set of 14 activities. Integrated care had higher average fre-

52

Table 3 Average frequency of direct care activities received by nursing home residents per day Activities

AT1a

AT2

AT3

BT1

BT2

PG 1.139 0.050 0.411 0.614 0.097 0.242 1.281† 0.575 0.402 0.196* 0.000 0.569 0.031 0.274 0.420 (0.39)

Som 0.944 0.104 1.291 2.011 0.203 0.528 1.058 0.505 0.339 0.256* 0.001 1.070 0.017 0.209 0.591 (0.60)

PG 1.126 0.071 0.425 0.787 0.097 0.289 1.266 1.080 0.453 0.215* 0.005 1.341† 0.077 0.204 0.531 (0.48)

Som 1.126 0.130 1.223 2.082* 0.281 0.412 1.032* 0.702 0.641* 0.086 0.005 0.902* 0.686 0.122 0.673 (0.57)

PG 1.047 0.127 0.747* 1.135 0.084 0.563* 1.068 0.866 0.734* 0.144 0.001 1.584* 0.055 0.201* 0.596 (0.50)

Som 1.087 0.113 2.581* 1.675 0.671* 0.529* 0.889 2.361* 0.648 0.099 0.000 0.843 0.147 0.567* 0.872 (0.81)

PG 0.974 0.115 0.913* 1.071* 0.378* 0.182 1.111** 0.972* 0.493 0.036 0.000 1.017* 0.055 0.225 0.538 (0.44)

Som 1.143* 0.101 2.244* 1.766 0.857* 0.796 1.027 2.667* 0.452 0.052 0.006 0.703 0.280* 0.243 0.881 (0.83)

PG 1.074 0.136 0.635* 1.281* 0.394* 0.295 1.132 1.086 0.259 0.019 0.001 1.333** 0.075 0.218 0.567 (0.50)

Total average frequency direct care activities

8.702

5.881

8.535

7.436

9.430

8.356

12.210

7.542

12.337

7.938

Activities

BT3

Morning care Coffee/tea-activity Medication Toileting Afternoon care Extra care Evening care Meal activities Medical care General activities Social group activities Transfer/transport Incidental care Additional direct activities Average frequency of an activity (standard deviation)

Morning care Coffee/tea-activity Medication Toileting Afternoon care Extra care Evening care Meal activities Medical care General activities Social group activities Transfer/transport Incidental care Additional direct activities Average frequency of an activity (standard deviation)

Som 0.982 0.085 1.564 1.293 0.615 0.430 0.822 1.177 0.321 0.082 0.006 0.534 0.129 0.444 0.606 (0.49)

CT1 PG 1.176 0.094 0.488 0.918 0.402* 0.283 1.046 1.109 0.147 0.082 0.000 1.198 0.104 0.100 0.510 (0.47)

Som 1.076 0.385 2.728† 3.308** 0.469 0.424 0.973 2.134† 0.661 0.286** , † 0.023 0.888 0.116 0.518† 0.962 (1.03)

CT2 PG 1.048 0.556 2.270** , † 2.968** , † 0.587** 0.278 0.794 3.159† 0.341 0.508** , † 0.008 0.865 0.230 0.302 0.993 (1.03)

Som 1.188 0.172 2.058† 2.705 0.755† 1.071† 1.054 2.187† 0.638† 0.138** 0.004 0.661 0.313† 0.433** , † 0.955 (0.83)

CT3 PG 1.276 0.643 1.296** , † 3.531** , † 0.959 0.867** , † 1.071 3.736** 0.827 0.265 0.082 0.561** 0.561† 0.633** , † 1.16 (1.10)

Som 1.183** 0.267 3.005** , † 2.962** 0.831 1.579** , † 1.277** 2.859** , † 0.537 0.080 0.008 0.564 0.285 0.621† 1.14 (1.07)

