Document 305901
CARETRAINING “Training for home care workers in the frame of local health care initiatives” Leonardo da Vinci Partnerships project TRAINING MANUAL 1 AUTHORS This Training Manual has been compiled by the Editorial Committee of the “Training for home care workers in the frame of local health care initiatives - CARETRAINING” project consortium, with contribution to the content by all project partners. The Editorial Committee is: Global Coordination Sylvianne Vroonen - International Officer for Health Care Department – KHLim Limburg Catholic University College Joke Lemiengre - Coordinator of Ethos, Expertise Centre of Ethics and Care - KHLim Limburg Catholic University College National Coordination Belgium Luc Van Gorp - Head of the Health Care Department – KHLim Limburg Catholic University College Hungary Pál Csonka jr. – project coordinator - Caritas Pécs Poland Agnieszka Basińska – project coordinator - Mutual Help Foundation Project partners’ delegates Jean-Pierre Descan – National Alliance of Christian Mutualities / Landsbond van Christelijke Mutualiteiten Bram Fret – White Yellow Cross Flanders / Wit-Gele Kruis van Vlaanderen vzw Luc Van Gorp – KHLim Limburg Catholic University College / Katholieke Hogeschool Limburg Joke Lemiengre – KHLim Limburg Catholic University College / Katholieke Hogeschool Limburg Pál Csonka jr. – Caritas Pécs / Pécs Egyházmegyei Katolikus Caritas Alapítvány Miklós Lukács – Comenius Pécs / Comenius Szakközépiskola és Szakiskola Pécs Agnieszka Basińska / Monika Konopa-Dudek – Mutual Help Foundation / Fundacja Wzajemnej Pomocy Tomasz Zawadzki / Anna Andruszkiewicz – District Chamber of Nurses and Midwives / Okręgowa Izba Pielęgniarek i Położnych w Bydgoszczy Editing and layout Pál Csonka jr. – Caritas Pécs / Pécs Egyházmegyei Katolikus Caritas Alapítvány 2 DISCLAIMER This document has been published within the scope of “Training for home care workers in the frame of local health care initiatives - CARETRAINING”, a project carried ied out with the support of the European Community in the framework of the Leonardo da Vinci Partnerships Lifelong Learning program. The content of this project does not necessarily reflect the position of the European Community, nor does it involve any responsibility sponsibility of the part of the European Community. All documents, as well as conclusions and opinions stated, are written by project partners and should in no way be interpreted as official views of the European Commission or any other official organizations. organizati The information and data included in this document have been compiled by the authors from a variety of sources, and are subject to change without notice. The authors make no warranties or representations whatsoever regarding the quality, content, completeness, completeness, or adequacy of such information and data. While every effort has been made to ensure that the information contained herein is accurate and complete, the authors shall not be liable for any damages of any kind resulting from use or reliance on thiss information. COPYRIGHT Copyright © 2014. text and photos “Training for home care workers in the frame of local health care initiatives - CARETRAINING” Leonardo da Vinci Partnerships project partners and respective copyright owners. Reference to source iss given at respective parts of the document. All rights reserved. You are welcome to use this information for non-commercial, non commercial, personal, or educational purposes. 3 CONTENTS PROJECT PARTNERS ................................................................................................................................. 6 INTRODUCTION ....................................................................................................................................... 7 CHAPTER I. BASIC ASPECTS OF HOME CARE ....................................................................................... 9 I.1 Introduction to the chapter..................................................................................................... 9 I.2 What is good basic home care?............................................................................................... 9 I.2.1 Belgium ................................................................................................................................ 9 I.2.2 Poland ................................................................................................................................ 14 I.2.3 Hungary ............................................................................................................................. 17 I.3 An introduction to the financing system of health care / home care ................................... 20 I.3.1 Belgium .............................................................................................................................. 20 I.3.2 Poland ................................................................................................................................ 23 I.3.3 Hungary ............................................................................................................................. 24 I.4 An introduction to the training and education system for nurses and health professionals 28 I.4.1 Belgium .............................................................................................................................. 28 I.4.2 Poland ................................................................................................................................ 31 I.4.3 Hungary ............................................................................................................................. 31 CHAPTER II. „CARETRAINING” - THE HOME CARE TRAINING PROGRAM .......................................... 34 II.1 Introduction to the chapter................................................................................................... 34 II.2 Financing ............................................................................................................................... 34 II.2.1 Macro Level: State Model – Legal Framework .............................................................. 34 II.2.2 Meso Level: Management tools .................................................................................... 35 II.2.3 Micro Level: Cost awareness - Sustainability ................................................................ 36 II.3 Competences ......................................................................................................................... 37 II.3.1 Macro Level: Expectations of the organization HRM policy.......................................... 37 II.3.2 Meso Level: HRM tools .................................................................................................. 37 II.3.3 Micro Level: Attitudes and competences of employees ............................................... 37 II.4 Ethics ..................................................................................................................................... 41 II.4.1 Macro Level: Ethics policy (end of life).......................................................................... 41 II.4.2 Meso Level: Reflections and suggestions for ethical decision-making from the ethics of care perspective ........................................................................................................................... 43 II.4.3 II.5 Micro Level: “Nurses as reflective practitioners” .......................................................... 44 Communication ..................................................................................................................... 45 II.5.1 Macro Level: Communication on top level ................................................................... 45 II.5.2 Meso Level: Communication with stakeholders ........................................................... 46 4 II.5.3 II.6 Micro Level: Bedside communication - Counselling - Digital communication .............. 47 Quality of care ....................................................................................................................... 48 II.6.1 Macro Level: Laws & policies concerning quality of care management ....................... 48 II.6.2 Meso Level: Quality improvement programs................................................................ 51 II.6.3 Micro Level: Quality indicators, implementation and follow-up .................................. 57 CONCLUSIVE NOTE ................................................................................................................................ 59 LIST OF PHOTOS ............................................................................................................................ 61 5 PROJECT PARTNERS Project Coordinator National Alliance of Christian Mutualities / Landsbond van Christelijke Mutualiteiten - BELGIUM Project partners White Yellow Cross Flanders / Wit-Gele Kruis van Vlaanderen vzw – BELGIUM KHLim Limburg Catholic University College / Katholieke Hogeschool Limburg – BELGIUM Mutual Help Foundation / Fundacja Wzajemnej Pomocy – POLAND District Chamber of Nurses and Midwives / Okręgowa Izba Pielęgniarek i Położnych w Bydgoszczy – POLAND Caritas Pécs / Pécs Egyházmegyei Katolikus Caritas Alapítvány – HUNGARY Comenius Pécs / Comenius Szakközépiskola és Szakiskola – HUNGARY 6 INTRODUCTION Healthcare is one of the most important societal challenges for the near future. Ageing is obviously in the EU an issue that we have to tackle with a European wide approach. European cooperation is important to share insights and experiences and to evolve to a European wide strong social security system with qualitative healthcare as one of the pillars. The Belgian LCM (Landsbond van Christelijke Mutualiteiten) is involved already since decades in processes to support national, regional and local healthcare systems and initiatives in other European countries, particularly in Poland and Romania. With the project CARETRAINING LCM focuses on education. Continuously training all main actors (boards, management, caregivers on field level) is of highest importance in a domain that is evolving every day with new insights and technologies. For this reason also universities and local healthcare institutions are involved in the partnership of this project. „Training for home care workers in the frame of local health care initiatives – CARETRAINING” is a partnership project in the frame of Leonardo Da Vinci Life Long Learning program, with partners from Belgium, Poland and Hungary. The project coordinator is National Alliance of Christian Mutualities / LCM - Landsbond van Christelijke Mutualiteiten, with partners White Yellow Cross Flanders / WitGele Kruis van Vlaanderen vzw and KHLim Limburg Catholic University College - Health Care Department / Katholieke Hogeschool Limburg Departement Gezondheidszorg from Belgium, Mutual Help Foundation / Fundacja Wzajemnej Pomocy and District Chamber of Nurses and Midwives / Okręgowa Izba Pielęgniarek i Położnych w Bydgoszczy from Poland, Caritas Pécs / Pécs Egyházmegyei Katolikus Caritas Alapítvány and Comenius Pécs / Comenius Szakközépiskola és Szakiskola Pécs from Hungary. The aim of the project was to exchange good practices on education for board and staff members of local healthcare initiatives, and to promote the importance of local health care especially in the home care context. The partners exchanged experiences and insights on home care with special attention to the challenges on daily management level and on the daily practice of nurses in long term and palliative care. Based on the exchange visits a manual was prepared with interesting information on local healthcare in the three partner countries, but also on specific topics like professional competences, finance, education systems, ethics, communication, and quality management. The manual is available for everyone interested in qualitative healthcare and is very useful for training of people involved in local healthcare initiatives. The manual is available via the following partner websites: www.cm.be www.wgk.be www.flandria.pl www.oipip.bydgoszcz.pl www.pecsi-caritas.hu www.comeniuspecs.hu www.wit-gelekruislimburg.be For more information you can always contact [email protected] We wish you a fascinating lecture and good luck with all your local healthcare initiatives. Jean-Pierre Descan, LCM Project leader 7 Getting in the car with help – home care nurses at work in Hungary 8 CHAPTER I. BASIC ASPECTS OF HOME CARE I.1 Introduction to the chapter The first chapter of the Manual deals with a comparative statement for the following three basic aspects of the home care context, in the dimensions of each participating country, compiled by the respective project partner organisations. 1) What is good basic home care? The partners make an attempt to define good basic home care from their context, including vision / mission, outlining state-of-the art conditions and future expectations. 2) An introduction to the financing system of health care / home care. The partners give a non-comprehensive overview of the financing system of health care / home care present in each participating country 3) An introduction to the training and education system for nurses and health professionals. The partners will introduce the vocational training and educational system in each country, that exists for nurses and health care professionals, who work in the scope of home care, including secondary and higher education, vocational training and continuing education possibilities. I.2 What is good basic home care? I.2.1 Belgium Every patient, every situation is ‘different’. Working as a caregiver, you need to adapt constantly. You are visiting patients in all sorts of family situations. You visit people that have big differences in views or lifestyles. Giving care at the patients home means that you enter in the own specific world of your patient. A patient that is being cared for in a hospital or a nursing home needs to adapt to this institution. A caregiver working at home needs to adapt to every specific situation at a patients home. Providing good basic care at the patients’ home includes different aspects: 1. Relation with the patient We consider the patient as a whole person with all his features in interaction with the people around him and his environment. It means that we work based on a patient system, that takes in account not only the patient, but also its environment. This explains why caregivers in Belgium are also committed to the relatives of a patient, the informal caregiver(s). When possible, they are actively involved in the process of caregiving. The first contact is very important both for the caregiver and the patient. The patient and his environment get a first impression of the caregiver and the caregiver gets a first impression of the patient and his environment. In home care, the first visit will be mainly focused on observation. 9 The caregiver in home care develops a relationship with the patient that goes further than just ‘giving care’. In home care, caregivers don’t work with groups of patients, but with the patient as an individual. Unlike in hospitals, the care relationship in home care is mostly a long-term relationship. The caregiver in home care gradually develops a relationship of trust with his patient and the informal caregiver(s). Although as caregiver it is important to keep working on a professional basis with the patient and the informal caregivers. That’s why in home care often is spoken about the development of a professional friendship. 2. Presence It seems obvious that caregivers at the patient’s home in the first place execute technical care acts. But at home with the patients, they both have to do practical things as well as being there physically and mentally for the patient. For that reason, there is no other healthcare provider closer to the patient than the caregiver that comes at home. The term ‘presence’ is therefore very well suited for a home caregiver. Not the caregiver, but the patient is the centre of the world. The care professional needs to communicate to the patient, but also with the informal caregivers and other healthcare providers which requires certain skills and knowledge. ‘A care setting in which the caregiver itself is attentive and committed to the patient, learns to look what is happening with the patient – from desires to fears – and that in connection to the understanding what can be done in that specific situation for the patient. What can be done, needs to be done. This is way of working that can only be accomplished with a feeling of subtlety, craftsmanship, with practical wisdom and loving fidelity’. 3. Dignity supporting care The patient at home emphatically manifests himself in his human existence, in his fragile autonomy. If care is needed and is concretized in a care relationship or care practice, then it can also be described as a practice of responsibility, in which different stakeholders carry responsibility to each other and themselves in a process of reacting to the vulnerability. The vulnerability of the human existence requires appropriate and good care. Good care is care referring to the promotion of the human person in all its dimensions. That assumes that good care is human care or dignity supporting care. Giving care is a practice in which the activity and attitude of the healthcare provider go together. This requires from the caregiver attentive involvement, responsibility, expertise and the promotion of independence. Dignity supporting care assumes that the caregiver is sensitive for situations of vulnerability and that they are attentive for the situation in which the patient is located. From this moral sensitivity, the caregiver searches creatively for the most appropriate care answer for the vulnerable situation in which the patient is located. 4. Quality Good basic care is care given with good quality. Quality of care takes place on two levels: primary and secondary. Actions of guarding quality are: updating the knowledge and the skills with all nurses or teaching the necessary professionalism, kindness and empathy. Primary quality of care affects the following question: are we giving the right care based on the latest scientific evidences (evidence based care)? 10 Secondary quality of care affects the question: do patients and others find that we are giving the right care? When wee know what good basic care is about, we have to answer ‘What is good optimal basic care?’ Optimal basic care is being able to give good quality care as optimal as possible or with the right level of performance. In other words: “Being able to give the right right care at the right moment, and are we doing this with the right employability of resources?”