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Abstract
Introduction What nurses do and how they do it can influence older people’s experiences of the quality of long-term care. In addition, a clear role definition for nurses supports them in giving patients appropriate basic care. Despite this, there is a lack of a clear role definition regarding policy, work descriptions and expectations. Therefore, the objective of this scoping review is to map the literature on nurses’ role, function and care activities and/or nursing interventions, as well as to identify nursing interventions (as models of nursing care, patient care pathways and/or clinical practice guidelines) in relation to older people in long-term care. Hence, to explore how nurse’s role, function and care activities in relation to older people’s basic care needs are described and understood by key stakeholders (older people, their next of kin, nurses) in long-term care.
Methods and analysis Arksey and O’Malley’s methodologic framework for scoping studies will be used for this upcoming scoping review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist will be followed. Search strategies will be developed in collaboration with the research team and an experienced librarian. Search strategies will be adjusted for each of the databases: PubMed, PsycINFO, CINAHL and Scopus. Data will be charted using a pilot extraction sheet. Quantitative data will be described numerically, and qualitative data will be analysed using thematic analysis. The key stakeholders will be consulted for validation.
Ethics and dissemination The upcoming study will follow All European Academies' principles for good research. The findings will be used to inform the design of future studies aiming to develop a nursing intervention targeting older peoples’ basic care needs.
- primary care
- geriatric medicine
- quality in health care
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The upcoming scoping review will be conducted in accordance with the well-described framework by Arksey and O’Malley and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for scoping reviews.
At least two members of the research team will independently assess study eligibility.
Studies conducted with qualitative, quantitative and mixed-methods designs will be included to achieve a comprehensive picture of the topic in foci.
Eligible studies will be quality appraised, and ethical standpoints will be included.
One limitation might be the lack of patients and public involvement in designing the study.
Introduction
Registered and non-registered nurses1 make up the main section of the healthcare profession and, therefore, are a crucial part of all healthcare organisations.2 Nowadays, one important care context is long-term care3 (box 1), in which the providers of direct basic care to older people mainly consist of non-registered nurses.4 What nurses do—their role, and how they do it, that is, their function—is known to influence the patients’ perceptions of the quality of care.5 6 A clear nursing role has been described as a way to support nurses to work effectively and prioritise basic nursing care,7 as well as to diminish the risk of missed care in the community care settings.8 Thus, research into nursing highlights the importance of a well-defined nursing role. However, the lack of a clear role definition regarding policy, work descriptions and expectations—role ambiguity—is described as being present within nursing.9 10 The research into nursing has additionally raised the issue of to what extent nurses take responsibility for the patients’ care needs, as well as to what extent healthcare organisations enable these responsibilities.11 12 The nurses’ role and function become visible by the care activities they perform and deliver.13 Nursing care activities have been described as containing direct nursing care, indirect nursing care and work that is not related to patient care.14 15 Independent activities/interventions are prescribed by nurses, while dependent and interdependent activities/interventions are prescribed by others or in collaboration with nurses.16 According to Kitson, more knowledge is still needed about nurses’ activities, especially their direct basic care activities, because such knowledge would improve the care provided to patients.17
Core concepts in the upcoming scoping review
Nurses will be operationalised as: registered nurses, registered practical nurses, licensed practical nurses, and nursing aides, according to Chu et a.1
Long-term care will be operationalised as: home healthcare, sheltered housing, special accommodation and nursing homes, according to Saunes et al.3
The term ‘basic nursing care’ can be defined as the care that patients recognise as being important and the most necessary; for that reason, others, for example, Kitson et al and Feo et al, have referred to basic nursing care as the essentials or fundamentals of care.11 18 In the upcoming scoping review, the term basic nursing care will be in accordance with Zwakhalen et al’s description: ‘aspects of care that are fundamental to all patients’ health and well-being, regardless of diagnosis, cultural background or healthcare setting’ (Zwakhalen et al, p2497).19 Despite the term basic care, it should not be seen as ‘simple’, but rather as complex and, at times, challenging for nurses to ensure.17 20 Basic care is a natural and unconscious part of daily self-care activities. Activities such as elimination, diet, personal hygiene and mobility are often the first to be compromised when people are confronted with any kind of health challenges, which makes these needs very quickly become critical.21 However, international evidence reflects that the delivery of basic nursing care appears to be highly inconsistent and, at times, absent altogether, resulting in unsafe and automated patient experiences originating from neglect.22–25 Single studies imply that basic care activities are undervalued21 26 27 and might be perceived by nurses as easy and not worthy of taking their time.27 Thus, these findings highlight the importance of exploring more in-depth what nurses do and how they do it, much like our case, which particularly focuses on older people in a long-term care context.