Average per activity (S.D.) PG 0.967 0.421 1.636** , † 2.124** 0.271 0.495 0.917 2.624 0.276 0.510 0.029 0.933 0.548 0.750** , † 0.892 (0.74)

1.1 (0.1) 0.2 (0.2) 1.5 (0.8) 1.9 (0.9) 0.5 (0.3) 0.5 (0.4) 1.0 (0.1) 1.7 (1.0) 0.5 (0.2) 0.2 (0.2) 0.009 (0.2) 0.9 (0.3) 0.2 (0.2) 0.3 (0.2) 0.7 (0.2) (0.51)

Total average frequency direct care activities 8.484 7.147 13.989 13.914 13.377 16.308 16.058 12.501 10.578 Values in italic: value not significant at alpha = 5% (two-sided test). Values underlined: significant change in comparison to first measurement point of same nursing home care type. a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point; Som: somatic residents; PG: psycho-geriatric residents. * Significant difference between A and B (* indicates that the average frequency of that specific activity in that specific care type is significantly higher for that specific measurement point). ** Significant difference between B and C (** indicates that the average frequency of that specific activity in that specific care type is significantly higher for that specific measurement point). † Significant difference between A and C († indicates that the average frequency of that specific activity in that specific care type is significantly higher for that specific measurement point).

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

Som 1.017 0.133 1.189 2.240 0.209 0.279 1.073 0.581 0.715 0.109 0.000 0.961 0.046 0.150 0.621 (0.62)

Table 4 Average duration per direct care activity (in min) Activities

Total average duration per resident per day Activities

Morning care Coffee/tea-activity Medication Toileting Afternoon care Extra care Evening care Meal activities Medical care General activities Social group activities Transfer/transport Incidental care Additional direct activities Average duration of an activity (standard deviation)

AT2

AT3

BT1

BT2

Som 19.20* 20.89† 3.86* 5.45 11.41 6.25 12.27 4.59 4.86 56.01* , † – 4.44* 8.63 6.47 11.73 (14.02)

PG 17.10 28.99† 3.37* , † 5.22 11.41* 7.53 11.67 7.54* 6.39* , † 87.29* , † – 3.24* 15.00* 3.07 14.84 (22.13)

Som 20.67* 24.33* 5.28* , † 6.68† 13.49* , † 7.25 14.20 5.15 6.96 69.46* , † 10.00 5.52* , † 9.08 7.40 14.67 (16.82)

PG 17.05 31.62† 4.29* , † 4.71 11.29* 5.10 11.84 9.04* , † 5.36* 69.93* , † 50.00 3.11 12.94† 8.35† 17.47 (19.80)

Som 15.09 21.21† 4.64* , † 6.15† 10.12† 7.41† 11.06 7.60* 7.65* , † 27.27† 6.25 4.71† 9.32 9.25 10.05 (4.92)

PG 17.19 35.21* , † 3.49 5.12 11.31 6.00 13.04 7.41* 4.62 56.58† 30.00 3.39 9.78 6.67 14.98 (15.42)

Som 16.36 17.91 2.86 5.20 9.98 6.61 12.06 5.19 4.57 26.01 – 3.03 7.19 6.34 8.80 (7.08)

PG 17.03 26.49** 2.47 6.15* 7.88 6.56 12.49* 5.28 5.09 49.30** – 2.33 5.21 6.79* 10.93 (12.96)

Som 16.99 18.83 3.71** 6.47** 11.20 7.76 13.38 6.02* 6.41 14.47 8.75 0.82 2.37 1.85 8.50 (5.71)

PG 16.61 23.58** 3.21** 6.05* , ** 9.23 6.25* 12.69* 5.96 3.90 43.54** 50.00 3.13 7.45 8.72** 14.30 (14.89)

74.21

70.83

90.92

81.39*

75.05

72.61

83.77

61.93

100.08

65.45

PG 16.53 25.63 3.63 5.72* 10.27 10.80* 12.83 6.16 6.74* 58.30** – 3.18 10.45 17.49* 13.40 (14.55)

