International Association of Gerontology and Geriatrics: A Global Agenda for Clinical Research and Quality of Care in Nursing Homes

Factors related to the use of physical restraints and hand restraints among older adults receiving home care services

OBJECTIVES

Physical restraints and hand restraints are used in medical settings to provide protection and control. However, few studies have investigated their use among community-dwelling older adults. The study explored variables associated with the use of physical restraints and hand restraints among older adults receiving home care services and the reasons behind their use.

METHODS

This cross-sectional study recruited 128 older adults receiving home care services and with catheters. Data were collected regarding demographic characteristics; activities of daily living (ADLs); muscle strength; family function; the use of nasogastric tubes, urinary catheters, and tracheal tubes; and the type and duration of restraint use and the reasons behind such use.

RESULTS

Among the participants, 76% experienced the use of physical restraints, and 34% experienced the use of hand restraints. The variables related to physical restraints were ADLs (adjusted odds ratio [AOR] = 0.95, p = .02) and the presence of a paid caregiver (AOR = 3.33, p = .02). The variables related to hand restraints were ADLs (AOR = 0.93, p = .03), use of a nasogastric tube (AOR = 13.46, p = .03) and the presence of a paid caregiver (AOR = 6.38, p = .02). The primary reasons behind restraint use were to prevent fall and extubation events.

CONCLUSIONS

The use of physical restraints among older adults with catheters may be affected by their functioning in ADLs and the presence of paid caregivers to ensure their safety. Thus, implementing interventions that target functional capabilities and caregiving skills may help reduce the use of restraints.

What Do We Know About Nurse Practitioner/Physician Care Models in Long-Term Care: Results of a Scoping Review

OBJECTIVES

Due to the rise of the nurse practitioner (NP) role in long-term care settings, it is important to understand the underlying structures and processes that influence NP and physician care models. This scoping review aims to answer the question, "What are the structures, processes, and outcomes of care models involving NPs and physicians in long-term care (LTC) homes?" A secondary aim was to describe the structural enablers and barriers across care models.

RESEARCH DESIGN AND METHODS

Seven databases were searched. Studies that described NPs and physicians working in LTC were identified and included in the review. We stratified the findings by care model and synthesized using the Donabedian model, which evaluates health care quality based on 3 dimensions: structure, process, and outcome. We then categorized macro, meso, and micro structural enablers and barriers.

RESULTS

Sixty papers were included in the review. The main structural influencers within 5 care models included policies on scope of practice, clarity of role description, and workload. A limited number of papers referred to the process of enabling the development of a working relationship. Thirty-five (49%) studies described resident, staff, and health system outcomes.

CONCLUSIONS AND IMPLICATIONS

Although structural characteristics of NP and physician care models are described in-depth, there is less detail on the processes that occur within the NP and physician care models. We highlight structural barriers and enablers within the care models, allowing for recognition of the importance of organizational influence on the NP and physician relationship. Future work should focus on the processes of the relationships in the models by identifying the drivers and initiators of collaboration between NPs and physicians and how these relationships influence outcomes.

Long-term care status for the elderly with different levels of physical ability: a cross-sectional survey in first-tier cities of China

BACKGROUND

Long term care (LTC) services for functionally impaired senior citizens are crucial for addressing the challenges of aging. However, research on eligibility criteria and coverage of LTC in China is lacking. Our objective is to assess the current status of LTC and explore eligibility criteria and coverage for the elderly.

METHODS

This is a cross-sectional study conducted in two first-tier cities in China. Residents aged 65 or over were recruited from a nursing home and four primary hospitals. Participants were divided into three groups (bedridden, domestic, and community), then six grades (grade one to six) according to the Longshi Scale, and their functional ability was assessed using the Modified Barthel Index. Information such as diseases, complications, and daily care needs were collected. Nursing staff were invited to indicate patients' needs for care. A one-way ANOVA test, Kruskal Wallis H test and Mann-Whitney U test were used to explore the differences of variables in three Longshi groups or Longshi grades.

RESULTS

Among all 1157 participants, with an average age of 80.54, 69.3% were in the bedridden group. The most common diagnosis was stroke (71.4%), with the most prevalent complication being pulmonary infection (25.2%). In the nursing assessment, basic health care, disease care, activity care, complication prevention care and psychosocial care were summarized as the five main aspects of LTC for the elderly. Feeding, bathing, drinking, bowel management and bladder management were identified as the basic care which fulfills participants' basic physical needs in each Longshi group. Mouth care, artificial airway management, and body reposition, which can prevent immobility complications, were highly demanded by bedridden elderly.

CONCLUSIONS

The elderly in grade one to three are the ones in need of LTC most. The content of LTC for elderly should include basic care which fulfills their basic physical needs and complication care which can prevent immobility complications. The evidence of this research may contribute to the design of LTC in China.

TRIAL REGISTRATION

The study design was registered in the Chinese Clinical Trial Registry (ChiCTR-2000034067, Registered 22 Jun 2020, http://www.chictr.org.cn/showproj.aspx?proj=54770 ).

Evaluation of Long-Term Institutions for Older People in Brazil: an overview of regional inequalities

This article aims to evaluate the Brazilian Long-Term Institutions for Older People (LTIE), according to the Integrated Multidimensional Theoretical Model of Quality and Service (MIQA), and compare the performance achieved between the regions of the country. Descriptive ecological study carried out with public secondary data from the LTIE participating in the 2018 Census of the Unified Social Assistance System. An Evaluation Matrix was constructed from the Census variables and the MIQA Theoretical Model. Quality parameters were used to classify the institutions' performance for each indicator as "incipient", "developing" or "desirable". The disparity index was obtained for each indicator. 1,665 institutions were analyzed. Differences were observed in the percentages of LTIE with "desirable" performance between Brazilian regions, and the need for improvement in most LTIE in relation to the proportion of caregivers of older people, the composition of the multidisciplinary team, accessibility and supply of health promotion actions. There was a need for government support for the suppression of exclusionary differentiation criteria and for the expansion of services to overcome overcrowding.

Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention

BACKGROUND

The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts.

METHODS

Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites.

RESULTS

The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline.

CONCLUSIONS

The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial's concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes "success" in complex interventions.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.

A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME)

BACKGROUND AND OBJECTIVES

Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs.

RESEARCH DESIGN AND METHODS

Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting.

RESULTS

Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention.

DISCUSSION AND IMPLICATIONS

CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

Defining the concepts of a smart nursing home and its potential technology utilities that integrate medical services and are acceptable to stakeholders: a scoping review

BACKGROUND AND OBJECTIVES

Smart technology in nursing home settings has the potential to elevate an operation that manages more significant number of older residents. However, the concepts, definitions, and types of smart technology, integrated medical services, and stakeholders' acceptability of smart nursing homes are less clear. This scoping review aims to define a smart nursing home and examine the qualitative evidence on technological feasibility, integration of medical services, and acceptability of the stakeholders.

METHODS

Comprehensive searches were conducted on stakeholders' websites (Phase 1) and 11 electronic databases (Phase 2), for existing concepts of smart nursing home, on what and how technologies and medical services were implemented in nursing home settings, and acceptability assessment by the stakeholders. The publication year was inclusive from January 1999 to September 2021. The language was limited to English and Chinese. Included articles must report nursing home settings related to older adults ≥ 60 years old with or without medical demands but not bed-bound. Technology Readiness Levels were used to measure the readiness of new technologies and system designs. The analysis was guided by the Framework Method and the smart technology adoption behaviours of elder consumers theoretical model. The results were reported according to the PRISMA-ScR.

RESULTS

A total of 177 literature (13 website documents and 164 journal articles) were selected. Smart nursing homes are technology-assisted nursing homes that allow the life enjoyment of their residents. They used IoT, computing technologies, cloud computing, big data and AI, information management systems, and digital health to integrate medical services in monitoring abnormal events, assisting daily living, conducting teleconsultation, managing health information, and improving the interaction between providers and residents. Fifty-five percent of the new technologies were ready for use in nursing homes (levels 6-7), and the remaining were proven the technical feasibility (levels 1-5). Healthcare professionals with higher education, better tech-savviness, fewer years at work, and older adults with more severe illnesses were more acceptable to smart technologies.

CONCLUSIONS

Smart nursing homes with integrated medical services have great potential to improve the quality of care and ensure older residents' quality of life.

The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study

BACKGROUND

Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices.

OBJECTIVE

This study's purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation.

METHODS

This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program's multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings.

RESULTS

This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023.

CONCLUSIONS

The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40611.

Physical environmental designs in residential care to improve quality of life of older people

BACKGROUND

The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function.

OBJECTIVES

To assess the effects of changes to the physical environment, which include alternative models of residential aged care such as a 'home-like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched.

SELECTION CRITERIA

Non-randomised trials, repeated measures or interrupted time series studies and controlled before-after studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled.

MAIN RESULTS

Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach, compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety. Six controlled before-after studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-after study included 74,449 of the participants (estimated on weighting). It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse effects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-after study examined the effect of home-like models on quality of life. The author stated "No statistically significant differences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no difference in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean difference (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary effect estimate. Two controlled before-after studies examined the effect of home-like models of care compared to traditional design on depression. After 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the effect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no difference in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-after studies examined function. One study (n = 242) reported little or no difference in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse effects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment).  The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are difficult to isolate from other influences such as health changes of the residents, changes to care practices over time or different staff providing care across shifts. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.

SCOPE: safer care for older persons (in residential) environments-a pilot study to enhance care aide-led quality improvement in nursing homes

Background

Nursing home residents require daily support. While care aides provide most of this support they are rarely empowered to lead quality improvement (QI) initiatives. Researchers have shown that care aide-led teams can successfully participate in a QI intervention called Safer Care for Older Persons in Residential Care Environments (SCOPE). In preparation for a large-scale study, we conducted a 1-year pilot to evaluate how well coaching strategies helped teams to enact this intervention. Secondarily, we measured if improvements in team cohesion and communication, and resident quality of care, occurred.

Methods

This study was conducted using a prospective single-arm study design, on 7 nursing homes in Winnipeg Manitoba belonging to the Translating Research in Elder Care research program. One QI team was selected per site, led by care aides who partnered with other front-line staff. Each team received facilitated coaching to enact SCOPE during three learning sessions, and additional support from quality advisors between these sessions. Researchers developed a rubric to evaluate how well teams enacted their interventions (i.e., created actionable aim statements, implemented interventions using plan-do-study-act cycles, and used measurement to guide decision-making). Team cohesion and communication were measured using surveys, and changes in unit-level quality indicators were measured using Resident Assessment Instrument-Minimum Data Set data.

Results

Most teams successfully enacted their interventions. Five of 7 teams created adequate-to-excellent aim statements. While 6 of 7 teams successfully implemented plan-do-study-act cycles, only 2 reported spreading their change ideas to other residents and staff on their unit. Three of 7 teams explicitly stated how measurement was used to guide intervention decisions. Teams scored high in cohesion and communication at baseline, and hence improved minimally. Indicators of resident quality care improved in 4 nursing home units; teams at 3 of these sites were scored as ‘excellent’ in two or more enactment areas, versus 1 of the 3 remaining teams.

Conclusions

Our coaching strategies helped most care aide-led teams to enact SCOPE. Coaching modifications are needed to help teams more effectively use measurement. Refinements to our evaluation rubric are also recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00975-8.

