Challenges of conducting research in long-term care facilities: a systematic review

Building relational research capacity in care homes in the COVID-19 era: applying recognition theory to the research agenda

Purpose

Research can be an influential driver in raising care home standards and the well-being and human rights of residents. This paper aims to present a case for how a relational research capacity building programme could advance this agenda.

Design/methodology/approach

This study uses Axel Honneth’s Recognition Theory as a lens through which to explore organisational and institutional factors (such as research capacity and investment) that can either enable or limit “recognition” in the context of research in care homes. This paper draws on recent evidence from the COVID-19 pandemic in the UK and worldwide, to argue that such a relational capacity building agenda is even more pressing in the current context, and that it resonates with evidence from existing relational capacity building initiatives.

Findings

A lack of relevant research arguably contributed to the crisis experienced by the care home sector early in the pandemic, and there are only tentative signs that residents, care home providers and staff are now informing the COVID-19 research agenda. Evidence from pre COVID-19 and insights from Honneth’s Recognition Theory suggest that relational approaches to building research capacity within the care home sector can better generate evidence to inform practice.

Originality/value

This is a novel application of recognition theory to research in the care home sector. Drawing on theory, as well as evidence, has enabled the authors to provide a rationale as to why relationship-based research capacity building in care homes warrants further investment.

Facilitators and Barriers to Attendance in a Nursing Home Exercise Program

Women and residents in Certified Nursing Homes (CNHs) with higher star ratings had better attendance in exercise and social engagement programming (ie, Bingocize) than men and residents in CNHs with lower ratings.

OBJECTIVE

The purpose of the current study was to determine whether resident factors and nursing home star ratings influenced attendance in Bingocize, a therapeutic exercise program that incorporates opportunities for social engagement in nursing homes.

DESIGN

This is a descriptive study of data collected across multiple nursing homes over 17 months.

SETTING AND PARTICIPANTS

Data were collected from residents in 25 certified nursing homes in the mid-southern United States.

METHODS

The program consisted of two 45-60-minute sessions each week. Bingocize attendance was recoded as number of sessions attended each month from September 2017 to February 2019 in 25 nursing homes. The impact of gender, age, cognitive functioning, and Nursing Home Star Ratings on adherence to the program based on percentage of Bingocize sessions attended was analyzed.

RESULTS

A total of 1165 residents of certified nursing homes were recruited and participated in Bingocize; 55% of participants attended Bingocize infrequently or had poor attendance, 21% of the participants had average attendance, and 24% had good attendance. The association between gender and level of attendance was significant (P = .045). The star rating of the nursing home also affected attendance. As star level of the nursing home increased, the percentage of good attendance increased (P < .001): 19.12% (1 star), 20.69% (2 stars), 23.57% (3 stars), 33.76% (4 stars), and 36.63% (5 stars). Neither age nor cognitive functioning [based on Brief Interview of Mental Status (BIMS)] had a significant impact on attendance.

CONCLUSIONS AND IMPLICATIONS

We examined adherence to an exercise program called Bingocize based on percentage of sessions attended in 25 nursing homes. Women and residents in nursing homes with higher star ratings were reported to have better attendance in Bingocize than men or residents in nursing homes with lower ratings, respectively. Residents of all ages and cognitive ability can successfully participate in the Bingocize program.

Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review

BACKGROUND

Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities' antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes.

METHOD

A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as 'very promising' (all outcomes statistically significant), 'quite promising' (some outcomes statistically significant), or 'not promising' (no outcomes statistically significant). 'Promise ratios' (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2.

RESULTS

Twenty studies (of19 interventions) were included. Seven interventions (37%) were 'very promising', eight 'quite promising' (42%) and four 'not promising' (21%). Most promising intervention types were 'persuasion' (n = 12; promise ratio (PR) = 5.0), 'enablement' (n = 16; PR = 4.33) and 'education' (n = 19; PR = 3.75). Most promising behaviour change techniques were 'feedback on behaviour' (n = 9; PR = 8.0) and 'restructuring the social environment' (e.g. staff role changes; n = 8; PR = 7.0).