. Good quality of care with the right resources is one thing, but it has to be given by the right people, in other words a good and involved team. 11 A good team eam contains not only yourself, but also your colleagues, the head of the team and (internal and external) multidisciplinary partners. A good team also works together with all professional caregivers. In an overview, basic care can be indicated with the following figure: 5. Total care As a caregiver in home care you often come in contact with patients with a geriatric profile. Typical for these patients is the multi pathology that is accompanied by poly pharmacy. These patients typically have a high gh age and often exhibit disorders in physical, mental and/or social functioning and are potentially vulnerable. Especially in this patient group it is important to observe and evaluate the complete situation of the patient. When you pass by for an injection, injection, it is possible that you notice that the patient needs help with administration or shopping. As a caregiver, you need to help finding solutions. Total care does not mean that you will perform all acts yourself. With total care it is to help to think about ab possible solutions and also to refer to other helpers who can execute these tasks in an appropriate way. 12 6. Working together in primary care In home care are a lot of opportunities were created to support the patient and the informal caregiver. If more than one aid worker/caregiver provides care or services, then it is desirable that they deliberate. It is important that the various health care providers know what other actors are present. There are at the home of the patient a lot of bilateral contacts between healthcare providers among themselves and with the patient and the informal caregivers, generally on the basis of the existing problems and to determine the care goals, or for making practical arrangements. In more difficult situations it may be necessary for all stakeholders to sit down with each other and a edit health care plan: in this case, a multidisciplinary consultation needs to be organized. 7. The role of the homecare nurse in the patients care pathway To develop optimal care for the patient, it is very important that, in addition to the daily care for the patient, there is mutual communication between the different caregivers and health care providers in primary care. The home nurse has a very important task in observing and identifying changes in the state of health of the patient. Including through the frequency and duration of her home visits, they can add essential information to the observations of the general practitioner. In addition, she has the necessary knowledge from her education in relation to pathology, possible side effects of treatments and medication. They must, however, always make a good assessment about what information they need to report. The home nurse often forms a bridge of communication between patient and the general practitioner and other caregivers in primary care. The home nurse in turn also needs information of the general practitioner about the medical history, the current treatment and any points of interest with the patient. There will be not only consultation between the primary health-care professionals, but by insertion in a hospital or discharge from a hospital there will also be the need of information flow. In addition to the general practitioner, the medical specialist is also a partner in the patient consultation. The homecare nurse works together with other caregivers in primary care and the general practitioner to maintain the patient as long as possible in his own familiar home. This commitment to good quality home care is not infallible and when it goes wrong, the patient must be temporarily hospitalized. Consultation between primary care and the hospital, day care or short stay is essential, both at admission and at discharge. References: Alex Fransen, Vincent Moermans. Training and development on ‘departmental and organizational goals’. th Presentation held during the partner meeting in Genk, 19 of February 2013. ‘Wegwijs in de thuisverpleging’. Wit-Gele Kruis van Vlaanderen. Standaard Uitgeverij (2011). ‘De rol van thuisverpleegkundigen. Vandaag en morgen’. Wit-Gele Kruis van Vlaanderen (2011). 13 I.2.2 Poland What makes proper full long-term home care considering organizational vision and mission? There have been intense debates in Poland concerning the need of creating an integrated, comprehensive and individualized long-term care system that would improve the current situation and, in particular, prepare institutional solutions for the future. It would be an optimal solution to implement a care system based on four cooperating sectors: medical care (in home and stationary conditions) – non-medical care – social care – educational care. This type of combination facilitates holistic treatment of patients, systematic monitoring and information exchange throughout the care process, as well as accommodating proper forms of assistance to people in care. Currently in Poland care services and welfare benefits are provided by two sectors: health care (medical care) and social welfare (social care). Therefore it's very important to put special pressure on cooperation among actual implementers of long-term care (health professionals, social institutions and NGOs employees, professionals involved in providing support for long-term ill patients). It's the key of a development of the full, adapted, simply good basic care. Long-term care in Poland apply to chronically ill and bedridden people whose health condition does not require treatment in an intensive care unit but results in serious problems related to self-care (i.e. inability to sustain self-reliance) making it impossible to manage independently at home. Such people require daily, in several instances 24-hour, professional, intensive care, nursing and continuation of treatment. Health care system provides long-term medical care carried out in stationary (health care centres and residential medical care facilities) and home conditions. Eligibility criterion to enter the longterm care program is the patient’s health condition. Medical services are aimed at both adults and children and include, among other things, services provided by a doctor, nurse, psychologist, as well as rehabilitation, pharmacological and dietary treatment, supplying medical equipment, care services, health education, help with solving health problems related to self-reliance in the home setting, including training the patient, their family members and carer in self-care. Social assistance system assures long-term care in accordance with Social Assistance Act and encompasses care services (stationary) and specialist care services provided in the home setting. Lonely people who, due to age, disease or disability require other people’s help, are entitled to such care. Such benefits may also be granted to a person that requires other people’s assistance in a situation in which the spouse and relatives are unable to provide it. Care services include: meeting everyday needs (cleaning, doing the laundry, shopping, meal preparation), hygienic care, care ordered by a doctor, maintaining contact with other people. Specialist care services are fit for special needs resulting from the type of condition or disability and are rendered by people with specialized vocational training. Taking into account the specificity of polish system there are various services covered by health insurance (free of charge) on the level of home care: - community nursing – on the level of Primary Health Care rendered by a family doctor and family nurse - this form of care can be provided for patients who, due to health problems, require regular nursing services, but are not in long-term home care program and do not qualify for home hospice services for health reasons. 14 - - long-term nursing care of the chronically ill staying at home, executed upon referral from a family doctor or a medical specialist. It includes nursing services (such as intravenous drip infusion, applying dressings, feeding through a tube or a stoma, stoma care, inserting and removing a catheter, bladder irrigation, taking care of an inserted tracheotomy tube), preparing both the patient as well as his family members or carer for self-care, care services (in accordance with the care process), health education, assistance with solving health problems. home hospice palliative care upon referral from family doctor or oncologist. Services include holistic care of patients suffering from terminal, unresponsive to causal treatment, progressive diseases, and aim at preventing and eliminating pain and other somatic symptoms, alleviating mental, spiritual and social suffering, as well as supporting the patients’ family members during the disease and the mourning period. Home nursing care can also be fully chargeable and executed by private medical companies or non-governmental organizations that hire nurses and carers. Within the scope of services provided by Social Assistance (partly chargeable depending on the amount of retirement pension and allowance received by the patient) on home care level the work is carried out by home carers hired by Municipal and District Social Services Centres and informal home carer (family members). The care can also be chargeable and carried out as part of services provided by private business entities and non-governmental organizations. While attempting to accomplish full, integrated home care, apart from long-term nursing care, Mutual Help Foundation strives to provide social welfare services cooperating with carers from the Municipal Social Assistance Centre, organize additional volunteer help, and in case of health deterioration stay in touch with the family doctor and family nurse from the Primary Health Care. District Chamber of Nurses and Midwives, as a professional self-government, associates nurses and midwives practising a profession of public trust. The Chamber’s tasks have significant impact on the quality of caring for chronically sick patients. Among other things, the tasks include: postgraduate education of nurses in the field of long term and palliative care, specialist and professional development courses, promoting health, organizing regional and national conferences. Apart from educational activities, District Chamber of Nurses and Midwives collects opinions and suggestions of problem committees, such as long-term care committee, cooperates with learned societies, higher education institutions and other health care institutions. Opinions of district and national nursing consultants can be found in nurses and midwives self-government professional bulletin. References: Law of March 12, 2004. on social assistance. (Dz.U.2009.175.1362), the date of entry 19.01.2013. Law of 15 April of the medical activity. (Dz.U.2011.112.654), the date of entry 19.01.2013. Law of July 15, 2011. the professions of nurse and midwife. (OJ 2011, No. 174, poz.1039), the date of entry 19.01.2013. Law of August 27, 2004. on health care services financed from public funds. (Dz.U.2008.164.1027, date of entry 19.01.2013. Decree of the President of the National Health Fund No. 83/2011/DSOZ dated. November 16, 2011. on the determination of the conclusion and implementation of agreements such as nursing and care services within long-term care, the date of entry 19.01.2013. 15 Measurement of blood pressure in Poland 16 I.2.3 Hungary Home care and nursing is a new element in the basic care system. Most of the clients in need of care and nursing feel much more comfortable and happy in their own surroundings that they are used to and they like, where they can be with their families. At home, when they are with their families the cooperation and the activity level of the patients is much better, and they feel less vulnerable. Personalised and individualized nursing and caring that is developed following Maslow’s Hierarchy of Needs can be realised in the home environments of the clients. The aim of this person-centred care is to maintain the physical, spiritual and social well-being of the clients, to preserve their human dignity and their quality of life. The unique and individualized nursing plan enhances the cooperation of the patient and helps to reduce the hospitalization damages. Home care and nursing is aimed at providing the optimal circumstances for healing and recovering for illness, and to serve the possible independence of patients suffering from chronic diseases. In the centre of the home care activities are always the client/patient, the family, the nurse or carer, and the nursing team. The home nursing and care activities are always based on the team work of a multidisciplinary professional team. This is the guarantee that the client receiving home care will be treated in an appropriate manner, based on his/her actual needs. The members of the team work according to the indication of the doctor, providing their nursing activities that correspond to their competences. The form of this special kind of health care is defined by the type, extent and needs of the health deterioration of the patient. Similarly the same parameters determine what other nursing and care professions should be involved in an interdisciplinary manner, to complement the home care. Home care is always referred to the patient, his/her family and their home environment. The professional activities of home care cover the medical treatment, nursing, rehabilitation, family help, direct assistance in the home of the patient and the coordination of community resources, in other words, basic home care has a holistic approach. The efficiency of the home care process is depending on the adequate total physical, psychosomatic and environmental assay of the patient. When detecting, recording and documenting the nursing results of the patient, it is not only necessary to plan the professional and precise nursing activity, but also to coordinate the resources and to control the practical nursing process. The nursing and caring process is based on a model of three pillars. The nursing and caring is a „process”, since it includes assay, planning, executing and evaluation; it is a „responsibility”, since it incorporates participation in the actual healing work, in the coordination and it is a „function”, since it categorises the activity groups (based on dostor’s orders, activities to be carried out together with the doctor, and activities to be carried out individually). Nursing and caring are evidence based medical practice, related to the linked competences and supporting environment. It provides worthy and just service for all members of the society, it is patient- and family-centred, practice oriented, and based on a nursing-caring model of supply levels building on each other. Nursing and caring is a profession, a trade represents values, with a commitment to professional development and lifelong learning. Core values of good basic care: Holistic health: The individual always reacts to the effects as a whole person. This concept thinks of a person as a totality of body and soul. 17 Humanism: Humanism as a core value is defined by the personality and the freedom of choice by the individual. It is a principle that all persons are unique and unreproductable. The person takes part in the decision that concern him/her. In relation to this topic, the rights of the patients are included in Act No. CLIV. of year 1997. on Health Care, such as right of self-determination, the right to refuse care, the right to keep contacts, the right to be informed etc. Autonomy: The concept states that the patient is capable of making better decisions concerning him/herself than the service provider professional. This value is not an obligation, but rather a possibility, since the individual transfers the right of decision making. He/she has to be well-informed about the issues and information concerning his/her future, and to be able to make decisions based on these. Partnership: The service provider performs the actions for the patient who is considered an equal partner, a client. The service provider takes into consideration the individuality of the client. The basis of partnership is that the available information is shared to make optimal decision possible. Intensive interpersonal relationships are necessary for this. The decisions are made together by the client and the caregiver during the care and nursing process. The necessary skills are good communication, interpersonal, teaching and psychological skills. All legal control and measures in elderly care should be based on these five core values, and to enable their expression: - dignity - independence - social inclusion and participation - self-expression - security References: Rice, R.: Nursing handbook of home medical care. Medicina, Budapest, 1998. (pp 19-31, 566-568). Act No. CLIV. of year 1997. on Health Care Welfare Minister’s Decree No. 20/1996. (VII.26.). on home nursing activities Oláh A.: Learning book on nursing science. Medicina, Budapest, 2012. Act No. III. of year 1993. on Social Administration and Social Care 18 What is Good basic home care? Good basic home care includes a number of aspects which require attention simultaneously and specifically identifiable for care of the patient in his home environment. These aspects include relation with the patient, presence, dignity supporting care, quality, total care and working together with other health care workers. In Belgium, the role of the home nurse is built around these 6 mentioned aspects. We see some of the same aspects within the basic care in Poland, where good basic care is a combination of medical, non-medical, social and educational care. We refer to the holistic approach or total care of the patient in his home. In Hungary the care is performed in a complex way, including all elements such as pre-caring, physical, medical and psychological care, animation). Care is holistic, specific, individualized and based on the patient’s needs. The caregiver and the client are equal parties in the decisions concerning the care, and the clients are prepared to be involved in their own care. The care and nursing process should serve rehabilitation. Home care and nursing 19 I.3 An introduction to the financing system of health care / home care I.3.1 Belgium The national health care system is based on a social security system. This social security system is based on solidarity between: - employed and unemployed, - the young and the elderly, - healthy people and sick people, - people with an income and people with no income, - families without children and families with children - etc. This solidarity is guaranteed because: - working people pay contributions in proportion to their wages; - the financing is largely done by the community, that are all citizens together; - the trade unions, health insurance funds and employers organisations (mutualities) decide together on the different aspects of the system. The Belgian social security system has three functions: 1. In case of loss of work income (unemployment, retirement, disability) the citizen will receive a replacement income. 