What Constitutes Preferred Long-Term Care Provided in Residential Aged Care Facilities? An Empirical Comparison of the Preferences of the General Population, Residents, and Family Members

OBJECTIVES

Relatively few studies to date have examined the preferences of members of the general population as potential future consumers of long-term aged care services. This study aimed to use discrete choice experiment methodology to compare the preferences of 3 groups: the general population, residents, and family members of people living in long-term aged care.

METHODS

A total of 6 salient attributes describing the physical and psychosocial care in long-term residential aged care were drawn from qualitative research with people with a lived experience of aged care and were used to develop the discrete choice experiment questionnaire. The 6 attributes included: the level of time care staff spent with residents, homeliness of shared spaces, the homeliness of their own rooms, access to outside and gardens, frequency of meaningful activities, and flexibility with care routines. The questionnaire was administered to 1243 respondents including consumers (residents [n = 126], family member carers [n = 416]), and members of the general population (n = 701).

RESULTS

For both the general population and resident samples, having their own room feeling "home-like" exhibited the largest impact upon overall preferences. For the family member sample, care staff being able to spend enough time exhibited the largest impact. Tests of poolability indicated that the resident and general population samples estimates could be pooled. The null hypothesis of equal parameters between the groups was rejected for the family members, indicating significant differences in preferences relative to the resident and the general population samples.

CONCLUSIONS

This study illustrates that preferences for residential aged care delivery may vary depending upon perspective and experience.

Israeli nursing home staff perspectives on challenges to quality care for residents with dementia

This study examines nursing home employees' perspectives concerning barriers to quality care for people with dementia. Data were derived from observations of care units and interviews with forty-one employees, including chief executive officers, social workers, nurses, occupational therapists, activity workers and nursing assistants at five Israeli nursing homes. Residents' behavior was reported as challenging for staff. Physical restraints and psychotropic medication were commonly used to address behavioral challenges, while few staff acknowledged these practices as problematic. Staff complained that some co-workers were insufficiently caring and wages and overall funding were inadequate, resulting in unsatisfactory staffing levels and insufficient activities for residents. Rigid care routines failed to meet resident needs, and staff failed to notice the relationship between care practices and resident behavior. While problems were described concerning multiple aspects of care, the root causes seemed to include the need for additional funding and for greater expertise in dementia care.

Care Process in Iranian Nursing Homes: A Grounded Theory Study

Introduction: The need and use of long-term care services for older people has increased with their rising population and there is little information about the state of serving in nursing homes. This study aimed to identify the caring process in Iranian nursing homes.

Methods: This qualitative study was conducted in three Iranian nursing homes using grounded theory approach. The participants included 28 individuals (14 older people and 14 caregivers). The data were collected using unstructured interviews up to data saturation, and analyzed by constant comparative method.

Results: Fragmented care emerged as the core variable. The main factor for developing the core variable was ‘experience-based caring’. Other factors included ‘inappropriate structure for care’ as contextual factors in the nursing homes environment and ‘keeping instead of caring’, ‘dismal life’, and ‘up and down of the path’ as strategies and consequences.

Conclusions: The most common type of care was the routine and unplanned one with focusing on physical aspects. To improve a delivery care system for older people in nursing homes, proposing a care plan with focus on an integrated model of care in nursing homes, provision of instructions for treatment, as well as supervision and training caregivers to provide better care are necessary

Falls may trigger body weight decline in nursing home residents

OBJECTIVES

The effect of falls on changes in body weight is still unknown. This study investigated the extent to which falls can modify the course of body weight in nursing home residents, and aimed to identify the factors that might modulate this effect.

METHODS

The sample included 132 residents aged ≥60 y who had experienced at least one fall after nursing home admission. Body weight was measured monthly in the 6 mo after the fall in the entire sample, and also in the 6 mo prefall in a subsample (n = 111). Sociodemographic and health data were obtained from medical records. Linear mixed models were used to estimate the average monthly changes in body weight after the fall in the total sample, and as a function of the sociodemographic and medical factors.

RESULTS

Falls modified the course of body weight in the total sample (β = -0.28, 95% confidence interval, -0.44 to -0.12, for the change in slope before and after fall) in all age classes and especially in individuals with severe cognitive impairment who received less-frequent informal visits (β = -0.55, 95% confidence interval, -0.87 to -0.22). Individuals aged ≥90 y and those with severe cognitive impairment had a steeper monthly weight decline in the 6 mo postfall, of 0.23 and 0.35 kg greater, respectively, than their younger and cognitively healthier counterparts.

CONCLUSIONS

Falls may trigger a body weight loss in nursing home residents, especially in the oldest old people and those with severe cognitive impairment who receive little support from informal caregivers. These findings highlight the importance of monitoring nutritional status of people who live in institutions after falls.

'I wouldn't choose this work again': Perspectives and experiences of care aides in long-term residential care

AIMS

To provide insight into the everyday realities facing care aides working in long-term residential care (LTRC), and how they perceive their role in society.

DESIGN

A qualitative ethnographic case study.

METHODS

Data were collected over. 10 months of fieldwork at one LTRC setting [September 2015 to June 2016] in Western Canada; semi-structured interviews (70 h) with 31 care aides; and naturalistic observation (170 h). Data were analysed using reflexive thematic analysis.

RESULTS

The findings in this work highlight the underpinned ageism of society, the gendered work of body care, and the tension between the need for relational connections - which requires time and economic profit. Four themes were identified, each relating to the lack of training, support, and appreciation care aides felt about their role in LTRC.

CONCLUSION

Care aides remain an unsupported workforce that is essential to the provision of high-quality care in LTRC. To support the care aide role, suggestions include: (i) regulate and improve care aide training; (ii) strengthen care aides autonomy of their care delivery; and (iii) reduce stigma by increasing awareness of the care aide role.