Som 23.65** , † 14.32 3.86** 5.82** 10.77 8.80† 14.51** , † 8.23** , † 7.03** , † 27.04 54.00 4.17** 6.81 13.87** , † 14.49 (13.29)

BT3 Som 16.07 24.32** 3.69** 6.07** 9.88** 8.66** 13.34* 4.06 5.73 47.36** 37.33 5.17 7.07 7.99 14.05 (13.33)

CT1

CT2 PG 19.25** , † 10.32 2.62 5.56 9.53** 10.07 12.78 6.70** 4.21 17.07 20.00 7.81** , † 6.34 9.78† 10.14 (5.40)

Som 22.00** 19.85 3.30 5.51 10.29 6.63 14.11 6.89** , † 5.83 25.27 5.00 3.80 5.90 6.87 10.08 (7.25)

CT3 PG 19.48** , † 11.05 2.42 5.13 10.91 5.31 13.56 6.70 6.13** 13.98 41.57 4.22** , † 5.60 4.90 10.78 (10.06)

Som 20.95** , † 14.81 2.76 5.28 8.64 5.89 13.67† 6.00** 4.83 8.59 25.00 3.35 6.04 6.80 9.47 (6.71)

Average per activity (S.D.) PG 21.06** , † 17.74 3.54 6.88** , † 11.96 8.55 13.92 7.69** 5.00 13.36 8.50 3.87 7.70 11.06† 10.05 (5.13)

18.4 (2.4) 21.5 (6.8) 3.5 (0.7) 5.7 (0.6) 10.5 (1.3) 7.3 (1.6) 13.0 (1.0) 6.4 (1.3) 5.5 (1.0) 40.2 (23.9) 19.2 (19.7) 3.8 (1.5) 7.9 (2.9) 8.0 (3.6) 12.2 (2.6) (9.79)

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

Morning care Coffee/tea-activity Medication Toileting Afternoon care Extra care Evening care Meal activities Medical care General activities Social group activities Transfer/transport Incidental care Additional direct activities Average duration of an activity (standard deviation)

AT1a

Total average duration per resident per day 71.05 73.77 126.75** , † 105.71** 120.73† 123.50 117.81** , † 111.66** , † 90.40 Values in italic: non significant value (p-value > 0.05). Values underlined: significant change in comparison to first measurement point of same nursing home care type. a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point; Som: somatic residents; PG: psycho-geriatric residents. * Significant difference between A and B (* indicates that the average duration of that specific activity in that specific care type is significantly longer for that specific measurement point). ** Significant difference between B and C (** indicates that the average duration of that specific activity in that care type is significantly longer for that specific measurement point). † Significant difference between A and C († indicates that the average duration of that specific activity in that specific care type is significantly longer for that specific measurement point).

53

54

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

quencies at all measurement points in comparison with traditional and hybrid care. Compared to T2, the average frequency increased at T3 for both traditional and integrated care (somatic residents only). A comparison of separate traditional and hybrid care activities showed that at T1 and at the second measurement point (T2), only the average frequency of one activity (general activities for somatic residents) was significantly higher in the traditional care type (see Table 3). For medication and afternoon care, this frequency was significantly higher in the hybrid care setting at T1 and T2. At T3, only the average frequency of afternoon care was significantly higher in the hybrid care setting. A comparison of hybrid care with integrated care showed that except for evening care (in B at T1) and transfer/transport (in B at T2), the average frequency of activities such as medication, toileting, extra care, meal activities, general activities and additional direct activities, at all measurement points, was significantly higher in the integrated care type. Similar patterns were noticed for the latter activities in the comparison of traditional care and integrated care. The average frequency of most activities was higher for integrated care than for other types of care. 3.1.4. Somatic versus psycho-geriatric care With respect to the set of activities, Fig. 1 makes clear that compared to traditional and hybrid care; the average frequency of integrated care activities was higher for both somatic and psycho-geriatric residents. The average frequency of separate activities such as medication, toileting, afternoon care and extra care was generally higher for somatic care than for psychogeriatric care. For coffee/tea-activities, evening care, general activities and transfer/transport, this frequency was higher for psycho-geriatric care (see Table 3). With the exception of C (at T2), the total average frequency of direct care activities was higher for somatic care in all care types and at all measurement points in comparison to psycho-geriatric care. In traditional nursing home care, the total average frequency of direct care activities varied between 5.8 and 9.4 activities per day. In hybrid and integrated nursing home care, these averages were 7.14–12.33 and 12.05–16.30, respectively. At T1 and T2, the total average frequency for both somatic and psycho-geriatric care was the lowest for traditional care and the highest for integrated care. At