2. With certain 'social charges' (additional costs), such as raising children or medical expenses, the citizen will receive a supplement to the income. 3. If the citizen involuntarily does not have a professional income, he receives unemployment benefits. The national health insurance Since the law of 9 August 1963 the sickness and invalidity insurance is compulsory. Because of the rising costs and the financing of the system, there is also by law of 15 February 1993 a compulsory insurance for medical treatments and benefits organized. The health and disability insurance is managed by the National Institute for Health and Disability Insurance (RIZIV/INAMI), under the tutelage of the Minister of Health and Social Affairs. The health insurance funds (mutualities) are the executive bodies of this insurance. In other words, everyone is required to join a health insurance fund, either if entitled, either as a dependent person. That way you can enjoy of the facilities of the compulsory sickness and invalidity insurance, part of a social security. This insurance provides, on the one hand, a reimbursement of the costs health care and, on the other hand, a replacement income in the case of sickness, disability and maternity leave. Employees are by their mandatory health insurance automatically insured for both types of risks. Since 1 January 2008 self-employed persons are also insured for minor risks within the compulsory sickness insurance. The law of 15 February 1993 was made for reasons of cost control of the health insurance. The financing of the system had already been a problem for years. A fundamental structure reform of the 20 health and disability insurance was therefore urgently needed. The reform of the law of 1963 – proposed by Minister of Social Affairs Moureaux – was based on the following principles: - all parties were pointed on their responsibility: the Government, - the insurance companies, the health care providers, the social partners and the patient. - the organizational structure of the health insurance was redrawn and cooperation - between the various partners was optimized with a view to cost control. - decision-making as from now on had to happen as close as possible to the daily reality, - so that the Minister of Social Affairs only had to act as the last actor. - determine the budgetary envelopes of the health insurance was - chronologically separated from the budgetary conclave of the Government. - the instruments for budgetary control were strengthened. Financing system in daily practice National Institute for Health and Disability Insurance (RIZIV/INAMI) Roles and functions in home healthcare: - To determine which interventions are reimbursed: negotiations between care providers and health insurance organizations in the agreement committee - To determine the tariffs of interventions: negotiations between care providers and health insurance organizations in the agreement committee - Control of the proper use of the Belgian Evaluation Scale, which determines the level of reimbursement (Medical Evaluation and Inspection Department) - Control of care delivery (Medical Evaluation and Inspection Department). The Convention The healthcare workers and the health insurance funds make by discipline an agreement with the RIZIV (cf. supra). This is the fact for the physical therapists, the doctors, nurses (also for homecare nurses). This agreement is called the Convention. Each individual healthcare worker may accede to this agreement, in which captured: - the fees and adjustments; - travel costs; - the modalities for the collection of fees, of the direct payment system and for the collection of the contribution; - the penalties for non-compliance of the agreement; - the corrective measures to be taken in the (risk of) exceeding the initial budgetary objective; - the stipulations regarding the role of the nurse in the diabetes treatment trajectories; - the registration number in the RIZIV; - the development and termination of the agreement In the RIZIV-Convention, for each care act a certain amount of money is assembled. If a caregiver provides a certain care act, he may ask the corresponding amount to the patient. The nomenclature 21 value is determined by the product of a weighting coefficient and a multiplication factor (adapted from 1 January each year). Every caregiver has a RIZIV-number he should mention on certificates, applications and other official documents. If the caregiver joined the Convention, he adds a 1 to the RIZIV-number and then he can reach out certificates for given assistant so that the patient can recover a greater share of the cost for the healthcare benefits with his health insurance fund. The Convention is tacitly renewed from year to year. The direct payment system in the home care nursing Within the sector of the home nursing there is generally chosen for the direct payment system. This means that nurses themselves collect the certificates of patients and forward them to the health insurance funds and the interventions of the funds directly paid to them. The patient itself must pay nothing to home nurse pay unless it's about a nursing care act that is not listed in the nomenclature (non-refundable care acts). However, a nurse who did not acceded to the Convention can determine its fees by herself. There are also other caregivers that chose to work with the direct payment system (for example some doctors, some dentists, etc.). Electronic devices help recording of the care tasks at Wit-Gele Kruis in Belgium 22 I.3.2 Poland Health care system in Poland is based on an insurance model. Stakeholders of the system can be divided into the following categories: beneficiaries (patients), health insurance institution which is a payer (National Health Fund), providers, i.e. healthcare entity, medical practices, chemists, etc., review and supervisory bodies, and Ministry of Health, which delineates national health policies. National Health Fund (NFZ) – the primary payer in the system, is responsible for financing health care and concluding contracts with public and private providers. The main source of financing the system is health insurance in NFZ. Citizens are encumbered with compulsory insurance premium which constitutes 9% of personal income (7,75% is deducted from income tax, whereas 1,25% is covered by the insured) and is transferred to health insurance institutions (NFZ). Insurance premiums, incurred entirely by employees, are collected by intermediate bodies and subsequently transferred to NFZ and passed to 16 district units of NFZ. Some of highly specialist services and pre-hospital emergency medical services (emergency ambulance service) are financed directly from the budget of the Ministry of Health, not NFZ. Supplementary private health insurance do not play a key role in financing health care and is predominantly limited to medical packages (so called vouchers) offered by employers. 98% of the population is subject to the mandatory health insurance system. It ensures formal access to a wide range of health care services. However, due to limited resources at NFZ’s disposal, several legally guaranteed services in reality are not invariably available. 1. National Health Fund cyclically puts in a tender for granting health services. Health care providers who offer the most convenient conditions sign a contract with NFZ for providing health care services financed from the public funds. The basic element of the system is a primary health care doctor, most frequently a family doctor, who is responsible for treatment and providing his patients with preventive health care. If a patient’s condition requires specialist treatment, a GP doctor issues a referral to a specialist clinic, hospital, or outpatient (e.g. home) care providers. 2. In Poland the crucial role in terms of long-term care is played by family; only in specific instances public institutions take over the responsibility. The tasks that fall within the scope of assisting dependent persons can be divided into: a. health care system – services provided by the system are stationary or outpatient (at home). The cost of the services is covered by compulsory health insurance premiums, the payer being National Health Fund. In case of home care calculation unit for health services carried out by a nurse is a man-day. In accordance with agreement concluded the payer (NFZ) finances man-days in the monthly-settlement system (e.g. if the patient stayed at a hospital the payer finances the stay, not the nursing care). The amount of subsidy for services established annually finances: nursing service – man-day and basic equipment of a medical nurse briefcase. The benefit does not include preventive care, the cost of commute, administrative expenses, specialist dressings, medical equipment, medicine. b. welfare system – assistance can be provided in the form of pecuniary benefits (designated and temporary benefits) taking into account the income criterion, or non-pecuniary (environmental or institutional care services like in the case of health care system – in this instance income criteria of the person in need are also taken into account). 3. Furthermore, the aforementioned long-care tasks are executed by non-governmental organizations and rapidly developing private sector. In this case the cost of the service depends on the provider. 23 I.3.3 Hungary The Hungarian providing system has two branches: health care and social care. Three levels are known in the service providing system: basic care, outpatient care and inpatient care. Provision of both health and social care is based on solidarity, and responsibility for future generations and those who need health. The legal background of the providing system is regulated by Act No. CLIV. of year 1997. on Health Care and Act No. III. of year 1993. on Social Administration and Social Care, based on the Constitution of Hungary, which declares that every citizen is entitled to the best possible physical and spiritual health. The main functions of the players of the health care system are: - the Parliament and the Government - creation of legal regulation, acts, decrees etc. concerning the system, and possessing ownership of the system, - National Health Care Council - definition and execution of public health tasks , - Local Governments - definition and execution of basic service tasks, - National Health Insurance Fund - definition and distribution of capacities and financing, - Public Health Authority - issuing permits of operation, - professional bodies, departments, NGO’s, chambers - advocacy and advisory tasks. The service provided to citizens is financed by the health contributions paid by tax payers/employees and employers, according to the amount of the income of the employee, to the National Health Insurance Fund. The first line of service of the Hungarian health care system is the basic care system, which has to be provided in or near the place of dwelling of the citizens, in order to have the right to choose a longterm health care service that is based on personal connections, and is independent of sex, age or the type of disease. The service providers of the basic care system are: - family doctor / general practitioner, pediatrician, - dentists basic care, - emergency care, - health visitors’ care, - school health care, - home specialised nursing and home hospice care. The patients choose their general practitioners, and they give their Social Security Cards to them, which is the basis for „card funding”. The second line of service is the outpatient care system. This provides care services within 24 hours, and is financed by a coded system of the healing and related actions that have been carried out, with so-called German points (1 point equals to 1,5 HUF). The third line of care is inpatient care, provided longer than 24 hours., which has acute and chronic disease financing. The active care is is provided by hospitals and clinics, according to disease groups (HBCS), and chronic diseases are treated by departments such as nursing, chronic medical care, rehabilitation care, unconscious patient care/coma treatment, hospice inpatient care. It is financed by a basic fee (5600 HUF/day) times special factors that are determined by the type of nursing. 24 The system of home care The goals: The home nursing care, based on the statutory definition of the patient's home or place of residence, your doctor may prescribe, carried out by qualified nurses. The purpose of home nursing care that the patient receives in their home environment is personalized, humane and proper care. Please use this form supply the number of hospitalizations reduced or shortened duration. The nursing home may be applicable in the case where the patient's health status - with no medical qualifications complex would require hospitalization, but you can replace it may be for home nursing care compiled from treatment. Of home nursing order: - a general practitioner on his own initiative or institution final report - outpatient or inpatient care institution providing care professional immediately if you contract with the provider of home nursing care. In the home nursing care, the following benefits are available: - gavage feeding and fluid intake related to care and teach them, - tracheal cannula cleaning, replacement deposits, and their teaching, - catheterization - associated with intravenous administration, nursing, - In case of accident or post-operative care, and self- limited to ensure the hygiene of the body and facilitate the movement - surgical care areas (open and closed wounds) - manage stomatherapy and drains for different purposes - after surgery profession-specific oral care activities, - ulcers care, decubitus care – wound management - As a consequence of disease temporarily or permanently lost or reduced functions to restore, upgrade or replacement of care within the context of : medical equipment, teaching the use of prostheses, teaching the use of movement and movement means, facilitate the location and position changes. - an additional special procedures as needed: fluid and electrolyte replacement parenteral drug - UH inhalation, respiratory therapy, - the use of suction, - oxygen therapy, - pain management, - speech therapy depending upon the condition of the patient, - physiotherapy, - electric therapy, - in patients performing home parenteral nutrition only chronic intestinal failure, dietary involving, if necessary. 25 Home special nursing is financed by visit units (1 visit = 3000 HUF), the first 56 occassions of which are free for the patient in one year, based on his/her actual needs. The ammount of visits can be increased two times. The system of home hospice specialised care: Home hospice specialised care is provided for advanced stage cancer patients in their homes. The service is free for the patient for 150 days/visits (1 visit = 3200 × 1,2 HUF). The following may be provided as home hospice care tasks: - Basic and special nursing activities - persistent pain specialist nursing jobs - physiotherapy - organization of social activities - dietary care, counselling - mental health care, counselling - medication planning, control The care system is complemented by other special services, such as Ambulance Services, Pharmaceutical and medical device supply, National Blood Services, End of life care – palliative department, hospice house, clinical consulting team, home care, pain ambulance, inpatient care, children hospice. THE SOCIAL SERVICE SYSTEM for personal benefits on taking care cover. The social care system is run by the state, by the local government, churches or civil organisations. The types of care are: - basic and day care may be eligible for people who are in their homes, - temporary and permanent institutionalization is needed placement provides benefits to those for whom The first group of social services by providing personal care, social law of basic services, which constitute the 1993 entry into force of the meals, home care, and belonged to the family support. The recent legislative changes this "special primary care work" supplemented called for support of community psychiatric care and services provisions. The main benefits are intended to provide the socially disadvantaged are those who have no need for the use of residential institutions, in their own homes living environment and provide social support. These include those of the elderly, the handicapped, mental health and addiction patients who do not require the permanent institutional placement or because of illness, disability, or status long-term residential care is not justified. The primary care among provide care for the homeless in local government organization is accordingly. The meals of the socially needy dependents, and provide at least one hot meals a day, who, because of age about themselves and / or their health permanently or temporarily they do not care. The home assistance with daily living and health state of preservation of providing service to those in need at home, which is catering together to be delivered. The need to provide meals for the homeless: - meals on wheels - home care - family Services - advanced primary care jobs 26 - village and remote homestead community service signalling assistance Home care is provided for a maximum of 4 hours daily, based on the daily needs amount of the client, specified by the experts’ opinion. If the daily needs amount of care exceeds 4 hours a day, the service provider informs the client of possibilities of care in care homes. As in the primary care of day care for those in need of care provided, who live in their own homes, but while the meals and home care assistance for their household take place up to the day-care institutions is to ensure that those in need contacting you, and so you get the proper care. - day care - club for the elderly people with disabilities, mental health and addicts day system - living homeless shelters The residential accommodation is to the age, health and social status as a result those in need who are not cared for in their homes, and more than 4 hours a day nursing care needs personal care, appropriate institutions to provide insurance. - care homes for the elderly and disabled mental health and addictions temporary homes - located transitional homeless and night shelter - services providing care homes - rehabilitation centres - homes - parent homes References: Governmental Decree 43/1999. (III.3.) on the detailed regulations of health care services financed by the National Health Fund Oláh A.: Learning book on nursing science. Medicina, Budapest, 2012. Act No. CLIV. of year 1997. on Health Care Act No. III. of year 1993. on Social Administration and Social Care Financing systems of health care / home care? Each participating country uses some form of social insurance system in order to provide basic healthcare to all citizens. For financing the home care in Belgium and Hungary, the social security systems function as the largest stakeholder. In Poland, however the National health Fund has limited resources, making several legally guaranteed services in reality not invariably available. There, the family plays a crucial role in long-term care. Specific to Belgium, there is a convention in which price fixing and payment methods regarding the performed home care is legally registered. It is equally worth noting that ’social care’ makes just as much part of the Hungarian insurance system. Note - in addition to the Hungarian government, churches and civil organizations are other important actors. 