Supporting the use of MDS in Everyday Work A Qualitative Investigation of the Perceptions of Complex Continuing Care Hospital Staff

Across Canada, the Minimum Data Set (MDS) is rapidly becoming the predominant resident assessment tool utilized by long-term care facilities and complex continuing care hospitals. Developed in the late 1980's in the United States, the instrument’s original intent was to provide health care workers with a systematic method for identifying long-term care residents’ needs and effective care interventions. Over the last two decades, both administrators and policy developers have also come to depend upon MDS assessment data to evaluate the relationship between residents’ needs, care provided, and health care outcomes. Furthermore, in addition to determining organizational funding, MDS is increasingly used for quality assurance programs and research initiatives. Consequently, MDS data has become an important component of care planning, evaluation, administration, and governmental policy development.

The quality of MDS data explicitly reflects input provided by the interdisciplinary team members, such as Registered Nurses, Occupational Therapists and Physiotherapists. Yet, previous research on MDS has focused considerable attention on issues of reliability and validity (Gruber Baldini et al, 2000; Horgas & Margrett, 2001) and with lesser attention directed at investigating the experiences of interdisciplinary team members completing MDS assessments.

Unfortunately, while essential to the provision of quality data, it has been suggested that interdisciplinary team members perceive completing a MDS assessment as one more assigned task among many other pressing care responsibilities. Completion of a MDS assessment has even been suggested to require more information than the average staff member has available (Brooks, 1996).

Research Purpose

Given the paucity of prior attention to the experiences of those interdisciplinary team members responsible for providing MDS data, the purpose of this qualitative study was to investigate complex continuing care hospital staff’s perceptions of how to best support the use of MDS in everyday work – or, more succinctly, ‘how to do it better’. Increased understanding of the perceptions of these team members will help to shape the structures, systems and supports to promote quality data input.

Research Design

Methodology

This study used a qualitative research approach to describe the perceptions of complex continuing care hospital staff about MDS. To provide opportunity for participants to describe their perceptions and experiences in their own words, qualitative research requires a relatively unstructured approach to data collection (such as the open ended, semi-structured interview format chosen for this study). Furthermore, as qualitative research is driven by an inductive and interactive process of ongoing analysis of emerging themes, this study did not utilize a conceptual model to explain the research data. Therefore, data collection and analysis continued until theoretical saturation and no new patterns emerged. Study Setting: The study setting consisted of six complex continuing care units in a 287-bed hospital located in a major urban area of Eastern Canada. In 1996, MDS version 2.0 was mandated by the provincial Ministry of Health and implemented in all provincial complex continuing care hospitals. At that time, MDS training was provided in the study setting for all employees who would be completing MDS assessments.

Sample

The study sample included 34 complex continuing care hospital staff who regularly completed MDS assessments. The sample represented a variety of interdisciplinary team members, including Nursing (25), Occupational Therapy (4), Physiotherapy (3) and Pharmacy (2).

Protocol

Prior to initiating the study, the research proposal was presented to all involved management staff and granted approval by the hospital’s Research Ethics Board. Invitations to participate in the study (including an explanation of the purpose, method of data collection, and a copy of the interview guide) were circulated to appropriate staff.

Data was collected in August and September, 2001 in 6 semi-structured focus groups lasting approximately one hour and scheduled at times conducive to participants’ work responsibilities. At the beginning of each focus group, all participants were again provided with an explanation about the purpose and design of the study and reassured about issues of confidentiality. Focus groups were facilitated by use of an interview guide which changed to explore emerging themes.

Data Analysis

Focus group data was hand-recorded and then transcribed on the computer. The initial step in data analysis, open coding, broke the data into fractured units and evaluated for similarities and differences in themes between and within each of the groups. Further analysis resulted in clustering of emerging themes into larger conceptual categories.

Research Findings and Discussion

As clearly evident in the focus group discussions, complex continuing care staff perceive common and important benefits of MDS. Specifically, many staff identified MDS as providing a common language and promoting more in-depth assessment. Staff also identified the relationship of MDS results and future governmental funding. As the study setting was not generating Resident Assessment Protocols (RAPs) or Quality Indicators from the MDS data at the time of this study, these particular benefits were not common knowledge amongst focus group participants.