T3, the total average frequency for both somatic and psycho-geriatric care was the lowest for hybrid care. 3.2. Duration Table 4 indicates the average duration of care activities. Except for the last row, the duration indicates how long, in terms of minutes, a particular activity on average lasted. The last row indicates how long residents, on average, received direct activities per day. 3.2.1. Activities The table shows that morning care, coffee/teaactivities, social group activities, evening care, afternoon care and general activities on average had the highest duration. Morning care on average took between 15.09 and 23.65 min. By and large, general activities seemed the most time-consuming. Medication, medical care and transfer/transport were among the activities with the lowest duration. On average, a resident obtained between 70.83 and 126.75 min of direct care activities in total per day. The total average duration per resident per day was the highest for integrated care. 3.2.2. Changes over time Over time, the average duration of activities significantly changed for medication, toileting, medical care, transfer/transport and additional direct activities. Mostly, duration increased for activities in A (T2) and B (T2; T3) and decreased for activities in C (T2; T3som). 3.2.3. Differences between care types Fig. 2 shows the average duration of the set of 14 activities. Except for hybrid care for somatic residents, the average duration at T3 decreased in all care types compared to T2. When traditional care and hybrid care are compared, the average duration of most activities (e.g. morning care, medication, afternoon care, general activities) was significantly longer in traditional care. A comparison of hybrid care with integrated care showed that among others morning care, afternoon care, social group activities, meal activities and transfer/transport were more time-consuming in the latter care type. Coffee/tea-activities and general activities, on the other hand, in general took substantially longer in hybrid

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

Fig. 2. Average duration direct care activities. Legend—Som: somatic residents; PG: psycho-geriatric residents; T1: first measurement point; T2: second measurement point; T3: third measurement point.

care. Our comparison of traditional care with integrated care demonstrated that, in several instances, activities in the former were more time-consuming. This was especially the case for coffee/tea-activities, medication, afternoon care and general activities. Social activities on the other hand lasted longer in integrated care.

55

3.2.4. Somatic versus psycho-geriatric care Fig. 2 shows that traditional care for psychogeriatric residents had a higher average duration at all measurement points in comparison with hybrid and integrated care. With the exception of C (T1 and T2), the average duration of coffee/tea-activities and general activities was higher for psycho-geriatric residents than for somatic residents. This was also true for social group activities (except for C at T1 and CT3). For medication (except C at T3) and toileting (except B at T1 and C and T3) the opposite was true. With the exception of B (T3) and C (T2), the total average duration per day was higher for somatic residents than for psycho-geriatric residents. 3.3. Relationship between frequency and duration Earlier we indicated that available studies suggest that there is a link between the occurrence of an activity and the duration of that activity [10,14]. Table 5 shows the links between the frequency and duration for the activities we investigated. Activities were categorized on the basis of a high or low frequency combined with a high or low duration.