27 I.4 An introduction to the training and education system for nurses and health professionals It is an important requirement in the European Union that professional qualifications, and therefore the national educational systems’ outputs can be comparable in the member states, providing the basis for the free flow of skilled care professionals on the labour market. The European Qualifications Framework for lifelong learning (EQF) provides a common reference framework which assists in comparing the national qualifications systems, frameworks and their levels. It serves as a translation device to make qualifications more readable and understandable across different countries and systems in Europe, and thus promote lifelong and life-wide learning, and the mobility of European citizens whether for studying or working abroad. ‘National Qualifications System’ means all aspects of a Member State's activity related to the recognition of learning and other mechanisms that link education and training to the labour market and civil society. This includes the development and implementation of institutional arrangements and processes relating to quality assurance, assessment and the award of qualifications. A National Qualifications System may be composed of several subsystems and may include a National Qualifications Framework. ‘National Qualifications Framework’ means an instrument for the classification of qualifications according to a set of criteria for specified levels of learning achieved, which aims to integrate and coordinate national qualifications subsystems and improve the transparency, access, progression and quality of qualifications in relation to the labour market and civil society. National Qualification Frameworks can be compared by online tools. Presently (May 2014.) 8 member countries have supplied sufficient data for the database for comparision. In the scope of the CARETRAINING project we provide a description of the education and training systems of the participating countries. References: European Qualifications Framework: http://ec.europa.eu/eqf/home_en.htm Compare Qualifications Frameworks (online tool): http://ec.europa.eu/eqf/compare_en.htm I.4.1 Belgium Education in Belgium for nurses and other home care professionals The diversity of education programs in Belgium is linked to the European Qualifications Framework (EQF), one of the existing quality frameworks to determine educational levels. In Belgium, the EQF is used as a common European reference at all levels in education and training, as detailed above. The organization of nurse training in Belgium vary among the different communities, the Flemish, French and German community. The Flemish and French speaking regions are the two major communities, whereas the German community follows mainly the nurse education system of the French community. In both communities, a distinction in the 'basic' nurses, more specialized nurses and nursing support healthcare providers is made. In 2009, the Flemish National Framework of Qualifications was referenced to the 8 levels of the EQF. For the French speaking community only the upper three levels are currently distinguished. 28 The different levels in nursing education and training for the Flemish region extends from EQF 5 until EQF 8, where level 5 stands for the higher vocational/professional nursing education, level 6 for the professional bachelor degree, level 7 for the master degree and level 8 for a PhD. Education programs for 'basic' nurses In the Flemish speaking community, the education programs for 'Basic' nurses are organized at two different levels. The first level is the higher vocational or professional level for nursing. This three-year program for nursing is situated within the qualification level 5 (EQF5), named ‘hoger beroepsonderwijs’ (HBO5) in Flemish. The HBO5 education program prepares for the exercise of the nursing profession. It is situated in terms of educational level between the secondary school and the professional bachelor degree. This education level leads to the recognized European diploma of ‘Graduate nurse’. On the other hand, there is the professional bachelor level for nurses. This education program is situated within the Bachelor-Master structure of higher education. The bachelor-master structure is after signing the Bologna Declaration (2003) the new structure for higher education programs. The higher educational system consists of a professional Bachelor’s degree, an academic bachelor’s degree, a Master’s degree and a PhD degree. The professional bachelor of nursing (EQF 6) is a 3 year course and is organized by university colleges after receiving a secondary school diploma. The professional bachelor educational level and the higher vocational level provide degrees which lead directly to the entrance of the health care institutions. Education programs for ‘specialist’ nurses Holders of a bachelor's degree can obtain a Particular professional title, named ‘bijzondere beroepstitel’ (BBT) in Flemish for a ranch of 5 nursing domains (by federal law registered). To do this, they must follow an advanced bachelor program of 60 ECTS (credits). It gives them an extra bachelor degree (bachelor after bachelor). To carry out the home care, bachelor nurses can obtain a special professional title in geriatrics or in mental health and psychiatry. Graduate nurses have no access to these Particular professional titles. However, Graduate nurses as well as bachelor nurses can acquire a Particular professional qualification, in Flemish named ‘bijzondere beroepsbekwaamheid’ (BBB) for 4 different domains, also legally registered. These domains include geriatrics and mental health and psychiatry, palliative care and diabetics. Beside the Particular professional titles and Particular professional qualifications nurses can follow a postgraduate program. Interesting programs for home care nursing are advanced practitioner in ethics, diabetic educator, palliative care, elderly care. Nurses with a professional bachelor’s degree can become further a Master in nursing degree. The Bachelor - Master structure allows them to do so. This includes two additional years of study on top of the bachelor’s degree. The master's degree is equivalent to EQF7. Holders of a master's degree with the qualification in medicine may legally bear the professional title of doctor. Only masters are admitted to the doctoral nursing program leading to a (PhD)doctorate (EQF8)). 29 Supportive nursing care providers Nurses are assisted by other professional supportive caregivers. In Belgium, there are in the current legal system two different types of support workers, each with their own tasks. Legally they are named: family helper and auxiliary or assistant nurse. The family helper is a polyvalent base worker. This care includes personal care, household services, psychological support and general pedagogical support of the client/patient. The family helper can work in the different health initiatives in home care, with the exception of the home care nursing. The auxiliary or assistant nurse performs the tasks of a family helper. On the other hand, the auxiliary nurse is trained to perform 18 additional nursing support tasks which are determined by law. These tasks are delegated by a nurse. The auxiliary nurse works under the supervision of a nurse and is part of the structured team. They are employed in the field of elderly care, home care, hospital settings and mental health institutions (especially in the psychiatric nursing homes). The training can be given through secondary education on secondary schools or adults can be trained as well. References: http://www.health.belgium.be/eportal/Healthcare/healthcareprofessions/Nursingpractitioners/Accessa ndpracticeoftheprofessi/Particularprofessionaltitles/index.htm#.U39b3vl_v3Q, available on 2 May 2014. http://www.health.belgium.be/eportal/Healthcare/healthcareprofessions/Nursingpractitioners/Accessa ndpracticeoftheprofessi/Particularprofessionalqualific/index.htm#.U39b8_l_v3Q, available on 2 May 2014. Project of the Euregion Meuse-Rhine. (2014). Future proof for cure and care. Brochure Euregionaal kwalificatiekader voor zorgopleidingen: www.futureproofforcureandcare.eu Nuffic. (2012). Country Module Belgium. Information about the structure of the education systems in Belgium and the evaluation of degrees obtained in Belgium: Netherlands organisation for international cooperation in higher education. Counselling in Poland by the home care nurse 30 I.4.2 Poland As one of four countries in Central and Eastern Europe Poland educated nurses in the high school system until the early 1990s. In the face of Poland entering the EU, the education of nurses and midwives started to undergo transformation in the mid 1990s in order to adapt Polish regulations to Council of the European Communities directives. Changes in vocational training of nurses and midwives were initiated in the Nurses and Midwives Act dated 5th July 1996. Ultimately nursing educational system was changed in 2000 and adjusted to the EU requirements. Since then the education takes place at universities and vocational higher education institutions (public and nonpublic). The system is based on two most important international regulations: European agreement on educating and training nurses compiled in Strasburg on 25th October 1967 (signed by the Republic of Poland in December 1995; ratified in March 1996) and WHO Strategy from 1999 concerning the education of nurses and midwives. The system is in accordance with the Bologna Process and includes: - Undergraduate studies – 3-year (bachelor’s degree) - Master’s studies – 2-year (master’s degree) - Bridging studies – (bachelor’s degree) - PhD studies Postgraduate education is part of obligatory education. The objective is to develop the ability to be flexible at taking on new tasks and adjusting them to the society’s needs, mainly including filling in gaps that result from the advance of general and medical knowledge. The forms of education incorporate: specializations, qualifying courses, specialist courses and in-service training courses. There are 20 specializations for nurses, 3 of which concern the care of the elderly and the chronically sick. Specialization takes 2 years and includes: - Geriatric nursing (1030 hours) - Long-term care nursing (900 hours) - Palliative care nursing (1070 hours) In order to carry out home care nurses are required to complete one of the specializations listed above or undergo a 6-month nursing qualifying course in long-term, palliative, geriatric, or family care, or one of various specialist courses, such as courses in wound care, or cardiopulmonary resuscitation. Since 2008 in order to fulfil the need of home care in Poland other specialists have been educated, such as health carers who fall into a category of auxiliary professionals that carry out nursing care either in the home or hospital setting. Health carers are educated in a 1-year vocational college system. A new specialist, an educator of the elderly called a gerontopedagog, geragog in Polish, has appeared in the educational system. It is a person who activates the elderly by organizing their free time, provides emergency aid, and coordinates proper functioning of institutions that deal with care of the elderly. The specialists are educated at 3-year undergraduate studies. I.4.3 Hungary Starting vocational training in Hungary can be possible after finishing primary school (8 years). This can be possible in Vocational schools, Secondary vocational schools or Secondary grammar schools. Levels of various vocational qualifications are different. Training in vocational schools is up to ISCED 3, which lasts 3 years, provides secondary training level, with studying 1 year academic subjects, 2 years vocational subjects. Training in secondary technical schools is corresponding to ISCED 4, lasts 31 4+1 years. The first 4 years end with obtaining General Certificate of Secondary Education (GCSE) to make further studies possible, and continue with 1 year basic vocational training for one specific trade, e.g. social services or health care. Secondary grammar schools last 4+2 years. The first 4 years end with obtaining General Certificate of Secondary Education (GCSE), and continue with 2 years of vocational training to acquire vocational qualification. Vocational qualifications are categorized into 22 trades in Hungary. Vocations linked to home care that are part of the Health care trade: nurse (training for 3 years), and those part of the Social trade are Social worker and nurse (training for 3 years), and Social worker (training for 2 years) followed by specialization in Gerontology for 1 additional year. A brief description of the working field Social worker and nurse Under the guidance of a social expert the Social worker and nurse is able to: - provide personal services outside and in the institutions for the elderly and the handicapped - establish contact with the client and the colleagues - assess the needs of the elderly and/or the handicapped - provide personal services in nursing, caretaking, developing and rehabilitation programs The holder of the certificate is able to: - present emotionally stable and balanced behaviour - perform adequate communication, non-directive assisting discussion - motivate clients - keep the professional and ethical rules - use caretaking devices, handle equipments - use info-communicational devices and the computer - maintain therapeutic appliances Educational modules of Social worker and nurse trade include the following modules: Basic nursing and caretaking module: - - - basic studies of health care (theory) - situation of the society and health - public health and epidemiological studies - health preservation basic studies of caretaking and nursing (theory) - general nursing studies - basic studies of caretaking - documentation of caretaking and nursing observational and first aid studies (practice) - observing caretaking and nursing studies - first aid practice 32 The Assessment of needs module 1. includes: - social studies - clinical studies - - circulation, illnesses of the respiratory and the digestive system - urological and rheumatological studies - dietetical and geriatric studies nursing practice - basic nursing in internal medicine and surgery Assessment of needs module 2. - - caretaking studies - assessment of caretaking needs - caretaking and rehabilitation of the handicapped and addicts - gerontology and rehabilitation of the elderly practice - caretaking needs of the handicapped - planning the process of caretaking Specific caretaking tasks module - theory of social work - practice of social work - social caretaking Caretaking and nursing administration module - administration of nursing and caretaking - information technology Education systems for nurses and health care professionals? Education for nursing is in Poland and Belgium structured within the Bachelor-Master structure. In addition, in the Dutch speaking region of Belgium, a second education for training nurses, although on a lower educational level, is legally organized. (Hungarian system was not so clear to me, please add your text) In all three participating countries, it is strongly recommended that nurses follow additional training programs to cater on the specific care needs of the patient and his/her home environment. It concerns mainly training in geriatrics, palliative care and long-term care. Nurses in home care are assisted by other health professionals, such as auxiliary nurses, family workers, social workers, health carers. The denominations differ a lot between the three countries. 33 CHAPTER II. „CARETRAINING” TRAINING PROGRAM II.1 - THE HOME CARE Introduction to the chapter Chapter II. of the Manual includes an outline and a thematic framework of a training program for home care workers, developed by the project partnership. The themes covered by the program are: - Financing - Competences - Ethics - Communication - Quality of care II.2 Financing II.2.1 Macro Level: State Model – Legal Framework Social protection in Belgium and its financial scheme Social protection is a vast structure that embraces both social security and the right to social assistance. It plays a central role in the protection against poverty and exclusion, and guarantees the cohesion in society. The two components work according the different principles, however: - Social security is a social insurance system whose purpose is to act as a solidarity-based safety net against the loss or lack of sufficient earned income. Social security therefore covers social risks through a vertical (the better-off share the burden with the less well-of) and horizontal (all workers insure themselves against future unequal risks) redistribution. As such, it is a preventive approach. - The aim of social assistance is to ensure the dignity of the individual through the provision of means-tested assistance. Its approach is problem-solution oriented. Sharing the burden 34 The social security system Belgium has different social security schemes. Each has developed independently around particular occupational groups, shaped by the prevailing social, political and economic circumstances. There is a difference between the scheme for self-employed and employed workers but in recent years there came a larger harmonisation between both schemes. The National Office for Social Security (ONSS-RSZ) is the main labor, collecting the social contributions of the workers. It provides overall management of the scheme by : - Collecting employer’s and worker’s national insurance contributions, state subsidies raised from taxation, and share of alternative financing; - Allocating the resources to the different branches in the social security sheme according to need. Employees’ national insurance contributions are calculated as a percentage of their pay and withheld from the gross salary. They create the entitlement to the following types of social security benefit: health care, work incapacity compensation, pensions, unemployment compensation, disability compensations, II.2.2 Meso Level: Management tools The National Institute for Sickness and Disability Insurance (INAMI-RIZIV) The INAMI-RIZIV is responsible for coordinating the health care and disability insurance. Its regulatory authority is the Federal Public Service for Social Security (SPF Sécurité sociale-FOD Sociale Zekerheid). Management: All those involved in health care provision have seats on the INAMI-RIZIV’s management bodies: - Public authorities; - Sickness funds; - Care providers (doctors, dentists, ancillary medical staff, etc.); - The social partners (trade unions, employers, small firms and trader’s organisations) Responsibilities: The INAMI-RIZIV allocates funding between the national unions of sickness funds and the auxiliary fund. In addition to general management of the health care and disability insurance, the INAMI-RIZIV also has the following responsibilities; - Composition of the standard coded schedule of medical care provision and the refund rates; - Approval of care providers and care facilities; - The conclusion of the agreements between doctors and sickness funds; - Recognition of disability; - Operational oversight of sickness funds; - Management of sickness funds’ financial accountability. 