CONCLUSION

Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Dog-assisted interventions and outcomes for older adults in residential long-term care facilities: A systematic review and meta-analysis

OBJECTIVE

To comprehensively review studies on dog-assisted interventions (DAIs) among older people in residential long-term care facilities (RLTCFs) and to provide an overview of their interventions, outcomes and methodological quality.

METHOD

We searched 18 electronic databases to identify English articles (published January 2000-December 2019) reporting on well-defined DAIs targeting older adults (≥65 years) in RLTCF. Data were extracted by two independent reviewers. Descriptive statistics were produced for quantitative studies, with key themes identified among qualitative studies. Where possible, estimates were pooled from randomised controlled trials using random effects meta-analyses.

RESULTS

Forty-three relevant studies (39 quantitative; 4 qualitative) were identified. The majority of quantitative studies were assessed as low-quality according to the MMAT criteria (n = 26, 67%). Almost half of the quantitative studies (n = 18, 46%) found no significant changes over time or between groups across outcomes measured. The most salient intervention effects included improved social functioning (n = 10), reduced depressive symptoms (n = 6) and loneliness (n = 5). A random-effects meta-analysis revealed a medium effect in favour of DAT on reducing depressive or loneliness symptoms (pooled SMD: 0.66, 95%CI 0.21-1.11; I²  = 50.5; five trials), relative to treatment as usual. However, compared to treatment as usual, no overall effect of DAI on activities of daily living was detected (p = .737). Key themes from qualitative studies included (a) animals as effective transitional objects, (b) the therapeutic value of pets and (c) the significance of the care environment and stakeholders in facilitating DAI.

IMPLICATIONS FOR PRACTICE

The findings of this review indicate that while DAI has value for older people in RLTCF, challenges remain in accurately measuring its impact to provide a stronger evidence-base. Standardisation of DAI service design, delivery and evaluation is required for future research and practice in providing holistic care for older adults.

Challenges of infection prevention and control in Scottish long-term care facilities

Residents living in long-term care facilities (LTCFs) are at high risk of contracting healthcare-associated infections (HAIs). The unique operational and cultural characteristics of LTCFs and the currently evolving models of healthcare delivery in Scotland create great challenges for infection prevention and control (IPC). Existing literature that discusses the challenges of infection control in LTCFs focuses on operational factors within a facility and does not explore the challenges associated with higher levels of management and the lack of evidence to support IPC practices in this setting.1-7 Here, we provide a broader view of challenges faced by LTCFs in the context of the current health and social care models in Scotland. Many of these challenges are also faced in the rest of the United Kingdom and internationally.

The Living Lab In Ageing and Long-Term Care: A Sustainable Model for Translational Research Improving Quality of Life, Quality of Care and Quality of Work

There is a strong need in long-term care for scientific research, so older people and their families, health care professionals, policy makers, and educators can benefit from new advancements and best available evidence in every day care practice. This paper presents the model of a sustainable and successful interdisciplinary collaboration between scientists, care providers and educators in long-term care: the "Living Lab in Ageing and Long-Term Care" by Maastricht University in the Netherlands. Its mission is to contribute with scientific research to improving i) quality of life of older people and their families; ii) quality of care and iii) quality of work of those working in long-term care. Key working mechanisms are the Linking Pins and interdisciplinary partnership using a team science approach, with great scientific and societal impact. A blueprint for the model is discussed, describing its business model and challenges in getting the model operational and sustainable are discussed.

A four-stage process for intervention description and guide development of a practice-based intervention: refining the Namaste Care intervention implementation specification for people with advanced dementia prior to a feasibility cluster randomised trial

Background

Some interventions are developed from practice, and implemented before evidence of effect is determined, or the intervention is fully specified. An example is Namaste Care, a multi-component intervention for people with advanced dementia, delivered in care home, community, hospital and hospice settings. This paper describes the development of an intervention description, guide and training package to support implementation of Namaste Care within the context of a feasibility trial. This allows fidelity to be determined within the trial, and for intervention users to understand how similar their implementation is to that which was studied.