Table 5 Relationship between average frequency and duration of activities Activity Morning care Coffee/tea-activities Medication Toileting Afternoon care Extra care Evening care Meal activities Medical Care General activities Social group activities Transfer/transport Incidental care Additional direct Activities

Low frequency Low duration

Low frequency High duration

High frequency Low duration

High frequency High duration X (A; B; C)

X (A; B; C) X (A: pg* )

X (A: som* ; B* ; C) X (A; B; C)

X (A; B: pg; C: som* ) X (A; B; C: pg)

X (B: som* ; C: pg* ) X (C: pg* )

X (A: som* ) X (A* ; B; C) (A:* ;

pg* )

X B: X (B: som; C* ) X (A* ; B; C) X (A; B; C* )

X (C: som* ) X (A: pg; B: pg* )

X (A: som* ; B: som* ; C: som)

X (A: pg* ; B; C) X (A; B; C* ) X (B: som* ; C* ) X (A; B: pg)

A = traditional care; B = hybrid care; C = integrated care; Som = somatic residents; PG = Psycho-geriatric residents. X indicates the relationship between the average frequency and duration of this activity. * Relationship was present at the majority of measurement points (figures without a * indicate that the relationship was found at all measurement points)

56

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

Activities with an above or below average score were considered as activities with a high or low frequency or duration. The average frequencies and durations of an activity (calculated as the average of the 14 activities) are indicated in Tables 3 and 4.

3.3.1. Activities The table shows that morning care and evening care were the most time-consuming activities, both in terms of duration as in terms of frequency. This relationship was present in all care types and for all types of residents for morning care, and for somatic residents (in A, B and C) for evening care. Most activities such as extra care, medical care, afternoon care, incidental care and additional direct activities had a low frequency and a low duration. While a high duration was combined with a low frequency for coffee/tea-activities, general activities and social group activities, a reverse relationship was present for medication, toileting and meal activities.

3.3.2. Type of care Most of the relationships mentioned in Table 5 were independent of the type of nursing home care. The most important exceptions included afternoon care (with a higher duration in C in comparison to A and B); social group activities and evening care (with a higher duration in B and C in comparison to A); transfer/transport (with a lower frequency in C in comparison to A and B).

3.3.3. Type of resident Many relationships between duration and frequency were also independent of the type of resident. Exceptions included medication (less frequent for pgresidents), meal activities (less frequent for somatic residents) and evening care (higher duration for pg-residents) in traditional care. In hybrid care, exceptions included afternoon care and social group activities (a higher duration for somatic residents) and evening care (more frequent for pg-residents). Integrated nursing home care showed different relationships for extra care (lower frequency for pgresidents) and afternoon care (higher duration for pgresidents).

4. Conclusions and discussion 4.1. Conclusions In the introduction of our paper we formulated three research questions in order to assess the impact of integrated care on the (relationship between) frequency and duration of direct care activities. From our analysis, the following conclusions in relation to these questions can be drawn. First, integrated care had an impact on the total average frequency of most direct care activities but not on individual activities. At most measurement points, the total average frequency was higher for integrated care than for traditional and hybrid nursing home care. The average frequency of individual activities such as extra care, general activities and medication, however, significantly changed over time (mainly increased) for all nursing home care types. When viewed per activity, the average frequency of medication, toileting, afternoon care and extra care was generally higher for somatic care. For coffee/tea-activities, evening care, general activities and transfer/transport, this frequency was generally higher for psycho-geriatric care. Second, integrated care also had an impact on the total duration of most direct care activities (per resident per day, irrespective of the type of patient). At most measurement points the total duration was higher for integrated care than for traditional and hybrid nursing home care. The duration per individual activity for most activities, however, was the most time-consuming for traditional nursing home care. The average duration of medication, toileting, extra care, meal activities, medical care, transfer/transport and additional direct activities significantly changed over time. In traditional and hybrid care, the average duration increased. In integrated care the opposite was true. Differences between somatic and psycho-geriatric residents did not depend on the introduction of integrated care. Third, most relationships between the average frequency and duration of activities (in terms of high (low) frequencies combined with high (low) durations) were unrelated to the type of resident and/or the type of nursing home care. In other words, integrated care hardly had an impact on the relationship between the frequency and duration of direct care activities. Our analysis also showed that on the whole and irrespective of the type of nursing home care, the (total) average