35 Structure: The INAMI-RIZIV comprises the following departments; - Health care; - Disability; - Evaluation of medical control; - Administrative control Each service has its own specifically-composed management bodies. II.2.3 Micro Level: Cost awareness - Sustainability On the micro-level are situated the sickness funds. They have a direct contact with the public and reimburse the costs to the patient and/or provider. Sickness funds in Belgium are organised as „mutual associations” with governing bodies, elected by their members. They represent the patients’ interests in the setting of reimbursement schemes. But they also have a view on the overall expenses and a financial responsibility in the management of health care. As such, they have both to take into consideration the demands of the patients (specifically of the social weaker groups) and of the national health authorities (in order to respect the budget for health care). Mutual associations play a vital role in the cost awareness on micro-level in Belgium. They organise this through information-campaigns, oriented to both the patients and the providers. But mutual associations in Belgium are also responsible to guarantee access for all population to a quality health care, on basis of a effective solidarity. This guarantees the sustainability of the national public health insurance scheme. The development of a volunteer movement contributes to this approach, as well as the focussing in alternative care, that keeps the patient as long as possible in his home environment. Wound treatment is part of the nursing tasks in Belgium 36 II.3 Competences II.3.1 Macro Level: Expectations of the organization HRM policy To perform nursing or caring activities, only those members of the health or social care staff are entitled, who are capable to do so, i.e. are in the suitable health, mental and physical conditions to perform such tasks. While performing these, the member of staff doesn’t pose a threat to his/her health or safety, or the health or safety of the client. The aim is - according to relevant legal regulations - to supply well trained adequate manpower to perform the tasks at suitable quality and quantity. The expectations and HRM needs of the organisation are to employ professionals who are well trained, possess the necessary professional, social and communal competences, have relevant practical experience, possess the prescribed permits and registry of operation, memberships in relevant professional chambers and have passed the test of eligibility. II.3.2 Meso Level: HRM tools A crucial criterion of the success of efficient care, and its adaptability to changing circumstances is the strategic planning and conscious management and development of resources. Strategic human resource management plays an equally important role in the everyday operation of organisations, in increasing of their competitiveness and in keeping their internal integrity. Health and social care is a branch that requires well trained, specially skilled work force in large number. The continuous maintenance of knowledge and lifelong learning are essential. The demand in the labour market is very high for skilled and experienced staff. The services they provide are basic for the society. II.3.3 Micro Level: Attitudes and competences of employees Introduction Competence is the ability or capacity, connected to the nursing role. That ability and suitability for being a nurse can be acquired through their studies. The nursing competence, however, can only continue to prevail in patient care, the nurse will keep you in the role of a „nursing school student”, or continuous improvement, change and it displays the following acts of nursing behaviour. To this end, as nursing leaders is seen as their responsibility to work fields to be systematic and purposeful learning process of nurses, this should provide a strong support. Four levels of the competency model Technical competences (professional knowledge, skills, abilities) The professional competencies are manifested in the mode, as we recognize the problems as they are differentially analyze and overcome operational procedures were developed. But manifested in the fact that we are able to knowledge, knowledge to organize, integrate, create new linkages, seek new solutions to be evaluated. Personality competences (internal values, stability, self-management, task orientation, willingness to learn) A personal reflection on the ability of competencies, as well as their strengths and areas for improvement in identifying and raising awareness expressed. These competencies specifically the 37 self-confidence and self- motivation manifested for example. Has its own individual insights, recommendations, solutions, whether we take responsibility, we are open to change) Social competences (coping skills, teamwork, effective communication, leadership skills) Social competence in the abilities manifested through which constructive working relationships we make long-term and stable contacts we create common goals and plans carried out. The high social competence units such as assertive communication - in case of differences of opinion - the open expression of their feelings, the use of self- communication, active listening and respectful treatment of others Methodological competences (analysis, design and abstraction, implementation and management, information processing and transmission) The methodological skills are described as cognitive abilities, which acquired the professional skills and knowledge in accordance with the methods developed independently, flexibly and effectively used. The methodological competencies we can observe in the mode of knowledge as complicated or complex phenomena structured, goal-oriented as we are treated like we are important are able to distinguish and emphasize as a focused manner and the results are to be obtained. The concept of competence The term competence includes the knowledge, skills, abilities and behaviours, which are required for the work and the results of the corresponding key to achieving the objectives of health care. Competence may change as a form of service, job function, individually but in each case determining the qualification and training requirements. The nursing competences necessary to determine the identities of the activity which is not in itself sufficient to obtain a specific nursing qualifications, but also a separate legal reassurance is needed. Necessary to isolate the independent, working with the physician and the physician to determine the activities of competencies. Competency objectives Objective 1: to improve the transparency and recognition of qualifications and competences: It helps to increase transparency and comparability of vocational education programs between the partner countries. The Competence Matrix makes these programs standardised and comparable with each other with regard to contents and aims. Objective 2: to improve the quality and to increase the volume of mobility throughout Europe: This project supports participants in the recognition of knowledge, skills and competences and therefore facilitates their personal development, employability and participation in the European labour market. Objective 3: to facilitate the development of innovative practices in the field of vocational and educational training and continuing education and training: A European labour market requires European-level information and monitoring. Target groups - Students-in-training/apprentices/job-seekers/practitioners in the field of „elderly care“ - Providers of vocational and educational training/continuing education and training /higher education - Employers/HR-departments 38 - Social partners - Policymakers - All other stakeholders who deal with the development of the European Qualification Framework for Lifelong Learning. - Public Employment Services - Funding Competences areas 1. Preparing, applying, assuring daily care 2. Preparing, applying, assuring medical care 3. Creating and maintaining a health promoting care environment 4. Communicating and consulting different target groups involved in the care process 5. Planning, documenting, assessing care processes 6. Expand and regularly update working methods and theoretical knowledge 7. Reflect and handle the impact of the job on the care giver and develop a job-related selfunderstanding Expectations, attitudes and competences of employees - communication skills accurate oral and written communication, logical and clear definite and understandable wording, be able to communicate in a positive manner, as the case, develop and implement communications with the communication technique - management skills managerial tasks, knowledge management problems daily, group leader to behave, conflict management, breadth of vision, problem-solving ability, self-management, the observed accurate communication with members of the healing team, be able to work in independent and professional groups, to develop interpersonal relationships and maintaining, get to know the concept and criteria of health and human specificities of somatic, psychological and social status, Co-operate with health and social services as a whole design, development, and execution of such works evaluation - using a foreign language oral and written communication, foreign language skills, the capability of mother language and foreign language conversation and correspondence - IT skills knowledge application and user level, knowledge of basic software - personality traits people skills, integrity, adaptability, integration, empathy, diligence, an ambition, openness, receptivity to learning, self-knowledge, self-discipline, sociability, the individual, family, community psychologically leads, the patient's somatic, psychological and mental 'needs promote, physical and emotional conditions, situations related to the health of an individual observation,, the dying psychological management, psychological support for family members, efforts to solve the people's 39 problems, cooperation, trust and acceptance intermediary behaviour, be able to provide adequate general and nursing professions behavioural, standards applied (individually and in groups), be able to lead an individual (individuals) to psychological, preserving the patient 's dignity, the environment of care to participate in preparing and involving, consulting carries out tasks, high level of responsibility and sense of vocation, standards applied (individually and in groups), external and internal causes and effects caused by the threat and / or critical condition identify and act accordingly, individual and person-centred care implementation, taking into account the patient's (young) mental condition. References: Hungarian Chamber of Health Care Professionals: List of competences Oláh A.: Learning book on nursing science. Medicina, Budapest, 2012. Health, Social and Family Affairs Minister’s Decree No. 60/2003. (X.20.) on the minimum professional requirements of providing of health care services Welfare Minister’s Decree No. 20/1996. (VII.26.). on home nursing activities Team briefing and discussion is an important element of quality management of home care 40 II.4 Ethics II.4.1 Macro Level: Ethics policy (end of life) In the following paragraphs, we want to address the need for ethics policies on end-of-life care, to define a written institutional ethics policy on end-of-life care, and to describe some recommendations regarding the development and implementation of written institutional ethics policy on end-of-life care. The text is mainly based on the findings of the dissertation of Joke Lemiengre: „Written ethics policies on euthanasia in Flemish hospitals and nursing homes: An empirical-ethical study on development, content and impact”1. Physicians and nurses are constantly confronted with decision-making processes that are ethical in nature. Dealing with ethical dilemmas that occur in daily care situations (e.g. use of physical restraints) and those that occur in extreme situations (e.g. cases involving the beginning or the end of life) challenge healthcare providers to search for appropriate ethical responses (Lemiengre, 2010). Recent research shows that more than half of the ethical dilemmas in clinical settings involve end-oflife issues. Thus, as care providers are frequently confronted with these kinds of dilemmas, patients, relatives and society expect providers to deal with them in a professional and ethical way. Medical end-of-life decisions (MELDs) are common in contemporary clinical practice. A substantial proportion of al deaths in Europe are preceded by some form of MELD 2. MELDs include whether to withhold or withdraw potentially life-prolonging treatment – e.g. mechanical ventilation, tubefeeding, and dialysis; whether to alleviate pain or other symptoms with, e.g. opioids, benzodiazepines, or barbiturates in doses large enough to hasten death as possible, but not intentional, side effect; and whether to consider euthanasia or physician assisted suicide, which can be defined as the administration, prescription, or supply drugs to intentionally end life at the patient’s explicit request. Healthcare institutions can take responsibility for dealing with MELDs by the development of a written institutional ethical policy as a possible organizational-ethical instrument. Written institutional ethics policy is defined as written agreements (statements, procedures, guidelines, protocols, etc.) authorized at an institutional level to guide care providers when approaching a clinical-ethical problem that includes a decision-making process and/or phased plan. Such a policy contains both a position paper describing the institution’s stance on MELDs together with the 1 Lemiengre, J., Dierckx de Casterlé, B., Denier, Y., Schotsmans, P., and Gastmans C. How do hospitals deal with euthanasia requests in Flanders (Belgium)? A content analysis of policy documents. Patient Education and Counseling 2008; 71(2): 293-301; Lemiengre, J., Dierckx de Casterlé, B., Denier, Y., Schotsmans, P., and Gastmans, C. Content analysis of euthanasia policies of nursing homes in Flanders (Belgium). Medicine Healthcare and Philosophy 2009; 12(3): 313-322; Lemiengre, J., Dierckx de Casterlé, B., Van Craen, K., Schotsmans, P., and Gastmans, C. Institutional ethics policies on medical end-of-life decisions: a literature review. Health Policy 2007; 83(2-3): 131-143; Lemiengre, J., Dierckx de Casterlé, B., Verbeke, G., Schotsmans, P., and Gastmans, C. Ethics policies on euthanasia in hospitals: a survey in Flanders (Belgium). Health Policy 2007; 84(2-3): 170-180; Lemiengre, J., Dierckx de Casterlé, B., Verbeke, G., Schotsmans, P., and Gastmans, C. Ethics policies on euthanasia in nursing homes: a survey in Flanders, Belgium. Social Science and Medicine 2008; 66(2): 376-386; Lemiengre, J., Gastmans, C., Schotsmans, P., and Dierckx de Casterlé, B. Impact of written ethics policies on euthanasia in hospitals from physicians’ and nurses’ perspectives: a multiple case study. Primary Research Journal of the American Association of Bioethics 2010; 1(2): 49-60; Lemiengre, J., Dierckx de Casterlé, B., Schotsmans, P., Gastmans, C. Written institutional ethics policies on euthanasia: an empirical-based organizational-ethical framework. Medicine, Health Care and Philosophy, 2014 (in press). 2 van der Heide, A., Deliens, L., Faisst, K., Nilstun, T., Norup, M., Paci, E., van der Wal, G., & van der Maas, P. End-of-life decision-making in six European countries: descriptive study. The Lancet 2003; 362(9381): 345-350. 41 philosophical and ethical legitimation of this stance, and a concrete procedure that includes a comprehensive concrete and practical guideline that covers clinical, legal, ethical, psychological, social and existential aspects of care, with special attention to the integration of palliative care and interdisciplinary cooperation. We recommend the development of written ethics policies on MELDs at institutional level as dealing with institutional ethical responsibility because of two reasons. Firstly, they have an external (societal) responsibility. As MELDs have become widely debated in many European countries, healthcare institutions are increasingly being confronted with these highly relevant societal issues. Consequently, hospitals, nursing homes, home care organizations and other healthcare institutions are not isolated, they operate within a broader society. Therefore, they should cultivate an open and critical attitude toward current trends in society, and especially toward societal evolutions that affect their core business, namely guaranteeing good patient care that meets the current scientific and social criteria. Secondly, they have an internal responsibility. In order to fulfil this responsibility, healthcare institutions should create adequate conditions for care providers to enable them to ensure good patient care by supporting them in dealing with ethical issues3. Research suggests that ethics policies could be a first and crucial step in taking on responsibility by creating transparency and stimulating professional practice. However, it is important to stress that administrators must put more effort to support the ethical dimension of care processes. Indeed, although ethics policies do have the ability to support the ethical practice of care providers, study findings suggest that the impact of these policies on ethical practice is rather limited and variable. If the policy is not to be merely used as window-dressing, administrators and managers must take responsibility to actively support (and not only in a symbolic way) and create an ethical climate supporting care providers who have to deal with ethical dilemmas in their practice4 (Lemiengre et al., 2014). Developing an ethical climate by means of the development of written ethics policy requires an active role of local institutional ethics committees, together with the support of the organizational management. By integrating the advisory (policy development), consultancy (in clinical practice), and educational tasks of ethics committees, ethics can be integrated more into clinical practice. By organizing ethics education and by providing ethics consultations, ethics committees can take on a more visible role in healthcare institutions, one that can actively support the implementation of ethics policies in practice. By investing in all of these kinds of activities, ethics committees can do more than being an administrative solution to ethical issues in healthcare institutions and may stimulate ethical reflection in clinical practice (Lemiengre et al., 2014). Therefore, to realize an ethical climate, we address the importance of the interpersonal dimension of ethics policy work, which is also mentioned by Frolic et al. (2012)5. Responsive evaluation” as addressed by Schildman et al. (2013)6 offers interesting opportunities to use the strength of dialogue with all stakeholders to evaluate the ethics policy and to understand and to reflect upon the practice. Instead of having a ‘procedural’ approach of evaluation Schildman et al. (2013) propose that responsive evaluation corresponds with a fundamental issue of ethics: a continuous reflection upon 3 Winkler, E. The ethics of policy writing: how should hospitals deal with moral disagreement about controversial medical practices? Journal of Medical Ethics 2005; 31(10): 559-566. 