The global shift in healthcare services towards community care during the past few decades has led to a long-term care context that nowadays has become the main place of care for older care recipients. Growing old, or ageing, is mainly described as being associated with multimorbidity, frailty and several chronic diseases.28 Consequently, people’s need for care increases with age. Therefore, focusing on curing diseases might not always be the most optimal strategy in the care of older people, and in a long-term care context, it is likely to be more beneficial if the care focuses on how to support older people’s functional ability and meet their basic care needs.29 Our initial exploration of the subject indicates that—especially in a long-term care context—literature reviews focusing on the role and function of nurses are scarce. One integrative literature review by Montayre and Montayre4 was identified, but it did not focus on exploring nurse’s role and function, instead examining the contemporary perspective of the work of registered nurses (RNs) in long-term care facilities. Their findings implied that RNs may find it difficult to define their role and that they mainly focused on planning and coordinating care delivered by others, thus focusing more on indirect care activities. However, it is worth noting—and in comparison with our upcoming review—that Montayre and Montayre4 focused on RNs, limiting the long-term care context to residential care and nursing homes while leaving out home healthcare and other nursing staff.4 Consequently, a broad understanding of both RNs’ and other nursing staff’s care activities targeting older people in this context is warranted. Such knowledge could aid in the quality of care and delivery of safe evidence-based nursing care for older people in long-term care.
One way to guarantee the above might be to support nurses in delivering care through distinctly articulated and defined models of care (MoC). In particular, MoC can be understood as a map of care, here aiming to ensure that the patients receive the right care at the right time and place. Hence, it outlines the best practices of care.30 Terms such as MoC, nursing model and framework have been described both as ambiguous and used interchangeably, even though referring to various but corresponding concepts.31 32 In long-term care, nurse-led integrative MoC are often highlighted.33–36 However, in a recent literature review by Deschodt et al that focuses on nurse-led integrative care models in long-term care (here among home-dwelling older persons), no significant positive outcomes on mortality, hospitalisation, nursing home admission, quality of life, activities of daily living and emergency department visits were identified.37 Despite this, according to Davidson et al, MoC can support nurses in working systematically towards a collective set of goals in care, as well as aiding in the assessment and evaluation of the deliverance of care. They can especially encourage nursing staff to have the same foundation and picture of given care.31 Taking all the above into account, the objective of the proposed scoping review is to map the literature on nurses’ role, function and care activities and/or nursing interventions, as well as to identify nursing interventions (as MoC, patient care pathways and/or clinical practice guidelines) in relation to older people in long-term care. Hence, our objective is to explore how nurse’s role, function and care activities in relation to older people’s basic care needs are described and understood by key stakeholders (older people, their next of kin, nurses) in long-term care.
Methods
The upcoming scoping review will address a particularly broad topic, and a diverse range of study designs can be relevant in answering our broad questions. Arksey and O’Malley’s methodologic framework for scoping reviews will be used for designing this upcoming study.38 In addition, the methodological developments by Levac et al39 and Daudt et al40 will be considered. To make a distinct analysis of this potentially complex account of data, both descriptive and thematic analysis will be used.41 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist—PRISMA-ScR—42 will be used to form the base of the upcoming review. PRISMA-ScR was also used for forming this protocol.
Stage 1: identifying the research question
A modified population, phenomenon of interest, context and study design framework43 was used to help us formulate the research questions and guide us in the search process (table 1). The following tentative questions regarding the literature were developed:
How are nurses’ role, function and care activities generally described by key stakeholders, specifically in relation to older people in long-term care (older people, next of kin and nurses)?
How are nurses’ role, function and care activities described—and by whom—in relation to older people’s basic care needs in long-term care?
What type of nursing interventions (dependent, independent and interdependent) are generally described—and by whom—in relation to older people in long-term care?
What MoC (as systematic models of nursing care, patient care pathways and/or clinical practice guidelines) are described—and by whom—in relation to older people in long-term care?
Framework (PICoS) for determination of eligibility of review questions
We will also tentatively ask the following subquestions: What long-term care contexts are described? What characterises are included in the papers’ study design regarding methods, quality and ethical standpoints?
Stage 2: identifying relevant studies
To identify relevant studies, the databases PubMed, CINAHL, SCOPUS and PsycINFO will be used. The databases are chosen to cover a broad sample of the literature. The search strategy will include headings specific to the database, as well as keywords and synonyms. Boolean operators AND/OR will be used to combine the search terms. Reference lists from the included studies will be manually searched for to ensure comprehensiveness.38 A search strategy will be formulated for each database. This will be done by the research team and will be assisted by an experienced librarian.39 A preliminary search strategy is made for PubMed (online supplemental appendix 1). Grey literature will not be included. Studies in languages other than English will be excluded. All reasons for exclusion will be carefully documented.