IMPACT

What problem did the study address? The unsupportive working conditions care aides experience in LTRC and the subsequent poor quality of care often seen delivered in LTRC settings. What were the main findings? Although care aides express strong affection for the residents they care for, they experience insurmountable systemic and institutional barriers preventing them from delivering care. Where and on whom will the research have impact? Care aides, care aide educators, care aide supervisors and managers in LTRC, retirement communities, and home care settings.

Determinants of compassion in providing care to older people: Educational implications

BACKGROUND

Care provision underpinned by compassion builds trust and ensures a deeper understanding of the health needs of older people. Yet nursing curricula in the United Kingdom focus on knowledge and skill acquisition rather than caring with compassion. This negatively impacts on the quality of care. Despite this, there is limited research on compassion in the care of older people.

AIM

To explore the views of nurse educators (NE), pre-registration nursing students (PNS) and clinical mentors (CM) of the determinants of compassion in the care of older people.

METHODS

A generic qualitative research design was used. Data were collected using semi-structured interviews with 39 participants (NE = 8; CM = 8; PNS = 23). These were digitally-recorded, fully transcribed and analysed thematically using NVivo software.

FINDINGS

Three main themes emerged from the data analysis: the meaning of compassion, extrinsic determinants of compassion in care, and intrinsic determinants of compassion in care.

DISCUSSION

The outcome of this study suggests that nurses and students think that compassion speeds up older people's recovery and enhances the quality of care. NEs consider its application in clinical practice a demonstration of competence.

CONCLUSION

The inclusion of compassion in practical sessions of pre-registration nursing curricula and in the care of the older person may result in improved understanding of the latter and provision of holistic, safe and effective care.

Effectiveness of individually tailored exercise on functional capacity and mobility in nursing home residents

Deterioration of physical and functional capacities is often seen in nursing homes. The present study aimed at assessing the effectiveness of an individually tailored physical exercise intervention on mobility and functional decline in nursing home residents in a 1-year follow-up period. Information on gender, age, education, profession and cognitive status was collected at baseline and at 6 and 12 months of the intervention. The decline in functional capacity and mobility was assessed using the Barthel index. Some 221 participants were included. Results from the multivariate logistic regression showed how residents who never participated in physical activities had a five-fold higher risk of mobility decline compared with residents who did engage for the whole follow-up time. A lower effect was seen in residents who participated for only 6 months. Although dementia appeared to be a significant predictor of decline, a substantial stabilisation in mobility capacity was noted in patients with both mild and severe dementia performing exercise. The findings suggest that preventing or slowing physical decline in nursing home residents is an achievable goal, and even those with a higher degree of cognitive decline may benefit from a tailored physical activity plan.

Predictors of Functional Decline in Nursing Home Residents: The Shelter Project

BACKGROUND

The aim of our study was to identify independent predictors of functional decline in older nursing home (NH) residents, taking into account both resident and facility characteristics.

METHODS

Longitudinal observational study involving 1,760 older (≥65 y) residents of NH participating in the SHELTER* study (57 NH in eight countries). All residents underwent a comprehensive geriatric assessment using the interRAI LTCF. Functional decline was defined as an increase of at least one point in the MDS Long Form ADL scale during a 1 year follow-up. Facility and country effects were taken into account.

RESULTS

During the study period 891 (50.6%), NH residents experienced ADL decline. Residents experiencing ADL decline were older, had lower disability at baseline, were more frequently affected by severe dementia and by urinary incontinence, and used more antipsychotics. In the mixed-effect logistic regression model, factors independently associated with a higher risk of functional decline were dementia and urinary incontinence, whereas the presence of a geriatrician was a protective factor.

CONCLUSIONS

Both resident and facility characteristics are associated with the risk of functional decline in NH residents. Increasing the quality of healthcare by involving a geriatrician in residents' care might be an important strategy to improve the outcome of this vulnerable population.

Mapping Research Conducted on Long-Term Care Facilities for Older People in Brazil: A Scoping Review

This scoping review aimed to explore the characteristics, strengths, and gaps in research conducted in Brazilian long-term care facilities (LTCFs) for older adults. Electronic searches investigating the residents (≥60 years old), their families, and the LTCF workforce in Brazil were conducted in Medline, EMBASE, LILACS, and Google Scholar, within the timescale of 1999 to 2018, limited to English, Portuguese, or Spanish. The reference lists were hand searched for additional papers. The Mixed Methods Appraisal Tool (MMAT) was used for critical appraisal of evidence. Data were reported descriptively considering the study design, using content analysis: 327 studies were included (n = 159 quantitative non-randomized, n = 82 quantitative descriptive, n = 67 qualitative, n = 11 mixed methods, n = 6 randomized controlled trials, and n = 2 translation of assessment tools). Regardless of the study design, most were conducted in a single LTCF (45.8%), in urban locations (84.3%), and in non-profit settings (38.7%). The randomized trials and descriptive studies presented the lowest methodological quality based on the MMAT. This is the first review to provide an overview of research on LTCFs for older people in Brazil. It illustrates an excess of small-scale, predominantly qualitative papers, many of which are reported in ways that do not allow the quality of the work to be assured.

Unmet needs, health policies, and actions during the COVID-19 pandemic: a report from six European countries

PURPOSE

The United Nations (UN) has published a Policy Brief on the impact of the Coronavirus Disease 2019 (COVID-19) that identifies policies and responses to protect older adults. Our objective was to summarize actions, health policies and clinical guidelines adopted by six European countries (Belgium, France, Italy, Poland, Spain and United Kingdom) during the pandemic, and to assess the impact of national policies on reducing adverse effects of the COVID-19 pandemic in older populations.