4 Lemiengre, J., Dierckx de Casterlé, B., Schotsmans, P., Gastmans, C. Written institutional ethics policies on euthanasia: an empirical-based organizational-ethical framework. Medicine, Health Care and Philosophy, 2014 (in press). 5 Frolic, A., Drolet, K., Bryanton, K., Caron, C., Cupido, C., Flaherty, B., Fung, S., and McCall, L. Opening the black box of ethics policy work: Evaluating a covert practice. The American Journal of Bioethics 2012; 12(11): 3-15. 6 Schildmann, J., Molewijk, B., Benaroyo, L., Forde, R., and Neitzke G. 2013. Evaluation of clinical ethics support services and its normativity. Journal of Medical Ethics 2013; 00:1-5. Doi:10.1136/medethics-2012-100697. 42 the leading question ‘what is good care?’. Consequently, responsive evaluation is not purely an evaluation method, it is a way to stimulate an ongoing process of ethics education in practice (Lemiengre et al., 2014). II.4.2 Meso Level: Reflections and suggestions for ethical decisionmaking from the ethics of care perspective A dominant model in medical ethics is the principlism perspective. From this viewpoint, good care can be defined in rights and duties, which are expressed in four important principles, namely, respect for autonomy, non-maleficence, beneficence and justice. An important feature of the principles approach is its time-limited or action-focused quality. The central question is always: ‘‘What is to be done?’’, that is, ‘‘What act or decision is to be taken, under what intentions, and with what foreseeable consequences?’’ The primary focus is a specific, delimited act or choice (e.g. act of euthanasia and sexual act), not, for example, a dynamic process of care or questions about someone’s attitudes. However, ethical dilemmas that nurses face cannot be contained within a few isolated decisions made in a single moment of time. Nurses caring for patients go through a whole process of care, during which they, in close interactions with patients, their relatives, and physicians, continually have to make minor and major decisions linked to daily life issues such as hygiene, eating and drinking, intimacy and sexuality, and so on. It is the whole history of the care process and its embeddedness in patients’ personal life story, and the relationships between all involved in the care process, that is crucial7. For instance, being involved in the care process for patients with at the end of life requires more than taking the right decision at a certain moment. It implies a continuous involvement of nurses with all their cognitive, attitudinal, communicative, and interpretative capacities. The ethical quality of this integral care practice should be the focus of a nursing ethics approach. Ethical decision-making from the ethics of care perspective gives important attention to explore and understand the relational embeddedness of ethical problems. Ethical problems relate to the tensions between the responsibilities of people who live and work in a network of relationships. For instance, a decision about withholding artificial fluid and food in case of a patient suffering in the terminal stage of dementia, puts the relational network under severe pressure. To reduce the pressure, it is important that all concerned are involved, acknowledged, and can understand the final decision. In this respect, several papers are published about ethical decision-making with attention to the relational embeddedness of ethical problems8. 7 The following paragraphs are based on the following papers: Verkerk, M., Lindemann, H., Maeckelberghe, E., Feenstra, E., Hartoungh, R., & De Bree, M. Enhancing reflection: an interpersonal exercise in ethics education. Hastings Center Report 2004; 34(6): 31-38; Vanlaere, L., & Gastmans, C. Ethics in nursing education: Learning to reflect on care practices. Nursing Ethics 2007; 14(6): 758-766; Gastmans, C., Dierckx de Casterlé, B., Schotsmans, P. Nursing considered as a moral practice: A philosophical-ethical interpretation of nursing. Kennedy Institute of Ethics Journal 1998; 8: 43-69. 8 Abma, T., Molewijk, B., & Widdershoven, G. Good care in ongoing dialogue. Improving the quality of care through moral deliberation and responsive evaluation. Health Care Analysis 2009; 17(3): 217-235.; Molewijk, B., Abma, T., Stolper, M., & Widdershoven, G. Teaching ethics in the clinic: The theory and practice of moral case deliberation. Journal of Medical Ethics 2008; 34:120-124.; Molewijk, B., Zadelhoff, E., Lendemeijer, B., & Widdershoven, G. Implementing moral case deliberation in Dutch health care: improving moral competency of professionals and quality of care. Bioethica Forum 2008; 1(1): 57-65. 43 II.4.3 Micro Level: “Nurses as reflective practitioners” Care ethics as theoretical inspiration source9 Nursing is essentially concerned with good patient care. Care is a complex concept. “What makes care good care” has been studied from several perspectives. Since the nineties, the ethics of care perspective evolved to an inspiring moral theory in healthcare ethics (Gastmans, 2006). According to Joan Tronto (1993), founder of the ethics of care, “good care entails care acts – and the skilled execution of these – that express an attitude of caring”. Gastmans et al. (1998) defines the essence of nursing as “the precise integration of expert activity (knowledge and skills) and caring (virtue)”. From this view, care is not only a way of life, but also an ethical task. The goal of nursing can be described as the promotion of patient well-being by providing good care in the broader meaning of the word, namely, on a physical level. Care ethics acknowledges the most profound vulnerability of people and is therefore fundamentally critical of the excessively pursued Western ideal of the intact, youthful body and of individuals acting autonomously. The relational dimension of care ethics emphasizes that giving and receiving care results in a meaningful relationship of engagement with each other (van Heijst 2005; 2011). Tronto (1993) distinguishes four phases of the care process. The first phase ‘caring about’: worrying about someone or something troubled, and seeing and understanding the vulnerability of the care receiver as the starting point of care. The corresponding ethical attitude is “attentiveness”. Attentive care providers take up a receptive position with genuine recognition of and respect to the care receiver; they are challenged to step out their own personal reference system and prejudices in order to have a better understanding of the care receiver’s real-life situation. In the second ‘taking care of’ phase, care providers have to take responsibility for initiating care activities. In her view, care starts from a genuine concern felt for someone else. People must be sufficiently attentive in order to confirm a specific need for care. It requires someone (else) taking the responsibility to respond to the need for care. Usually it is yet someone else who then provides the actual care, based on prevailing professional standards. The strongly innovative element of Tronto’s theory is that she calls for attention to the manner in which the unique care recipient responds to the care provided, and how this reciprocity challenges the care giver to reflect on the care provided. Each care context is unique and the cluster of relational involvements, as described by Joan Tronto, clarifies the weight of this unicity. The various people involved in providing care and the care recipient all contribute to this unique care context. In her latest book published in 2013, Tronto adds a fifth phase to caring process: caring with. “This final phase of care requires that caring needs and the ways in which they are met need to be consistent with democratic commitments to justice, equality, and freedom for all” (Tronto 2013, 23). 9 Text is mainly based on the following papers: Tronto, J. Moral boundaries. A political argument for an ethic of care. New York: Routlegde 1993; Gastmans, C., Dierckx de Casterlé, B., Schotsmans, P. Nursing considered as a moral practice: A philosophical-ethical interpretation of nursing. Kennedy Institute of Ethics Journal 1998; 8: 43-69; van Heijst, A. Menslievende zorg. Een ethische kijk op professionaliteit (in Dutch: Human loving care. An ethical perspective on professionalism). Kampen: Klement, 2005; Vanlaere, L., & Gastmans, C. To be is to care: a philosophical-ethical analysis of care with a view from nursing. In: Leget, C., Gastmans, C., & Verkerk, M. (eds.). Care, compassion and recognition: an ethical discussion. Leuven: Peeters, 2011, 15-32; Tronto, J. Caring democracy: Markets, equality, and justice. New York and London: New York University Press, 2014. 44 Nurses as reflective practitioners: Care-ethics lab as educational project10 Care providers are expected to be able to reflect on the ethical aspects of their own practices, which means that they need to be able to determine what is ‘good care’. When care providers’ ethical reflection and ability to integrate their personal involvement and empathy into their overall ethical ability happen, their education on ethics need to include more than just ethical theory. Care ethicists believe that care providers learn ethical reflection ‘by doing’, not only by acquiring theoretical knowledge. In 2008, the care-ethics lab sTimul was founded in Flanders, Belgium, to provide training that focuses on improving care providers’ ethical abilities through experiential working simulations. The curriculum of sTimul focuses on empathy sessions, aimed at care providers’ empathic skills. An empathy session consists of a two-day and one night session in which 8 to 12 care providers receive simulated care as patients. They take on the profile of a patient in need of care, and they receive care from nurses in training who act as care providers during the empathy session (bathing, feeding, caring, recreation, etc.). The afternoon of the second day is dedicated to discussing and reflecting on what the care providers, in their capacity as patients, and their simulated care providers experienced during the empathy session. After a month, care providers’ are invited to attend a reflective intervision session about what they try to do with their experiences in actual nursing practice. The first explorative studies show promising results: Providing contrasting experiences affect the care providers’ ability to self-reflection. However, further research is needed to provide more insight into how empathy leads to long-term changes in behaviour. II.5 Communication II.5.1 Macro Level: Communication on top level In order to sustain continuity of financing medical services in the area of palliative and long-term care, a constant contact with an insurer should be maintained – reporting and accounting for the services provided. NFZ (National Health Fund) performs a function as the insurer in Poland. Each home care team member visit is noted in a nursing visit record, marked with the date of the services provided and signed by the patient, their family member, or the actual guardian. In Poland a bill with an enclosed statistical report includes information regarding the number of visits constitutes the basis for settlement and financing services provided in the course of the reporting period. Healthcare provider submits a bill and a digital statistical report to the relevant branch office of the National Health Fund (NFZ) by the 10th day of the month (for the previous month). The statistical report subsequently undergoes verification by the Fund’s office. A significant element of working in palliative and long-term care facilities is also maintaining communication with external organizations bringing aid to patients with long-term illnesses, general 10 The following paragraphs are mainly based on the following papers: Vanlaere, L., Coucke, T., & Gastmans, C. Experiential learning of empathy in a care-ethics lab. Nursing Ethics 2010; 17(3): 325-336; Vanlaere, L., Timmerman, M., Stevens, L., & Gastmans, C. An explorative study of experiences of healthcare providers posing as simulated care receivers in a ’care-ethical’ lab. Nursing ethics 2012; 19(1): 68-79. Verkerk, M., Lindemann, H., Maeckelberghe, E., Feenstra, E., Hartoungh, R., & De Bree, M. Enhancing reflection: an interpersonal exercise in ethics education. Hastings Center Report 2004; 34(6): 31-38. 45 practitioners, Social Assistance Centres, as well as pharmaceutical and medical equipment manufacturers, etc. Patients’ families, who learn during the first visit what kind of help they might expect from particular medical and social organizations, most frequently contact primary healthcare doctors and nurses. In exceptional circumstances palliative or long-term care nurses schedule appointments with primary healthcare nurses in order to plan and discuss joint assistance that would be provided to the patient. In the event of stating, during home visit, that the patient’s state of health has changed due to disease exacerbation or developing complications, the nurse is obliged to immediately consult a primary healthcare doctor about the ensuing situation, or, if necessary, to call emergency medical services. Furthermore, the palliative or long-term care nursing coordinator is obliged to notify both the primary healthcare doctor and nurse about the exact time when rendering the services to the patient started and ended, and, as part of current cooperation within the period under care, about significant changes in the patient’s health that would condition alterations in the services provided. All the information is handed over in written form, also via e-mail and any serious changes in the state of health are to be reported on the same day they have been recognized. II.5.2 Meso Level: Communication with stakeholders Doctor’s referral constitutes key document which entitles to long-term or palliative care. Referrals issued by health insurance doctors include essential information related to the patient’s state of health and required treatment. During the first encounter with a long-term or palliative care facility the patient is registered in the computer system under a subsequent number. Each application consists of basic data: applicant’s surname and telephone number, patient’s personal data, carer’s personal data and telephone number, diagnosis and ailments, date and time of accepting the application. The facility worker vets the application in terms of correctness, completeness and explicitness. Personal data and telephone numbers are subject to particularly close scrutiny. Additionally, each application is verified with special attention paid to the possibility of providing effective aid within the scope of long-term or palliative care. Only if meeting the patient’s requirements is viable, the facility worker is able to schedule an appointment. In the course of the first visit a long-term home care nurse carries out a reassessment of the patient’s state of health and arranges her schedule basing on previously diagnosed nursing problems. The nurse is responsible for familiarizing the patient and their family members with the work schedule and methods of obtaining medical supplies essential to carry out care and nursing services. Palliative care centre worker, however, schedules a doctor’s and nurse’s appointment with the patient’s family or carer. They might also suggest an alternative form of medical consultation, such as referring the patient to a Palliative Medicine Clinic, arranging a home visit of a hospice doctor, admitting the patient to a stationary ward, seeking consultation among doctors from the patient’s other medical facilities, and an alternative one depending on the situation, needs and arrangements made by interested parties. As a result of various consultations the doctor states whether the patient is either eligible for palliative-hospice care or should undergo treatment in other medical facilities. A nurse maintains an actual contact with the patient and their family and an ad hoc contact with the primary healthcare doctor and nurse. 