Methods

A four-stage approach: a) Collating existing intervention materials and drawing from programme theory developed from a realist review to draft an intervention description. b) Exploring readability, comprehensibility and utility with staff who had not experienced Namaste Care. c) Using modified nominal group techniques with those with Namaste Care experience to refine and prioritise the intervention implementation materials. d) Final refinement with a patient and public involvement panel.

Results

Eighteen nursing care home staff, one carer, one volunteer and five members of our public involvement panel were involved across the study steps. A 16-page A4 booklet was designed, with flow charts, graphics and colour coded information to ease navigation through the document. This was supplemented by infographics, and a training package. The guide describes the boundaries of the intervention and how to implement it, whilst retaining the flexible spirit of the Namaste Care intervention.

Conclusions

There is little attention paid to how best to specify complex interventions that have already been organically implemented in practice. This four-stage process may have utility for context specific adaptation or description of existing, but untested, interventions. A robust, agreed, intervention and implementation description should enable a high-quality future trial. If an effect is determined, flexible practice implementation should be enabled through having a clear, evidence-based guide.

Feasibility and usefulness of a leadership intervention to implement evidence-based falls prevention practices in residential care in Canada

Background

Leadership is critical to supporting and facilitating the implementation of evidence-based practices in health care. Yet, little is known about how to develop leadership capacity for this purpose. The aims of this study were to explore the (1) feasibility of delivering a leadership intervention to promote implementation, (2) usefulness of the leadership intervention, and (3) participants’ engagement in leadership to implement evidence-based fall prevention practices in Canadian residential care.

Methods

We conducted a mixed-method before-and-after feasibility study on two units in a Canadian residential care facility. The leadership intervention was based on the Ottawa model of implementation leadership (O-MILe) and consisted of two workshops and two individualized coaching sessions over 3 months to develop leadership capacity for implementing evidence-based fall prevention practices. Participants (n = 10) included both formal (e.g., managers) and informal (e.g., nurses and care aids leaders). Outcome measures were parameters of feasibility (e.g., number of eligible candidates who attended the workshops and coaching sessions) and usefulness of the leadership intervention (e.g., ratings, suggested modifications). We conducted semi-structured interviews guided by the Implementation Leadership Scale (ILS), a validated measure of 12-item in four subcategories (proactive, supportive, knowledgeable, and perseverant), to explore the leadership behaviors that participants used to implement fall prevention practices. We repeated the ILS in a focus group meeting to understand the collective leadership behaviors used by the intervention team. Barriers and facilitators to leading implementation were also explored.

Results

Delivery of the leadership intervention was feasible. All participants (n = 10) attended the workshops and eight participated in at least one coaching session. Workshops and coaching were rated useful (≥ 3 on a 0–4 Likert scale where 4 = highly useful) by 71% and 86% of participants, respectively. Participants rated the O-MILe subcategories of supportive and perseverant leadership highest for individual leadership, whereas supportive and knowledgeable leadership were rated highest for team leadership.

Conclusions

The leadership intervention was feasible to deliver, deemed useful by participants, and fostered engagement in implementation leadership activities. Study findings highlight the complexity of developing implementation leadership and modifications required to optimize impact. Future trials are now required to test the effectiveness of the leadership intervention on developing leadership for implementing evidence-based practices.

End-Users and Caregivers' Involvement in Health Interventional Research Carried Out in Geriatric Facilities: A Systematic Review

Public involvement (PI) is of great interest. However, little is known about this topic in the design, development, and/or implementation of health interventions in geriatric facilities. This study aimed to provide a critical overview of the involvement of caregivers and end-users in interventions in these facilities, based on Rifkin’s analytical framework. This systematic review, supplemented by a questionnaire to the corresponding authors, covered non-drug intervention reports targeting nurses, doctors, residents, and their relatives. Articles were published in Pubmed, Medline, Scopus, and Cinahl, from January 2016 to April 2018. Ninety-seven articles were included. The review shows a low level or partial PI in geriatric facilities where it exists. These results are further supported by the authors’ responses to the questionnaire. PI remains uncommon in geriatric institutions and consists of a consumerist model, suggesting the need for improved practices. More efforts are needed to experiment with recommendations to meet the challenges of PI and enhance the public ownership of interventions. The protocol was registered on Prospero under the number CRD42018098504.