METHODS

Reports by geriatricians on the measures and actions undertaken by governmental institutions in each country between March and July 2020, as well as the role of primary care during the pandemic, covered three areas: (a) general health strategies related to the pandemic; (b) impact of COVID-19 on health inequity; and (c) initiatives and challenges for the COVID-19 pandemic and beyond.

RESULTS

In the six countries, COVID-19 mortality in nursing homes ranged from 26 to 66%. Although all countries endorsed the World Health Organization general recommendations, the reports identified the lack of harmonized European guidelines and policies for nursing homes, with competencies transferred to national (or regional) governments. All countries restricted visits in nursing homes, but no specific action plans were provided. The role of primary care was limited by the centralization of the crisis in hospital settings.

CONCLUSIONS

The older population has been greatly affected by COVID-19 and by the policies initiated to control its spread. The right to health and dignity are transgenerational; chronological age should not be the sole criterion in policy decisions.

COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe

The nursing home sector has seen a disproportionately high number of deaths as part of the COVID-19 pandemic. This reflects, in part, the frailty and vulnerability of older people living in care homes but has also, in part, been a consequence of the failure to include care homes in the systematic planning of a response to COVID, as well as a measure of neglect of standards and quality improvement in the sector. In response, the EUGMS published a set of medical standards of care developed in consultation with experts across its member national societies in 2015. The standards consisted of seven core principles of medical care for physicians working in nursing homes as a first step in developing a programme of clinical, academic and policy engagement in improving medical care for older people who are living and frequently also dying as residents in nursing homes. The gravity of the concerns arising for nursing home care from the COVID-19 pandemic, as well as emerging insights on care improvement in nursing homes indicate that an update of these medical standards is timely. This was performed by the writing group from the original 2015 guidelines and is intended as an interim measure pending a more formal review incorporating a systematic review of emerging literature and a Delphi process.

Motivational climate of group exercise sessions in nursing homes

Background

Motivational climate in exercise group environments would have an impact on adherence, effort and enjoyment. We examined the motivational climate among nursing home residents who were involved in group exercise sessions.

Methods

This cross-sectional study was conducted in 10 nursing homes of Liège area that offer group exercise sessions. Sociodemographic data (age, sex, body mass index), cognitive status (by the Mini Mental State Examination) and independence in activities of daily living (by the Katz Scale) were retrieved in the medical records. The “Abbreviated-Perceived Motivational Climate in Exercise Questionnaire” was translated into French and then administered face to face with a clinical researcher. This is composed of 6 ego-involving climate items (corresponding to rivalry, comparison and favoritism) and 6 task-involving climate items (corresponding to valorization, individual efforts, self-improvement and cooperation). Each item is ranged on a 5-point Likert scale ranging from 1 (not at all focused on ego or task) to 5 (totally focused on ego or task). Each subscale has a total score expressed as an average.

Results

A total of 102 subjects of exercise group sessions were included (84.3 ± 7.7 years and 83 (81.4%) women). The mean score of task-involving and ego-evolving motivational climate was respectively 3.57 (SD = 0.67) and 1.52 (SD = 0.49), suggesting that the motivational climate was more focused on the task-involving climate than on ego-involving climate. Some items results were of particular interest: 55.9% of the respondents found that the instructor doesn’t remark/reward when they try hard, 63.7% said that the instructor doesn’t encourage mutual aid and 38.2% found that instructor doesn’t encourage to do new exercises.

Conclusions

Participants tended to perceive motivational climate as more task-involving than ego-involving. The absence of individual positive feedback, new exercises and mutual aid were also highlighted.

Senior physical activity contests in nursing homes: a feasibility study

BACKGROUND

Competition has been shown to improve motivation and physical performance in young people. This method has been rarely studied in older people.

AIMS

To evaluate the feasibility of senior physical activity (PA) contests between two nursing homes and to assess changes in the motivational level and physical performance of the residents over time.

METHODS

Residents from two Belgian nursing homes were invited to participate in PA contests. A pretest and three contest sessions were organized over a period of 3 months. The activities proposed were body balance, gait speed, sit-to-stand performance, arm curl and address tests. Feasibility was measured by contest session adherence (expected score > 80%), difficulty scores (expected score < 40%) and appreciation scores (expected score > 80%). Motivational questionnaires were administered: the BREQ-2 (assessing amotivation, introjected regulation, identified regulation, intrinsic motivation and external motivation) and the A-PMCEQ (assessing ego- and task-involving climates). Friedman's analysis of variance was performed to evaluate the changes in physical performance and motivational levels.

RESULTS

Of the 24 participants, seven did not complete all sessions because of medical or personal reasons not related to the study. During the three sessions, the adherence was 86%, the mean difficulty score was 30.8% and the satisfaction score was 87%. After three sessions, residents experienced a significant decrease ranged from 3 to 0 point for amotivation (p = 0.03), 1 to 0 point for external motivation (p = 0.03) and 2.5 to 2 points for ego-involving climate (p = 0.02) and a significant improvement ranged from 0.7 to 0.9 m/s for gait speed (p < 0.001), 18.5 to 15.6 s for sit-to-stand performance (p < 0.001) and 11.5 to 15 curls for arm curl scores (p < 0.001).

CONCLUSIONS

In nursing home settings, senior PA contests are feasible and may improve the motivational climate and physical performance.

Recommendations for reducing harm and improving quality of care for older people in residential respite care

OBJECTIVES

Residential respite care (RRC) is a vital service that supports older people and their informal caregivers to continue to live in the community. Older people in RRC have an increased risk of injury-related harm, such as choking and suicide, compared to permanent nursing home residents. However, the opportunities for the prevention of harm during a RRC admission are largely unknown. This study developed recommendations to reduce harm and improve quality of care for older people in RRC.