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

frequency of many direct care activities at most measurement points was higher for somatic care than for psycho-geriatric care. The same was true with respect to the total average duration per resident per day. 4.2. Discussion The implementation of integrated care mainly leads to increases in the duration and frequency of the total package of direct care activities but not of separate activities. Policymakers and managers should be careful. The introduction of integrated nursing home care could imply a pressure on the resources available for direct care. This is not to say that the introduction of integrated care will turn the whole package of nursing home care topsy-turvy. Our conclusions seem to indicate that the frequency and duration of individual direct care activities are less sensitive for the underlying type of nursing home care and type of resident. A study by Keith and Cowell [40] found a comparable result with respect to the type of care for treatment activities for stroke patients in three different organizational hospital settings. Although not always related to nursing home care, studies point to the likely influence of the characteristics of caregivers [41–44]; the age of patients [41,44,45]; gender [46] and the (in)ability of (older) patients to express what they want [12,47] on the duration and frequency of activities. We did not investigate such factors. In this sense our research was limited. Instead, we consider the routine nature of many direct care activities as providing an explanation. Direct care is a significant proportion of nursing home care. Some authors have found that approximately between 35% [10] and 70% [8] of (nursing) time spent on nursing home care concerns direct patient care activities. Activities such as morning care or evening care occur daily in every nursing home, irrespective of the type of care. They are typical examples of routines. The durability of routines explains why the introduction of integrated care did not result in a set of care activities that was completely different from traditional care. A number of workers, who were supposed to provide integrated care, were in the habit of providing these daily care activities. Such habits are difficult to shake off, especially when they are bound by rules that exist on all kind of levels, including the mind of the worker. Nevertheless, the fact that the introduction of integrated

57

care did affect the duration and frequency of the total set of direct care activities emphasises the possibility for routines to change. This change was accompanied by change of rules on two levels. The organization introduced new rules in order to bind the concept of integrated dare. In addition, the involved workers were trained in performing new sorts of care activities. Assumingly this resulted in a change of their mindsets. Currently, many health care policies are aimed at introducing integrated care [1,2]. If this assumption is valid, it indicates the direction which must be taken in order to change existing routines to make room for integrated care: a simultaneous change of rules at different levels. Even then, however, chances are that change is not as all-encompassing as the concept of integrated care might have us believe. Because of the very nature of routines (changeable but also durable), high expectations on the effect of integrated care on service delivery (and the subsequent effect on the quality of care for residents) may be (partly) offset. In any case, further research on dissecting which activities are routines or not and how these routines can be changed is therefore recommendable. After all, routines may be a major barrier to achieving the policy goal of actually implementing integrated nursing home care [48], but as soon as integrated nursing home care has become a routine, this routine will probably remain in place for a comforting while.

Acknowledgements The research was financed by the Dutch Ministry of Health; The Province of Limburg; VGZ Insurers; the Boncura Foundation/Care Group ‘Noord-Limburg’; the Foundation Stimulating Scientific Research on Nursing Home Care (SWBV).

References [1] Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: a synthesis of the evidence. International Journal of Geriatric Psychiatry 2003;18(3):222–35. [2] Leichsenring K, Alaszewski A, editors. Providing integrated health care and social care for older persons. A European View of Issues at Stake. Aldershot/England: Ashgate Publishing Limited; 2004.