Analysis of the research data also highlighted participants’ lack of broad understanding of MDS. For example, participants expressed interest in learning how and why the instrument was developed and current implementation of the instrument across Canada. In addition, staff expressed the desire to better understand the varied potential uses of MDS data, (such as generation of RAPs), potential research initiatives, how to provide optimal care using MDS data and the use of MDS data to determine governmental funding allocations.

Without such a broad understanding of MDS, staff reported that the assessment tool was often perceived as “something separate” from the delivery of care or an assigned task with no apparent benefit to the goal of providing optimal care. It was evident that staff could perceive MDS as negatively impacting quality of care delivery. As one nurse expressed, “When the patient is deteriorating, MDS takes you away from the bedside”. Similarly, lack of understanding of the rigorous development of the instrument was also identified as influential to staff’s decreased confidence in the validity of MDS data. For example, as one study participant expressed, MDS is only “a snapshot...and does not accurately picture the patient”.

An additional outcome of staff not understanding the importance of MDS data was apparent when some focus group participants described feeling that colleagues often devalue the effort required to complete an assessment. For example, some nurse participants described nursing colleagues as viewing the completion of a MDS assessment as “getting out of doing patient care”. As one nurse explained: “When I have to go into the little room and do MDS on the computer, I almost apologize. Staff think I don’t want to do patient care and they don’t view you as doing work. They say to themselves ‘Oh, she’s only doing MDS.’ It never seems to occur to anyone that you are doing something.”

A better understanding of how MDS was developed may also address the perceptions of some staff that the instrument does not capture the essence of their professional interventions. For example, as one Occupational Therapist in the study focus groups reported: "MDS sees us (Occupational Therapists and Occupational Therapy Aids) all the same and this just isn’t accurate.” Nursing staff were similarly vocal in expressing their perceptions that MDS appears to undervalue nursing care and as one nurse explained: "Having a catheter is considered continent, yet there is work about caring for a catheter that is not recognized."

In the study setting, Resource Assessors (designated staff nurses) were described as helpful for better interpretation of the instrument. To further promote staff’s understanding of MDS, focus group participants recommended the need for both introductory MDS training sessions and regular, ongoing education and meetings between these MDS Assessors and the MDS Coordinator. Both Occupational Therapists and Physiotherapists agreed that MDS discipline-specific consultative support would also be helpful.

While increased understanding of the instrument was identified as essential, focus group participants also described some structural changes that would better support the use of MDS in everyday work. In particular, participants clearly identified that staff require adequate time to complete MDS assessments. For nursing staff, an admission MDS assessment can often require more than 45 minutes – time not generally recognized in daily workload assignments. Yet, as staff described, the responsibility to complete a MDS assessment should not be incorporated or ‘added on’ to an existing workload assignment. Instead, nursing staff strongly recommended that workload assignments be reviewed to insure adequate time for both collecting MDS data and completing the assessment tool.

A factor influencing the amount of time required to complete MDS assessments was the organization’s documentation system. Staff suggested that the documentation system be reviewed to ensure retrieval of MDS data in a timely manner. For example, nursing staff described that MDS assessment requires ‘digging out’ information not readily available on the admitting history. Indeed, focus group participants clearly advocated for a documentation system that better supports MDS data collection.

In addition to these suggestions for promoting the use of MDS in everyday work, focus group participants also described the need for a model of care delivery (such as primary nursing or case management) that best supports MDS assessment. Lacking a supportive model of care delivery, study participants forecasted frequent inaccuracies in MDS assessments completed by staff members with only "second-hand information”.

In summary, the findings of this research can be conceptualised as three distinct categories of strategies that support staff’s use of MDS in the workplace. As depicted in the diagram below, the use of MDS by the interdisciplinary team members can be best supported by:

1. promoting a shared vision amongst all staff about MDS (helping all staff to understand how MDS was developed and the instrument’s positive potential outcomes),
2. providing process supports (such as MDS Resource Assessors and ongoing opportunity for discussion) and
3. implementing system integration (such as changes in documentation systems and models of care).

Conclusion

In conclusion, the findings of this qualitative investigation research identified complex continuing care hospital staff’s perceptions of use of MDS. As evident in the research data, when lacking a common understanding and appreciation, staff can too often view MDS as an assigned task with no apparent rational or contribution to quality care. This study also generated practical and specific suggestions for process supports and system integration strategies to better support staff’s use of MDS in the workplace – and, ultimately, promote quality care.