METHODS

Experts developed, refined and prioritised recommendations through two consultation forums applying the modified nominal group technique and a follow-up online survey. Participants were purposively sampled from an existing network and were selected based on their expertise in aged care practice, nursing, policy, research, caregiver advocacy and quality improvement in the aged and healthcare sectors. Haddon's Matrix, an injury prevention framework, was applied to the recommendations. Final recommendations were released to over 300 organisations for validation and feedback.

RESULTS

Five experts were involved in forum one, seven attended forum two, and a further seven completed the survey. Seventeen draft recommendations were developed and refined to 11 final recommendations, four of which were prioritised as most important for implementation. These included the following: (a) a planned preventative care model of RRC; (b) facilities that specialised in RRC; (c) optimising information gathered on RRC residents; and (d) a standardised procedure for admission, handover and discharge from RRC. We received limited feedback from the organisations, which did not alter the recommendations.

IMPLICATIONS FOR PRACTICE

The recommendations developed in this study provide a valuable basis for the development of strategies to reduce harm and improve care in RRC and are a valuable first step towards improving practice. The next step is to empirically test the suggested recommendations to determine their effectiveness.

Nursing home care for people with dementia: Update of the design of the Living Arrangements for people with Dementia (LAD)-study

AIM

The aim of the current study is to describe the extended design of the Living Arrangements for people with Dementia (LAD)-study.

BACKGROUND

The demand for long-term care in care homes increases with the growing number of people with dementia. However, quality of care in care homes needs improvement. It is important to monitor quality of care in care homes for the purposes of conducting scientific research, providing input for policy, and promoting practice improvement.

DESIGN

The Living Arrangements for people with Dementia -study monitors changes in - quality of - care in care homes since 2008. With its extended design, the Living Arrangements for people with Dementia -study now also focuses on additional topics that are considered to improve quality of care: implementation of person-centred care, involvement of family carers and volunteers and reducing psychotropic drugs and physical restraints using a multidisciplinary approach.

METHODS

The data collection of the Living Arrangements for people with Dementia -study entails an interview with the manager and questionnaires are completed by care staff, family carers, volunteers, and multidisciplinary team members. This study is partly funded by the Dutch Ministry of Health, Welfare and Sports, grant number 323,088 and partly funded by the participating care homes.

DISCUSSION

Results of the Living Arrangements for people with Dementia -study will shed more light on variables related to quality of care in care homes for people with dementia.

IMPACT

Based on the obtained information, appropriate efforts to improve quality of care can be discussed and implemented. Furthermore, the results of this study guide policy making, because it expands knowledge about the effects of changing policies and exposes topics that need further attention.

TRIAL REGISTRATION

Not applicable. This article does not report the results of a healthcare intervention on human participants.

Specialist healthcare services for UK care home residents: a latent class analysis

Aim:

To identify discrete approaches to specialist healthcare support for older care home residents in the UK and to estimate their prevalence.

Background:

Internationally, a range of new initiatives are emerging to meet the multiple and complex healthcare needs of care home residents. However, little is known about their relative effectiveness and, given their heterogeneity, a classification scheme is required to enable research staff to explore this.

Method:

A UK survey collected information on the funding, age, coverage, aims, staffing and activities of 64 specialist care home support services. Latent class analysis (LCA) was used to allocate the sample into subgroups with similar characteristics.

Findings:

Three classes were identified. Class 1 (55% of sample) contained services with a high probability of providing scheduled input (regular preplanned visits) and support for all residents and a moderate probability of undertaking medication management, but a low probability of training care home staff (‘predominantly direct care’). Class 2 (23% of sample) had a moderate/high probability of providing scheduled input, support for all residents, medication management and training (‘direct and indirect care’). Class 3 (22% of sample) had a low probability of providing scheduled input, support for all residents and medication management, but a high probability of providing training for care home staff (‘predominantly indirect care’). Consultants were more likely to be members of services in Class 1 than Class 2, and Class 2 than Class 3.

Conclusions:

LCA offers a promising approach to the creation of a taxonomy of specialist care home support services. The skills and knowledge required by healthcare staff vary between classes, raising important issues for service design. The proposed classification can be used to explore the extent to which different organisational forms are associated with better resident, process and service outcomes.

Needs-based provision of medical care to nursing home residents: protocol for a mixed-methods study

INTRODUCTION

Nursing home residents typically have greater needs for medical care than community-dwelling elderly. However, restricted cognitive abilities and limited mobility may impede their access to general practitioners and medical specialists. The provision of medical care in nursing homes may therefore be inappropriate in some areas of medical care. The purpose of this mixed-methods study is to systematically assess, evaluate and explain met and unmet medical care needs in German nursing homes and to develop solutions where medical care is found to be inappropriate.

METHODS AND ANALYSIS

First, statutory health insurance claims data are analysed to identify differences in the utilisation of medical care between nursing home residents and community-dwelling elderly with and without need for long-term care. Second, the health status and medical care of 500 nursing home residents are assessed and evaluated to quantify met and unmet medical care needs. Third, qualitative expert interviews and case conferences and, fourth, quantitative analyses of linked data are used to provide structural, case-specific and generalisable explanations of inappropriate medical care among nursing home residents. Fifth, a modified Delphi study is employed to develop pilot projects aiming to improve medical care in nursing homes.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the University of Bremen on 23 November 2017. Research findings are disseminated through presentations at national and international conferences and publications in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00012383.

Effects of horticultural therapy: Perspectives of frail and pre-frail older nursing home residents

AIM

The aim of the study was to explore the perceptions and experiences of a group of frail and/or pre-frail older nursing home residents in relation to horticultural therapy.

METHOD

A total of 22 frail/pre-frail residents were interviewed. A qualitative content analysis approach was adopted to interpret the data from four nursing homes.