46 Each patient and their family get information about telephone numbers of the health team, the lead nurse and the doctor, as well as numbers of round-the-clock telephone services to an on-call doctor and nurses from the stationary ward. Each patient must receive help or, alternatively, be instructed as to where they may seek such help. Therefore all guides issued by various organizations, or palliative care clinics that include information related to institutions, the scope of help such institutions provide, and procedures of obtaining them, are welcome. II.5.3 Micro Level: Bedside communication - Counselling - Digital communication It should be noted that enduring physical pain is a long-term experience for the ill persons as well as for their family and close ones. Faced with an illness and numerous problems patients are frequently unable to manage on their own. The key objective of long-term and palliative care is to improve patients’ quality of life to the greatest extent possible. Nurses, who encounter patients while catering for their nursing needs on a daily basis, commonly become their confidants and play a significant role in the final weeks or days of another human being. Nurses are responsible for alleviating suffering which entails caring assistance in enduring both physical and emotional pain of each individual patient. Nurse’s fundamental role in palliative and long-term care is to accommodate the patient with reasonably optimal quality of life, including providing support and assistance for the patients’ families in the course of the illness and bereavement period. By opening to communication with the patient and their world as well as learning about their life history, one may draw on their experiences and knowledge. Active listening, the core of effective communication, is essential while interacting with the patient. Being skilled at listening to and comprehending what the patient attempts to convey, either verbally or non-verbally, is extremely beneficial to communication. This also involves the ability to patiently hear out the patient’s family, not only on the matter of complaints, but also emotions and spiritual distress. Experiencing an illness triggers off a variety of reactions, such as: screaming, crying, or anger. The carers are therefore expected to maintain clear communication and, additionally, display patience and understanding. Each human being is different and experiences their own illness and passing in another way. Conversation with the patient should be based on clear and honest information as well as gaining and maintaining trust. Such rule should concern all conversations, particularly the most difficult ones – related to the patient’s future fate, suffering and passing.Facing the truth may either motivate the patient to take up an intensive battle against the illness or result in depression and frustration. The problem is to recognize whether the patient prefers to learn the truth or remain unaware of the situation. Palliative and long-term care workers’ first-hand experiences indicate that patients who are aware of the illness and its consequences (with families also being aware) have a greater chance to experience the final stage of the disease with their close ones in a full, more creative way, devoid of pretending, lies, and avoiding certain topics. Moreover, such approach 47 facilitates the possibility to support one another in situations when very strong, almost unbearable feelings and emotions stand in the way of accepting one’s own mortality. Excellent observation skills and recognizing patients’ needs, even the non-verbal ones, is essential to take care of the sick. It is important to notice the patient’s hardships as well, the fact that they might be guilt-ridden and embarrassed, and put their suffering before being a burden to somebody. Nonverbal communication with the patient should not be disregarded either. The significance of touch, which can be a source of solace and support, is invaluable. Needless to say, providing spiritual and psychological support is an extremely important responsibility of a palliative and long-term care nurse. If giving hope for restoring a patient to health and prolonging their life is not an option, it is necessary to offer what is still possible, such as: support, company – also during the most difficult moments, the best nursing and care possible, alleviating the suffering effectively, caring for the patient’s close ones, engage in conversations, preparing the family for care of the loved one and their passing. References: Augustyn M., Błędowski P., Wyrwicka K., Łukasik J., Witkowska B., Wilmowska - Pietruszyńska A., Czepulis – Rutkowska Z. : Opieka długoterminowa w Polsce. Opis, diagnoza, rekomendacje. (Long-term care in Poland. Description, diagnosis, recommendations.) Warszawa 2009. Wieczorowska – Tobis K., Talarska D. (red.): Geriatria i pielęgniarstwo geriatryczne. Podręcznik dla studentów medycznych. (Geriatrics and Geriatric Nursing. Handbook for medical students.) Wyd. PZWL, Warszawa 2008,Kędziora – Kornatowska K., Muszalik M. (red): Kompendium pielęgnowania pacjentów w starszym wieku. (Compendium of nursing in elderly patients) Wyd. Czelej Lublin 2007, Kleja J., Filipczak-Bryniarska I., Wordliczek J.: Komunikacja w opiece paliatywnej. (Communication in palliative care). Medycyna Paliatywna w Praktyce 2010, tom 4, nr 2 II.6 Quality of care II.6.1 Macro Level: Laws & policies concerning quality of care management You can be assured of the highest-quality medical care in Belgium, regarded on a par with the best healthcare systems in Europe. As in most countries, the system divides itself into state and private, though fees are payable in both, so you need to ensure that you are adequately covered through either the state insurance and/or private insurance. The advantages of the state mutuality scheme is that you can choose any doctor, clinic or hospital you like, in any location and without referral, according to your needs, in much the same way as you can with private insurance. 48 Patient rights law The rights and duties of physicians and patients are regulated in the law on the rights of patients of 22 August 2002. Patient means ‘the natural person to whom health care services are provided, whether at his request or not’ (Art. 2, 1°). This means that a patient is also someone who undergoes an examination of his state of health at the request of a third party, for example an employer or insurer. Health care means ‘the services that a health professional provides in order to promote, determine, preserve, restore or improve a patient’s state of health or in order to support a dying patient’ (Art. 2, 2°). This is a customary definition of health care. Removing an organ from a donor, terminating a pregnancy and performing euthanasia are therefore activities which do not constitute health care in the sense intended by the law on patient rights. They are regulated by other acts. Moreover, medical experiments involving persons are not covered by the law’s domain of application. For the purposes of the patient rights law, health professional means the practitioner provided for in Royal Decree No. 78 of 10 November 1967 on the practice of the health professions (Art. 2, 3°). As far as the current state of the legislation is concerned, this means the following professional groups: physicians, dentists, midwives, pharmacists, physiotherapists, nurses, paramedics and nurse’s assistants. Practitioners of non-conventional medicine, as defined in the Act of 29 April 1999 concerning such practices, are also health professionals. Right to informed consent 1. The patient has the right to consent well informed, freely and in advance to any service provided by a health professional. The consent of the patient is only valid for the medical intervention consented to. Sometimes during an operation a new ailment may be discovered which requires an immediate intervention. Such a so-called extended operation creates no problem when this discovery was foreseeable and the extension has been discussed previously with the patient. However, not all events are foreseeable. There is a distinction as to whether the ‘extended operation’ of the unforeseeable ailment has important disadvantageous consequences for the patient or not. In the latter case, consent to the ‘extended operation’ may be presumed. In the former case, however, consent has to be asked for except for an emergency in which case the duty to help prevails. 2. Consent must be given expressly except when the health professional, after having informed the patient adequately, can reasonably infer consent from the patient’s behaviour. Consent not given expressly is also referred to as implicit, tacit or non-verbal consent. The consent shall be recorded and added to the patient’s medical record at the patient’s or health professional’s request and with the health professional’s or patient’s approval. 3. When, in an emergency case, there is uncertainty as to the will of the patient or his representative, health professionals shall immediately deliver all necessary services in the interest of the patient’s health. The health professional shall record this in the patient’s medical record and shall act as soon as possible in accordance with the provisions of the preceding paragraphs. 4. Patients have the right to refuse or withdraw their consent for any service. Article 8, 4°, third paragraph provides explicitly that neither refusal nor withdrawal of consent shall end the right to high-quality care. In other words, refusal by itself does not terminate the legal relations between the patient and physician. 5. If the patient has made a written statement refusing a given medical service at the time when he or she was still capable of asserting the rights covered in the law on the rights of patients, this refusal shall be respected as long as the patient does not revoke it in a period when he is competent to exercise his rights himself. This provision, which establishes the binding character of a so-called advance refusal, is perhaps the most controversial part of the patient rights law. According to the explanatory report, an advance refusal has in principle 49 the same legal effect as a currently expressed refusal: the health professional is not authorized to act, and must respect the refusal. In order for an advance refusal to be binding, two conditions must be met. Firstly, it must apply to a ‘well-defined medical service’. A refusal that uses vague terms is not binding. Secondly, there may be no lingering doubt that the refusal comes from the person involved. In an emergency situation a physician will often not have enough time to verify this and his the duty to provide assistance will take precedence. Right to information about his or her health 1. The patient has the right to receive from the health professional all relevant information necessary to assess his state of health and his prognosis. It is question of all the relevant information that is necessary for gaining some idea of the patient’s state of health and its likely progression. This may be not only information already available but also information not yet available, which can be brought to light by appropriate diagnostic methods. Communication with the patient must take place in clear language, which means that the method of providing information is adapted to each individual patient. The patient may request that the information be confirmed in writing. 2. Because informing the patient is a fundamental element of medical practice, this obligation cannot be delegated by a physician to nursing or paramedical personnel. This is not to say that nurses and paramedics have no duty to inform the patient concerning the activities that they may legally perform. Therefore, physicians and other health care providers should make clear arrangements to guarantee that the right to information of the patient is fully respected. 3. Information is not provided to the patient if the latter explicitly requests not to know. If the patient exercises this right, the health professional may not inform the patient: the duty to inform becomes a duty not to inform. 4. The explicit request not to know can be given in writing, in which case it is annexed to the patient’s medical record, or orally, in which case it is noted in the medical record. Notwithstanding the patient’s explicit request not to know information, the health professional will communicate this information to the patient when not communicating it would clearly do grave harm to the health of the patient or to a third party, and on condition that the health professional has previously sought the opinion of another health professional in this matter and a confidant designated by the patient, if any. 5. Long before the right not to know was recognized, it was already accepted that the patient has a right to relinquish his right to information. In order to be legally valid, this relinquishing must take place voluntarily and it must be certain. If the patient relinquishes his right to information, then the physician is no longer required to inform (he does not need to inform the patient). If the patient exercises his right not to know, then the physician is prohibited from informing. 6. In exceptional cases, the health professional may withhold information about the patient’s state of health if disclosure would cause grave harm to the patient and on condition that the health professional has sought the opinion of another health professional. Not informing the patient under these circumstances is referred to as the therapeutic exception. It is generally accepted. Right to Complain and to Compensation The patient has the right to register a complaint regarding the exercise of rights granted by this law with the competent ombudsperson’s office. The responsibilities of the ombudsperson’s office are established in Article 11, 2°. In addition to a preventive 50 (preventing complaints and preventing the shortcomings that gave rise to them) and mediating function, the ombudsperson also has a twofold informative function: to provide information about alternate possibilities for dealing with a complaint in the event that mediation fails and to provide information about the organization and functioning of the ombudsperson’s office. Quality Decree for healthcare providers – Flemish Community (17 October 2003) The purpose of this Decree is to strengthen the quality of care in the Flemish care sector. With this Decree the Government wants to empower facilities to constantly monitor and optimize the quality of care. A facility is required to each user without distinction on the basis of age, gender, ideological, philosophical or religious beliefs, race, orientation and financial situation, to provide responsible care. (art. 3, § 1) The welfare and health facilities are accessible to the whole population and not for some privileged. Of the facilities, efforts are also expected to reach for example disadvantaged and immigrants. Users and facilities are together responsible for the quality of care. (art. 3, § 3) Users have a private responsibility in the care, who determines the quality of care. Active involvement and collaboration are needed for a positive outcome of the care. Users should be encouraged to get to know their expectations, needs and complaints.. To work on quality is in everyone's interest and searches for a balance where all are involved. What does the Government expect from the facilities? The facilities are expected to have an active quality policy. The quality policy must be expressed by the management of the facility formally in a written statement. The policy must be at least related to the mission, the vision, objectives and strategy of the facility with regard to quality. Quality policy is organizational policy and is authorized by the senior management. To carry out the quality policy a quality management system and a self-evaluation are necessary. The quality management system ensures the establishment and development of the quality policies and quality objectives and should warrant that the fixed quality objectives are achieved effectively. The quality management system includes a organizational structure, responsibilities, procedures and processes. II.6.2 Meso Level: Quality improvement programs Meso Level – Micro Level: Quality improvement programs Kwadrant (University College Leuven) Kwadrant is a management model. It is explicitly tailored to care organisations (hospitals and health care centres and home care), it is explicitly aligned with management and it is explicitly aligned with excellent care. Kwadrant is often used as a quality management tool in hospitals and healthcare / homecare institutions in Belgium. General characteristics and principles of Kwadrant are: - Aligned on self-evaluation - Emphasis on striving for excellence - Performance - Support for continuous improvement - Focus on the systems perspective 51 - Focus on processes and results Strongly customer-oriented Not normative Flexible JCI Accreditation (Joint Commission International) The Joint Commission International, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, and still known more commonly by the acronym, JCAHO, is an independent, not-for-profit organization that evaluates and accredits more than 15,000 healthcare organizations in the United States. It was founded in 1951. JCAHO's Joint Commission International (JCI) was founded in the late 1990s to survey hospitals outside of the United States. JCI, which is also not-for- profit, currently accredits facilities in Asia, Europe, the Middle East, and South America. A count of JCI-accredited hospitals worldwide (as listed on the JCI website in June 2012) shows 375 hospitals in 47 countries. JCI is an organisation which sets the international JCI standards for care quality and patient safety. If inspection by JCI shows that the care institution’s quality system meets the high requirements set by the standards, JCI issues hospital accreditation. The accreditation also reveals points for improvement in an organisation and checks whether a culture prevails in the organisation of addressing such points and striving to optimise care and quality. This is done with reference to the 300 JCI standards, which are translated into 1,300 objective and measurable criteria. In early July, JCI awarded accreditation to UZ Leuven, making it the first Belgian hospital to achieve this distinction. JCI has thus confirmed UZ Leuven’s focus on superior quality and on the constant improvement of patient safety. How does JCI accreditation work? JCI inspects the hospital from the viewpoint of how it works from day to day. The most important approach involves following what happens to the individual patient during all aspects of treatment and care, from pre-admission to post-discharge. Personnel, patients and visitors are all involved in the evaluation. Analogous approaches are used to evaluate the prevention and control of infections, medication policy, personnel policy, building and infrastructure safety, fire safety and clinical policy. There too, it is important for the JCI standards to be monitored. This method predicated on a patient focus distinguishes JCI from other forms of recognition and certification, which are often heavily based on a policy and organisational viewpoint. JCI’s approach focuses on all aspects of the hospital’s functioning right across the institution. The audits are performed by a group of JCI-trained and JCI-appointed auditors. Key elements of the JCI standards The JCI standards firstly relate to how care providers deal with patients, but also to the organisational structure around the patient. The whole process is evaluated with reference to a total of 1,300 measurable elements. 52 One priority point for attention is the international patient safety goals. Complying with these six standards is a minimum requirement to be eligible for accreditation. They are a matter of priority and an absolute necessity for safe care provision. 