58

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

[3] Van Raak A, Mur-Veeman I, Hardy B, Steenbergen M, Paulus A, editors. Integrated Care in Europe. Description and comparison of integrated care delivery and its context in six EU countries. Maarssen/The Netherlands: Reed Business Information; 2003. [4] Paulus A, van Raak A, Keijzer F. Informal and formal caregivers’ involvement in nursing home care activities: impact of integrated care. Journal of Advanced Nursing 2005;49(4):354–66. [5] Paulus A, van Raak A, Keijzer F. Nursing home care: whodunit? Journal of Clinical Nursing 2006;15(11):1426–39. [6] Paulus A, Van Raak A, van Merode F, Adang E. Integrated health care from an economic point of view. Journal of Economic Studies 2000;27(3):200–10. [7] Reed J, Cook G, Childs S, McCormack B. A literature review to explore integrated care for older people, International Journal of Integrated Care 2005; 5, January (electronic journal: www.ijic.org). [8] Smith D, Molzahn-Scott A. A comparison of nursing care requirements of patients in long-term geriatric and acute care nursing units. Journal of Advanced Nursing 1986;11(3):315–21. [9] Lundgren S, Segesten K. Nurses’ use of time in a medicalsurgical ward with all-RN staffing. Journal of Nursing Management 2001;9(1):13–20. [10] Cardona P, Tappen R, Terrill M, Acosta M, Eusebe M. Nursing staff time allocation in long-term care: a work-sampling study. Journal of Nursing Administration 1997;27(2):28–36. [11] Linden L, English K. Adjusting the cost-quality equation: utilizing work sampling and time study data to redesign clinical practice. Journal of Nursing Care Quality 1994;8(3):34–42. [12] Norbergh K-G, Asplund K, Rassmussen B, Nordahl G, Sandman P-O. How patients with dementia spend their time in a psycho-geriatric unit. Scandinavian Journal of Caring Sciences 2001;15(3):215–21. [13] Harrington C, Swan J. Nursing home staffing, turnover, and case mix. Medical Care Research and Review 2003;60(3): 366–92. [14] Abdellah F, Levine E. Work sampling applied to the study of nursing personnel. Nursing Research 1954;3(1):11–6. [15] Paulus A, Van Raak A, Keijzer F. ABC: the pathway to comparison of the costs of integrated care. Public Money and Management 2002;22(3):25–32. [16] Lemonidou C, Plati C, Brokalaki H, Mantas J, Lanara V. Allocation of nursing time. Scandinavian Journal of Caring Sciences 1996;10(3):131–6. [17] Kaplan R, Atkinson A. Advanced Management Accounting. Upper Saddle River: Prentice-Hall International; 1998. [18] Kaplan R, Cooper R. Cost and Effect: Using Integrated Cost Systems to Drive Profitability and Performance. Harvard Business School Press; 1998. [19] Weech-Maldonado R, Meret-Hanke L, Neff M, Mor V. Nurse staffing patterns and quality of care in nursing homes. Health Care Management Review 2004;29(2):107–16. [20] Bowers B, Lauring C, Jacobson N. How nurses manage time and work in long-term care. Journal of Advanced Nursing 2001;33(4):484–91.