RESULTS

Four main themes were identified: (a) "Horticultural therapy is an enjoyable activity and a good pastime in nursing home life"; (b) "Joining the programme made me happier"; (c) "Horticultural activities facilitated socialization among the residents"; and (4) "Not much mention was made of the programme by the staff outside the sessions."

CONCLUSION AND IMPLICATION FOR PRACTICE

The findings provide evidence of the positive effects of horticultural therapy on perceived well-being among frail nursing home residents and expand the existing state of knowledge on the use of horticultural therapy in long-term residential care. Among others nursing implications, they are also important to develop appropriate and meaningful nursing practice to improve frail residents' perceived quality of life in the institution they now call "home."

Recommendations for the prevention of deaths among nursing home residents with unexplained absences

OBJECTIVES

Unexplained absences (UAs) contribute to the mortality and morbidity rates in the nursing home (NH) population. Valuing expert professional knowledge and skills is central to the achievement of improved care in NHs. This study developed and prioritised recommendations to prevent deaths of NH residents (NHRs) with UAs.

METHODS

Two expert consultation forums using the modified nominal group technique to develop recommendations were conducted, followed by an online survey to prioritise the most important recommendations for implementation. A framework applying the temporal dimension ("pre-event," "event" and "post-event") of an internationally accepted injury prevention framework, Haddon's Matrix, was applied to the recommendations. Participants were purposively sampled and identified via aged care organisations; and were selected based on their experience in aged care practice, policy, research, elder rights, seniors' law, or missing persons search and rescue (SAR).

RESULTS

Forum one comprised six, and forum two comprised nine experts from mixed disciplines. Seven participants completed the online survey. Twenty recommendations to prevent future injury and death were developed, five of which were prioritised for implementation in the aged care sector. In order of priority, these include: universal UA definition; mandated SAR plan, early assessment of NHRs; unmet needs behavioural assessments; and participation in decision-making.

CONCLUSIONS

The recommendations cover the broad spectrum of complex issues raised in managing unexplained absences, and are a vital first step towards informing care providers, governments and SAR teams about how to prevent injury and death of NHRs in residents with UAs. Future research should explore how to translate and evaluate the recommendations into practice.

Research priorities in residential aged care services: A statewide survey

OBJECTIVES

To ascertain the research priorities of staff working in Victorian residential aged care services (RACS).

METHOD

In October 2016, all 754 Victorian RACS were asked to list three most important research priorities in a confidential postal survey. Descriptive statistics and content analysis were used to analyse the data.

RESULTS

One hundred and sixty-two (21.5%) RACS participated. Research priorities, in order of importance, were grouped thematically as workforce issues, strategies to manage residents with dementia and funding to the sector. Staffing numbers and mix, particularly nurse-to-resident ratios, dominated workforce issues. The management of responsive behaviours was highlighted as a pressing clinical issue, and insufficient funding to the sector impacted on most issues reported.

CONCLUSIONS

The research priorities identified were inter-related. Some were already well researched, suggesting RACS staff have little time and/or limited access to research evidence to inform the care and management of residents, possibly because of inadequate staffing and funding.

Nursing Home Staff Perceptions of Barriers and Facilitators to Implementing a Quality Improvement Intervention

OBJECTIVES

Quality improvement (QI) may be a promising approach for staff to improve the quality of care in nursing homes. However, little is known about the challenges and facilitators to implementing QI interventions in nursing homes. This study examines staff perspectives on the implementation process.

DESIGN

We conducted semistructured interviews with staff involved in implementing an evidence-based QI intervention ("LOCK") to improve interactions between residents and staff through targeted staff behavior change. The LOCK intervention consists of 4 practices: (1) Learn from the bright spots, (2) Observe, (3) Collaborate in huddles, and (4) Keep it bite sized.

SETTING AND PARTICIPANTS

We interviewed staff members in 6 Veterans Health Administration nursing homes [ie, Community Living Centers (CLCs)] via opportunistic and snowball sampling.

MEASURES

The semistructured interviews were grounded in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change and covered staff experience, challenges, facilitators, and lessons learned during the implementation process. The interviews were analyzed using thematic content analysis.

RESULTS

Overall, staff accepted the intervention and appreciated the focus on the positives. Challenges fell largely within the categories of capability and opportunity and included difficulty finding time to complete intervention activities, inability to interpret data reports, need for ongoing training, and misunderstanding of study goals. Facilitators were largely within the motivation category, including incentives for participation, reinforcement of desired behavior, feasibility of intervention activities, and use of data to quantify improvements.

CONCLUSIONS/IMPLICATIONS

As QI programs become more common in nursing homes, it is critical that interventions are tailored for this unique setting. We identified barriers and facilitators of our intervention's implementation and learned that no challenge was insurmountable or derailed the implementation of LOCK. This ability of frontline staff to overcome implementation challenges may be attributed to LOCK's inherently motivational features. Future nursing home QI interventions should consider including built-in motivational components.

Associations between clinical indicators of quality and aged-care residents’ needs and consumer and staff satisfaction: the first Australian study