1. Identifying patients by means of double identification 2. Noting down and repeating phone messages 3. Increasing safety during the use of high-risk medication 4. Performing the right intervention, at the right time, on the right patient 5. Reducing the risk of infection through correct hand hygiene 6. Preventing falls Next, other standards relating to quality patient care and safety for patients, visitors and personnel are investigated and evaluated in detail. Among other points, these involve: - Evaluation and daily monitoring of every patient - Safe care in the case of vulnerable patient groups and high-risk procedures - Striving for a hospital with less pain - Informing the patient accurately via informed consent - Managing privacy and confidentiality - A safe medication policy - Preventing and controlling infections - The importance of a good infrastructure - What to do in the event of danger, fire or a resuscitation - Monitoring the clinical performance of personnel - Working with procedures and protocols More information: www.jointcommission.org. NIAZ The Netherlands Institute for Accreditation in Healthcare (NIAZ) offers a contribution to the assurance and improvement of the quality of health care, in particular by developing quality standards and by using them in the external evaluation of health care institutions and health care services, resulting in a judgment giving third parties - health care consumers, health care insurers, collaboration partners, government agencies and society in general - assurance that healthcare is being produced in an adequate and safe way. The 'Z' in NIAZ stands for 'zorginstellingen', meaning healthcare organisations. All types of healthcare organisations, (e.g. hospitals, mental healthcare institutions, nursing and long term care homes, dialysis centres, physiotherapy practices, GP practices and private clinics, home care organisations) may participate in the NIAZ accreditation program. NIAZ has described its mission, vision and values in the Core Document on Mission, Vision and Values. The Netherlands Institute for Accreditation in Healthcare develops quality standards and assesses whether healthcare organisations comply with these. Appraised is whether they have an organisational set-up that guarantees that an acceptable quality level of care can reproducibly be 53 delivered. If so the organisation is awarded an accreditation for four years, after which a full reexamination will take place. In between NIAZ will check the progress on the (mandatory) improvement action plan. Accreditation seeks to offer third parties - e.g. patients, healthcare insurers, government bodies - an assurance that the organisation is robustly and safely organized. Participation in the NIAZ accreditation program is on a voluntary basis. It always starts with a request by the individual healthcare organisation. The health care organisation signs a general Accreditation Agreement stating rights and obligations of all parties concerned. The survey procedure is performed using standards and assessment procedures that are published beforehand. These are disclosed through the NIAZ website. The NIAZ General Quality Standard for Healthcare Organisations is forged on the template of the INK model, which in itself is the Dutch version of the model of the European Foundation for Quality Management (EFQM). Its content is mostly derived from standards that are developed by experts within the healthcare field. NIAZ on its website publishes the accreditation status of the healthcare organisations that participate in its program, even if they did not pass the test for being accredited or continuing their accreditation status. NIAZ is a member of the International Society for Quality in Health Care (ISQua). NIAZ itself is accredited by this organisation for all three possible standards (organisation, standards, training). For Healthcare, by healthcare NIAZ was founded in 1998 by organisations of healthcare professionals and healthcare organisations. The predecessor originated in 1989 when the PACE Foundation was founded in order to prepare for a healthcare-wide institute for accreditation. This initiative was taken by the International Health Development Foundation - a cooperation of industries, universities and healthcare - and eight hospitals (four general hospitals and four university centers). Because of these 'hospital roots' NIAZ still works predominantly in hospitals, but ever more other healthcare organisations opt for the NIAZ program. Assessing healthcare requires knowledge of healthcare. Therefore NIAZ uses a system of peer review, meaning that surveying is done by people who themselves are actually working in the healthcare field. People who are knowledgeable about what it is really about in healthcare and who know to distinguish between the vital few and the trivial many. The surveyors are experienced senior health care workers (senior management, medical specialists, nurses, other professions), who have had an additional training as a surveyor. NIAZ has strict rules for surveyors not having (had) ties with the institution they survey. This way NIAZ combines maximum expertise with objectivity. Medio 2010 NIAZ has 250+ trained surveyors, about 50 of whom are from Belgium (Flanders) and 5 from Surinam. Assurance and improvement NIAZ believes that survey activities must inspire the people in the organisation and stimulate quality improvement. It should as little as possible add to bureaucratic behaviour. The ultimate goal is better healthcare, not rearranging the bookshelves. Healthcare institutions and their associates need room to work well. There are usually lots of different ways to achieve that. Therefore the choice for NIAZ accreditation does not imply the choice for any particular 'system'. Healthcare organisations are free in that, provided they in the end meet NIAZ' standards. NIAZ evaluates healthcare institutions as little as possible on rigid detailed standards and as much as possible on 'band widths'. Does evaluate on 'What' not on 'How'. With regard to risk-critical issues, where the safety of healthcare is at stake, NIAZ is strict in its judgement. 54 NIAZ performs standards development and surveying activities. NIAZ sees those as links in a continuous circle of improvement that therefore belong in one organisation. Knowledge and experience generated whilst performing surveys remain available as input for a new phase of standards development. Knowledge generated in developing standards provides the know how during survey processes in order to assess not only in accordance with the (dead) letter of the standards but with its deeper meaning. Sphere of activity NIAZ is a healthcare-wide institute, working for all healthcare sectors, inspired by what is common to all care, led by what is important to healthcare consumers and other relevant third parties and with respect for the particular characteristics of each healthcare sector. NIAZ works for healthcare organisations in the Dutch speaking countries. To these belong the Netherlands and Belgium (Flanders). NIAZ sees this working in different countries as an impuls for being a knowledge institution. Public domain NIAZ works not for profit and without government grants. The costs of the program are covered by the contribution of the healthcare organisations that participate in its program. These contributions are based on the size and complexity of the organisation and are published on the NIAZ website. All NIAZ materials are accessible for free to any citizen and to any institution and they may freely be used for any reasonable purpose. This low threshold of disclosure of knowledge best contributes to the ultimate goal: better healthcare. Organisations that as their business survey other organisations for a fee are asked for a contribution in the development costs of NIAZ. For healthcare consumers NIAZ has a regulation for complaints about the accredited healthcare organisations or about NIAZ itself. The value of accreditation Accreditation is an important but not the only quality instrument. Other entries are e.g. quality indicators ('past results') and specifications of consumers and healthcare insurers. Accreditation seeks to add value in two respects. One, offering confidence in a reproducible quality level ('future expectations'). Second, judging quality aspects that are essential to third parties bus as such can not be judged by them. NIAZ assesses whether an organisation has robustly organised itself. This does not imply that in that organisation nothing can go wrong. Healthcare will remain in the hands of fallible people using fallible technology. The NIAZ accreditation therefore does not offer a guarantee for error free care. NIAZ does seek to exclude structural shortcomings. Furthermore at present NIAZ does not assess the quality of the individual healthcare professionals, but limits itself to checking whether the institution has an adequate management of this. More information: www.niaz.nl, www.isqua.org 55 References www.health.fgov.be www.europatientsrights.eu www.zorgengezondheid.be www.cvz.kuleuven.ac.be www.jointcommission.org www.uzleuven.be www.niaz.nl www.isqua.org Visiting a patient in her home 56 II.6.3 Micro Level: Quality indicators, implementation and follow-up Quality indicators: implementation and follow-up To measure the quality of care, so called quality indicators are used. Without indicators no quality management is possible, and vice versa. Indicators give direction to an organization. They are signals of good or poor quality. They indicate where an organization stands another, how warm or how cold it is and where improvements can be made. In healthcare indicators can be used for different purposes: for internal control, for benchmarking or for making external accountability. A distinction can be made in different types of indicators. What is an indicator? To give an opinion about the quality of care some information is required. Data should be collected to obtain information. Data are obtained by measuring. An indicator gives meaning to a measurement, has a signal function. However, an indicator can only have a meaning, if there is also a standard determined. When there is a deviation from the standard, then adjustment is needed. Indicators give information about the degree of quality of an aspect of health care. Colsen and Casparie (1995) define it as follows: "an indicator is a measurable aspect of the care that gives an indication about the quality of care." Some examples of indicators: - the waiting time for treatment; - the number of fall incidents in a nursing home; - the percentage of clients with decubitus ulcers in a nursing home; These examples indicate that an indicator can always be expressed, for example as a percentage. A good indicator has the following characteristics (Colsen and Casparie, 1995): - An indicator has a relationship with what quality of care means, either, the organization must define what they understand under quality of care. - An indicator should indicate changes in quality. - An indicator can be registered, everyone registers it in the same way. Sorts of indicators A distinction can be made between process, structure and outcome indicators: - Process indicators give an indication on the progress of processes in an organization, such as the time between a request from a client for home care until the time that the care is given. - Structural indicators provide information about the organizational conditions which an institution can deliver, such as the percentage of employees that participated in meetings in the field of professional development or about absenteeism among employees. - Outcome indicators give an indication about the outcome of the care, for example about the level of satisfaction of clients, about the treatment by employees or on the percentage of clients with complications after a certain operation. 57 Implementation and follow-up Indicators don’t stand on themselves. There must be a relationship with the vision that the organization has on the quality of care. This vision must be defined and known in the institution. The vision is typically derived from the mission of the organization. The vision gives direction to the organization and is usually for a longer period. The vision is the basis for the policy and the strategy of the institution. For example, policy and strategy are described in a strategic annual plan. However, a policy plan is steering, if there are measurable objectives. To know to which extent the objectives are achieved, the institution reports on this regularly in the Management Team. The Management Team then determines whether and what actions need to be taken there. Reference: http://www.zbc.nu/management/ontwikkeling-zorginstelling/kwaliteitsindicatoren-in-de-zorg/ 58 CONCLUSIVE NOTE With a continuous growth of its ageing population, Europe is facing huge challenges for the future. Challenges that have a humanitarian, a social and an economic impact on the continent. The improvement of the living standards and the quality of health care resulted in a higher life expectancy but raised also the question how to deal with the new problems faced by a vast group of elderly people. European society changed profoundly in the last decades. The care for the elderly is no longer within reach of the families – and most often taken over by public or charitable institutions. It is a common statement in Europe that a good quality care should also be guaranteed to this community but their health expenditures are also the largest part of the health budgets in almost all European countries. The ultimate challenge is to find a good balance between the financial possibilities of the health and social sector and a human, qualitative and affordable care … In most western countries, elderly care is facilitated through family care homes, nursing homes, assisted living facilities and home care services. Due to different forms of organizational structures and financing schemes but also because of different traditions and national specifications, these forms of care developed in a very different way in all European countries. The social-economic reform in the Central European countries gave also an extra dimension to the problem. The better economic situation contributed to higher life expectancy, what resulted in a need for more and better services. But these needs could not be answered because the health system did not develop with the speed of the economical and societal changes. But also in Western Europe, the long standing schemes of elderly care are confronted with new problems in order to keep up a system of adequate elderly care. It is a general belief that keeping the elderly as long as possible in their traditional living environment is the best solution. It is the most human approach but is also cost-saving compared to permanent care facilities. But this implies that an efficient system of care at home must be developed, in order to guarantee social and medical care for this target group. In many countries, such home care is not fully developed. In some situations, there are no specialized providers, no adequate trainings, no public financing schemes. In many countries, home care is provided by a broad range of providers and supporting institutions without any coordination. This project was an important contribution to start up an international approach on home care but allowed also the partners within the participating states to grow to a closer cooperation. The project focused on the mutual training of health managers, educators and providers. It will allow the health managers to set up new forms of local health care initiatives with home care as a central service. As a result of the project, the Polish partners started already with the organizing of local health units in rural areas, keeping together the project partnership and working in close cooperation with the local authorities. The implication of these local authorities will allow to develop the model further into the regional and finally in the national health policies. The tools developed in this project, especially the training manual, will surely be useful along this process in the coming years. The project was organized on basis of an international partnership, comparing the situations in the participating countries. Comparing the different environments, it was obvious that the elderly care was approached in a specific way in each country. An important part of the project was dedicated to the mutual understanding of the situations in the different countries. Through that process, it became clear that the needs are similar. In order to find answer to these needs, it was important to get acquainted with the financial and institutional frameworks in relation to home care. The mapping of the different home care schemes allowed a clearer definition of the potential areas for complementary training schemes, taking into consideration a general approach but with local specifications. Having training institutes, providers and patient organizations working together, allowed a “complete” approach in the setting up of a training scheme and in the training manual. That made the training manual “universal”, usable in all EU-countries and also “practical”, allowing complementary schemes in countries with a traditional well-developed home care scheme but also 59 facing new challenges (such as Belgium) and in countries with limited home care facilities but searching for a modernized model of home care in the future. During the cooperation, some specific aspects were highlighted: the need for quality care and the emphasis on ethics in home care. The project resulted in a good working instruments for training and implementation, both on the educational level as on the workplace of home care managers. It is easily transferable to the situation of home care in other EU-countries. The international networks, where all partners are involved will be the ideal way to disseminate the results of the project. There is a general consensus that the ageing of the population is a major challenge in Europe. Answering that challenge will be most urgent and an international (European) approach is needed, even if the national situations are different. This project was looking at the real needs of the patients through the perspective of a multinational approach in identifying the solutions. It offered to all partners new instruments, new ideas and a new spirit in order to strengthen the home care in their own regions and to contribute to the national and European debate for an adequate and human care for the ageing population. The project is as such an important step in a long process development. Jean-Pierre Descan, LCM Project leader 60 LIST OF PHOTOS The photos in this manual have been prepared by the project partners. Belgium: cover, pages 19, 22, 36, 40, back cover. Poland: pages 16, 30. Hungary: pages 8, 56. 61 Delegates of the project partners in Genk, Belgium, in front of Wit-Gele Kruis van Vlaanderen Building, February 2013. 62
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