Concordance Between Self-Reported Completion of Advance Care Planning Documentation and Availability of Documentation in Australian Health and Residential Aged Care Services

CONTEXT

Advance care planning (ACP) documentation needs to be available at the point of care to guide and inform medical treatment decision-making.

OBJECTIVE

To examine concordance between self-reported completion of ACP documentation and self-reported storage of the documentation at the person's current point of care with the availability of the documentation in that person's health record.

METHODS

A national multicenter audit of health records and a self-report survey of eligible audit participants in 51 Australian health and residential aged care services. The audit assessed availability of ACP documentation in the health record, whereas the survey assessed self-reported completion and storage of the ACP documentation at the person's current place of care. To ascertain concordance, survey and audit data were cross-tabulated and concordance rates and kappa statistics were calculated overall and by health care sector and ACP documentation type.

RESULTS

The audit included 2285 people, of whom 1082 were eligible for the survey. Of 507 who completed the survey (response rate = 47%), 272 (54%) reported completing ACP documentation, of whom 130 (48%) had documentation identified in the audit. Conversely, 39 of 235 people (17%) who reported not completing ACP documentation had documentation identified (concordance rate = 64%; κ = 0.303, P < .001). The concordance rate increased to 79% when self-reported storage of ACP documentation at the person's current point of care was compared with the existence of the document in their health record (κ = 0.510, P < .001). Concordance varied by health care setting and type of ACP documentation.

CONCLUSION

Discrepancies exist between self-reported completion of ACP documentation and the presence of these documents in the health records of older adults, representing a significant patient safety issue. Public education campaigns and improvements to systems for document storage and accessibility are required to support person-centered medical and end-of-life care.

Interventions for preventing delirium in older people in institutional long-term care

BACKGROUND

Delirium is a common and distressing mental disorder. It is often caused by a combination of stressor events in susceptible people, particularly older people living with frailty and dementia. Adults living in institutional long-term care (LTC) are at particularly high risk of delirium. An episode of delirium increases risks of admission to hospital, development or worsening of dementia and death. Multicomponent interventions can reduce the incidence of delirium by a third in the hospital setting. However, it is currently unclear whether interventions to prevent delirium in LTC are effective. This is an update of a Cochrane Review first published in 2014.

OBJECTIVES

To assess the effectiveness of interventions for preventing delirium in older people in institutional long-term care settings.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group (CDCIG) 's Specialised Register of dementia trials (dementia.cochrane.org/our-trials-register), to 27 February 2019. The search was sufficiently sensitive to identify all studies relating to delirium. We ran additional separate searches in the Cochrane Central Register of Controlled Trials (CENTRAL), major healthcare databases, trial registers and grey literature sources to ensure that the search was comprehensive.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single and multicomponent, non-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were prevalence, incidence and severity of delirium; and mortality. Secondary outcomes included falls, hospital admissions and other adverse events; cognitive function; new diagnoses of dementia; activities of daily living; quality of life; and cost-related outcomes. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes, hazard ratios (HR) for time-to-event outcomes and mean difference (MD) for continuous outcomes. For each outcome, we assessed the overall certainty of the evidence using GRADE methods.