Supplemental material
Stage 3: study selection and eligibility criteria
Eligible criteria’s will be conducted to ensure consistency, validity and reliability.37 A summary of initial inclusion and exclusion criteria are described below. Due to the tentative nature of a scoping review, eligibility criteria might be adjusted at any time during the selection process. Adjusted criteria will be applied to all records.38 Inclusion and exclusion criteria will initially depart from the search terms mentioned in table 1. Key stakeholders are nurses, older people, and significant others. The latter refers to persons who have a close relation to the older people, and older people will be defined as 65 years old and above. Due to the reviews broad approach and wide research questions, we have had to limit the number of key stakeholders. Other perspectives such as care managements and care providers (ie, unpaid carers), are therefore excluded. Due to time and resource constrains only peer-reviewed papers published in English containing an abstract and following the research process will be included. All study designs (qualitative, quantitative and mixed methods) will tentatively be eligible for inclusion. Literature reviews, opinion or discussion papers, conference proceedings and theses will be omitted.
The screening process will be done in several swifts: (1) titles and abstracts will be assessed for inclusion, (2) records in line with our research questions, or if the relevance is unclear, will be read in full text.38 Two independent reviewers will screen the records for eligbility39 40 Any cases of disagreements during the screening process will be resolved through consensus discussion with a third team member.39 Rayyan will be used for managing the screening process, and for using the opportunity to ‘blind on’ and ensure consistency between the reviewers.44 The screening process (figure 1) will be visualised in the PRISMA flow diagram.45
PRISMA flow chart: Overview of study selection process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Arksey and O’Malley did not recommend assessing the quality of studies because the aim is to cover a topic, not rank it.38 Despite this, Levac et al and Daudt et al suggested assessing the quality of the included studies.39 40 Assessing the quality of the studies can give the scoping review even more useful content. However, studies will not be excluded because of quality issues.39 40 Checklists from the Critical Appraisal Skills Programme46 will be used to assess the quality of qualitative and quantitative studies. For mixed-methods studies, the Mixed Methods Appraisal Tool47 will be used. Assessments will be performed by a minimum of two reviewers. Ethical aspects will be assessed and charted to highlight ethical issues in research (box 2).48 49
Tentative ethical criteria inspired by Weingarten et al48 and Westerdahl et al49
Was informed consent obtained? Yes/No
Was the study approved by a research ethical committee? Yes/No
Were adequate measures taken to protect personal data? Yes/No
Is there a declaration on financial support? Yes/No
Is there a declaration on potential conflicts of interest? Yes/No
Stage 4: charting the data
The research team will develop the data charting form (box 3). At least two of the team members will independently extract data from 10 articles supporting us in testing the suitability of the form. The data charting form can be modified after piloting and, if needed, later during the process.39
Tentative data charting form
Author and date.
Journal full reference.
Aim, objective and/or research questions.
Study and recruitment context (eg, in what country and setting people were recruited).
Participant characteristics (eg, profession, patient, relative, age, gender).
Sampling method.
Number of study participants.
Study design.
Data collection (eg, what data collection methods were used?).
Data analysis (eg, how was the data analysed?).
Described ethical approval and/or considerations.
Main result concerning nurses role/function, activity/interventions or described care models.
Stage 5: collating, summarising and reporting the results
In the fifth stage, the findings from the studies conducted with qualitative, quantitative and/or mixed-method designs will initially be processed separately before findings are combined in the discussion.38 Qualitative data will be summarised by using Braun and Clark’s thematic analysis41 as recommended by others.39 40 The analysis method is described as flexible and appropriate to apply to a complex account of data.41 50 Quantitative data will be summarised using basic descriptive analysis.38 Finally, following Arksey and O’Malley’s framework, all data from the charting stage will be analysed and presented to give an overview of the research area. The results will be described in text, tables and charts.38
Consultation
Consultation is an optional step, but it is recommended to involve stakeholders in the process. Stakeholders can validate a preliminary result while offering new perspectives on the topic.38 39 In this upcoming study, stakeholders will be consulted in stage 5.39 Discussion groups with key stakeholders will be conducted as a form of input into analysis.
Patient and public involvement
Patients and the public have not been involved in designing the upcoming study but will be involved through consultation. This study will hopefully contribute to the development of nursing interventions that improve patient care in long-term care contexts.
Ethics and dissemination
The upcoming scoping review will follow All European Academies' (ALLEA) four fundamental principles for research integrity: reliability, honesty, respect and accountability.51 Reliability will be ensured using a clearly declared method. The findings will be included without any distortion, and the researchers’ preunderstanding will be carefully discussed. The research process will be truthfully described to follow the principle of honesty. The methods used in the thesis will get proper credit, and the investigators will take full responsibility for the studies. The upcoming review will be submitted to a peer-reviewed journal. We expect to report on the findings at the beginning of 2023.
The upcoming scoping review will be the first study in a series of studies adhering to the Medical Research Council’s framework for Complex Interventions.52 The overarching objective is to develop and pilot the acceptability and feasibility of a nursing intervention targeting older people’s basic care needs in long-term care contexts. The upcoming scoping review is part of the development phase—identifying the evidence.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors KS, CO, ERG and GB were responsible for the initial design of this study. KS conceptualised the review approach and led in the writing of the manuscript. KS, CO, ERG and GB contributed to the protocol’s development and approved the final version of this protocol. CO, ERG and GB supervised manuscript preparation.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.