[21] Urden L, Roode J. Work Sampling: a decision-making tool for determining resources and work redesign. Journal of Nursing Administration 1997;27(9):34–41. [22] Nelson R, Winter S. An Evolutionary Theory of Economic Change. Cambridge, MA: Harvard University Press; 1982. [23] Feldman M, Pentland B. Reconceptualizing organizational routines as a source of flexibility and change. Administrative Science Quarterly 2003;48(1):94–118. [24] Minyard K, Wall J, Turner R. RNs may cost less than you think. Journal of Nursing Administration 1986;16(5):28–34. [25] Schuster G, Cloonan P. Nursing activities and reimbursement in clinical care management. Home Health Care Nursing 1989;7(5):10–5. [26] Hendrikson G, Doddato T, Kovner C. How do nurses use their time? Journal of Nursing Administration 1990;20(3):31–7. [27] Paulus A, Boumans N, Keijzer F, Vijgen S, Mur I. Ge¨ıntegreerde vraaggestuurde verpleeghuiszorg. Een longitudinaal en transversaal onderzoek naar de effecten, kosten en het proces van verandering van aanbod- naar ge¨ıntegreerde vraaggestuurde vormen van verpleeghuiszorg (Integrated demand-oriented nursing home care. A longitudinal and transversal research of the effects, costs and process of changing from supply-oriented towards integrated demand-oriented types of nursing home care). Maastricht: University of Maastricht. 2003. [28] Boman L, Andersson J-U, Bj¨orvell H. Needs as expressed by women after breast cancer surgery in the setting of a short hospital stay. Scandinavian Journal of Caring Sciences 1997;11(1):25–32. [29] Finkler S, Knickman J, Hendrickson G, Lipkin M, Thompson W. A comparison of work-sampling and time and motion techniques for studies in health services research. Health Services Research 1993;28(50):577–97. [30] Burke T, McKee J, Wilson H, Donahue R, Batenhorst A, Pathak D. A comparison of time-and-motion and self-reporting methods of work measurement. Journal of Nursing Administration 2000;30(3):118–25. [31] Stevens B. The Nurse as Executive. Rockvill, MD: Aspen Systems; 1995. [32] Adams A, Bond S. Staffing in acute hospital wards. Part 1. The relationship between number of nurses and ward organizational environment. Journal of Nursing Management 2003;11(5):287–92. [33] Adams A, Bond S. Staffing in acute hospital wards. Part 2. Relationships between grade mix, staff stability and features of ward organizational environment. Journal of Nursing Management 2003;11(5):293–8. [34] Ekman S-L, Norberg A, Viitanen M, Winblad B. Care of demented patients with severe communication problems. Scandinavian Journal of Caring Sciences 1991;5(3):163–70. [35] Adams A, Bond S, Hale C. Nursing organizational practice and its relationship with other features of ward organization and job satisfaction. Journal of Advanced Nursing 1998;27(6):1212–22. [36] Raak A. van, Paulus A., Made J. van der. The conditions for health and social care policy: routines and institutions in the

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

[37] [38]

[39]

[40]

[41]

[42]

Dutch case of need assessment. Public Administration 2007; in press. Feldman M. Organizational routines as a source of continuous change. Organization Science 2000;11(6):611–29. Jones O, Craven M. Beyond the routine: innovation management and the Teaching Company Scheme. Technovation 2001;21(5):267–79. Watson P, Lower M, Wells S, Farrah S, Jarrel C. Discovering what nurses do and what it costs. Nursing Management 1991;22(5):38–45. Keith R, Cowell K. Time use of stroke patients in three rehabilitation hospitals. Social Science and Medicine 1987;24(6):529–33. Radecki S, Kane R, Solomon D, Mendenhall R, Beck J. Do physicians spend less time with older patients? Journal of the American Geriatric Society 1988;36(8):713–8. Katz P, Karuza J, Kolassa J, Hutson A. Medical practice with nursing home residents: results from the National Physician Professional Activities Census. Journal of the American Geriatric Society 1997;45(8):911–7.

59

[43] Bertakis K, Robbins J, Callahan E, Helms L, Azari R. Physician practice style patterns with established patients: determinants and differences between family practice and general internal medicine residents. Family Medicine 1999;31(3):187–94. [44] Chin M, Zhang J, Merrell K. Specialty differences in the care of older patients with diabetes. Medical Care 2000;38(20):131–40. [45] Keeler E, Solomon D, Beck J, Mendenhall R, Kane R. Effect of patient age on duration of medical encounters with physicians. Medical Care 1982;20(11):1101–8. [46] Woodward C, Hurley J. Comparison of activity level and service intensity of male and female physicians in five fields of medicine in Ontario. Canadian Medical Association Journal 1995;153(8):1097–106. [47] Kravitz R, Bell R, Azari R, Kelly-Reif S, Krupat E, Thom D. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Archives of Internal Medicine 2003;163(14):1673–81. [48] Van Raak A, Paulus A. A sociological systems theory on interorganisational network development in health and social care. Systems Research and Behavioral Science 2001;18(3):207–24.