MAIN RESULTS

We included three trials with 3851 participants. All three were cluster-RCTs. Two of the trials were of complex, single-component, non-pharmacological interventions and one trial was a feasibility trial of a complex, multicomponent, non-pharmacological intervention. Risk of bias ratings were mixed across the three trials. Due to the heterogeneous nature of the interventions, we did not combine the results statistically, but produced a narrative summary.It was not possible to determine the effect of a hydration-based intervention on delirium incidence (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00; 1 study, 98 participants; very low-certainty evidence downgraded for risk of bias and very serious imprecision). This study did not assess delirium prevalence, severity or mortality.The introduction of a computerised system to identify medications that may contribute to delirium risk and trigger a medication review was probably associated with a reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51; 1 study, 7311 participant-months; moderate-certainty evidence downgraded for risk of bias) but probably had little or no effect on mortality (HR 0.88, CI 0.66 to 1.17; 1 study, 9412 participant-months; moderate-certainty evidence downgraded for imprecision), hospital admissions (HR 0.89, CI 0.72 to 1.10; 1 study, 7599 participant-months; moderate-certainty evidence downgraded for imprecision) or falls (HR 1.03, CI 0.92 to 1.15; 1 study, 2275 participant-months; low-certainty evidence downgraded for imprecision and risk of bias). Delirium prevalence and severity were not assessed.In the enhanced educational intervention study, aimed at changing practice to address key delirium risk factors, it was not possible to determine the effect of the intervention on delirium incidence (RR 0.62, 95% CI 0.16 to 2.39; 1 study, 137 resident months; very low-certainty evidence downgraded for risk of bias and serious imprecision) or delirium prevalence (RR 0.57, 95% CI 0.15 to 2.19; 1 study, 160 participants; very low-certainty evidence downgraded for risk of bias and serious imprecision). There was probably little or no effect on mortality (RR 0.82, CI 0.50 to 1.34; 1 study, 215 participants; moderate-certainty evidence downgraded for imprecision). The intervention was probably associated with a reduction in hospital admissions (RR 0.67, CI 0.57 to 0.79; 1 study, 494 participants; moderate-certainty evidence downgraded due to indirectness).

AUTHORS' CONCLUSIONS

Our review identified limited evidence on interventions for preventing delirium in older people in LTC. A software-based intervention to identify medications that could contribute to delirium risk and trigger a pharmacist-led medication review, probably reduces incidence of delirium in older people in institutional LTC. This is based on one large RCT in the US and may not be practical in other countries or settings which do not have comparable information technology services available in care homes. In the educational intervention aimed at identifying risk factors for delirium and developing bespoke solutions within care homes, it was not possible to determine the effect of the intervention on delirium incidence, prevalence or mortality. This evidence is based on a small feasibility trial. Our review identified three ongoing trials of multicomponent delirium prevention interventions. We identified no trials of pharmacological agents. Future trials of multicomponent non-pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence-based care for this vulnerable group.

What do care home managers believe constitutes an 'assessment for frailty' of care home residents in North-West London? A survey

Background

Frail individuals are at risk of significant clinical deterioration if their frailty is not identified and managed appropriately. Research suggests that any interaction between an older person and a health or social care professional should include an assessment for frailty. Many older care home residents are frail when admitted, but we have little knowledge of whether or how this is assessed. The aim of this paper is to understand and establish the characteristics of the reported ‘assessments for frailty’ used in care homes with nursing (nursing homes) across North-West London. This will help understand what an ‘assessment for frailty’ of care home residents mean in practice in North-West London.

Methods

Telephone contact was made with every Care Quality Commission (CQC) (independent regulator of health and adult social care in England) regulated nursing home across North-West London [n = 87]. An online survey was sent to all that expressed interest [n = 73]. The survey was developed through conversations with healthcare professionals, based on literature and tested with academics and clinicians. Survey responses were analysed using descriptive statistics. The Mann-Whitney U test was used for statistical analyses.

Results

24/73 nursing homes completed the survey (33%). Differences in the characteristics of reported ‘assessments for frailty’ across nursing homes were evident. Variation in high level domains assessed (physical, social, mental and environmental) was observed. Nurses were the most common professional group completing assessments for frailty, with documentation and storage being predominantly paper based. A statistically significant difference between the number of assessments used in corporate chain owned nursing homes (3.9) versus independently owned nursing homes (2.1) was observed (U = 21, p = .005).

Conclusions

Great variation existed in the characteristics of reported ‘assessments for frailty’ in nursing homes. Our study suggests that not all physical, social, mental and environmental domains of frailty are routinely assessed: it appears that frailty is still primarily viewed only in terms of physical health. The consequences of this could be severe for patients, staff and healthcare settings. Research illustrates that frailty is a broad, multifactorial health state and, as such, an overall ‘assessment for frailty’ should reflect this.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1083-5) contains supplementary material, which is available to authorized users.