Objectives To ascertain Australian multistate prevalence and incidence of five commonly collected clinical indicators of aged-care home quality and to measure associations between these clinical indicators and levels of care needs and consumer and staff satisfaction. Methods A retrospective analysis of national audit data collected from 426 facilities between 2015 and 2016 was performed. Regression models were used to examine associations between five clinical indicators (falls, pressure injury, physical restraint, unplanned weight loss and polypharmacy) and level of care needs measured by the Aged Care Funding Instrument (ACFI) and consumer and care staff survey responses. Results With the exception of polypharmacy, commonly collected negative clinical outcomes were rare events. Compared with care homes with &lt;25% of residents having high-level care needs (high ACFI), homes with 25&lt;75% high-ACFI residents had more occurrences of all negative clinical outcomes except pressure injury. Homes with ≥75% high-ACFI residents reported the highest rates of polypharmacy (odds ratio 1.48, 95% confidence interval 1.39 – 1.57). Falls, unplanned weight loss and pressure injury were inversely associated with satisfaction scores adjusted for residents’ level of care needs. Conclusions This first Australian study of multistate clinical indicator data suggests interpretation of clinical indicators of aged-care home quality requires consideration of the level of residents’ care needs. What is known about the topic? Many Australian aged-care providers use quality indicators (QI) through benchmarking companies or in-house programs. The five most widely used aged-care clinical QIs in Australia are falls, pressure injury, physical restraint, unplanned weight loss and polypharmacy. Prevalence and incidence of these QIs are highly variable among Australian studies. A consistent message in the international literature is that residents’ clinical characteristics influence QI outcomes at baseline and may continue to influence outcomes over time. Study of associations between Australian aged-care home characteristics and QI outcomes has been limited. What does this paper add? This is the first Australian study of multistate clinical QI data. It is also the first to consider the level of resident care needs in the interpretation of clinical QI outcomes and exploration of the association between level of consumer and staff satisfaction and QI outcomes. What are the implications for practitioners? Understanding the connections between aged-care home characteristics, consumer and staff perceptions and clinical QIs is crucial in the meaningful interpretation of QI outcomes in context. With the recent introduction of the National Aged Care Quality Indicator Program, it is timely to review national policy, to gauge current quality of care and the measure of care quality in the sector, and to develop directions for possible research to inform and resolve debates regarding the potential influence and unplanned effects that such a program may have.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: Protocol for a systematic review

AIM

To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life.

DESIGN

Systematic review and narrative synthesis.

METHODS

Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016.

DISCUSSION

Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes.

IMPACT

Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.

Long-acting opioid initiation in US nursing homes

PURPOSE

To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics.

METHODS

This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents <50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79).

CONCLUSION

United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible.

Applying a Theory-Driven Framework to Guide Quality Improvement Efforts in Nursing Homes: The LOCK Model

Purpose of the Study

Implementing quality improvement (QI) programs in nursing homes continues to encounter significant challenges, despite recognized need. QI approaches provide nursing home staff with opportunities to collaborate on developing and testing strategies for improving care delivery. We present a theory-driven and user-friendly adaptable framework and facilitation package to overcome existing challenges and guide QI efforts in nursing homes.

Design and development

The framework is grounded in the foundational concepts of strengths-based learning, observation, relationship-based teams, efficiency, and organizational learning. We adapted these concepts to QI in the nursing home setting, creating the "LOCK" framework. The LOCK framework is currently being disseminated across the Veterans Health Administration.

Results

The LOCK framework has five tenets: (a) Look for the bright spots, (b) Observe, (c) Collaborate in huddles, (d) Keep it bite-sized, and (e) facilitation. Each tenet is described. We also present a case study documenting how a fictional nursing home can implement the LOCK framework as part of a QI effort to improve engagement between staff and residents. The case study describes sample observations, processes, and outcomes. We also discuss practical applications for nursing home staff, the adaptability of LOCK for different QI projects, the specific role of facilitation, and lessons learned.

Implications

The proposed framework complements national efforts to improve quality of care and quality of life for nursing home residents and may be valuable across long-term care settings and QI project types.

IAGG/IAGG GARN International Survey of End-of-Life Care in Nursing Homes

This article reports the findings of a survey on end-of-life (EOL) care in nursing homes of 18 long-term care experts across 15 countries. The experts were chosen as a convenience-based sample of known experts in each country. The survey was administered in 2016 and included both open-ended responses for defining hospice care, palliative care, and "end of life," and a series of questions related to the following areas-attitudes toward EOL care, current practice and EOL interventions, structure of care, and routine barriers. Overall experts strongly agreed that hospice and palliative care should be available in long-term care facilities and that both are defined by holistic, interdisciplinary approaches using measures of comfort across domains. However, it appears the experts felt that in most countries the reality fell short of what they believed would be ideal care. As a result, experts call for increased training, communication, and access to specialized EOL services within the nursing home.

Healthcare support to older residents of care homes: a systematic review of specialist services

Purpose

A growing ageing population with complex healthcare needs is a challenge to the organisation of healthcare support for older people residing in care homes. The lack of specialised healthcare support for care home residents has resulted in poorer outcomes, compared with community-dwelling older people. However, little is known about the forms, staff mix, organisation and delivery of such services for residents’ physical healthcare needs. The paper aims to discuss these issues.

Design/methodology/approach

This systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aimed to provide an overview of the range of healthcare services delivered to care homes and to identify core features of variation in their organisation, activities and responsibilities. The eligibility criteria for studies were services designed to address the physical healthcare needs of older people, permanently residing in care homes, with or without nursing. To search the literature, terms relating to care homes, healthcare and older people, across ten electronic databases were used. The quality of service descriptions was appraised using a rating tool designed for the study. The evidence was synthesised, by means of a narrative summary, according to key areas of variation, into models of healthcare support with examples of their relative effectiveness.

Findings

In total, 84 studies, covering 74 interventions, identified a diverse range of specialist healthcare support services, suggesting a wide variety of ways of delivering healthcare support to care homes. These fell within five models: assessment – no consultant; assessment with consultant; assessment/management – no consultant; assessment/management with consultant; and training and support. The predominant model offered a combination of assessment and management. Overall, there was a lack of detail in the data, making judgements of relative effectiveness difficult. Recommendations for future research include the need for clearer descriptions of interventions and particularly of data on resident-level costs and effectiveness, as well as better explanations of how services are implemented (review registration: PROSPERO CRD42017081161).

Originality/value

There is considerable debate about the best means of providing healthcare to older people in care homes. A number of specialist initiatives have developed and this review seeks to bring these together in a comparative approach deriving models of care of value to policy makers and commissioners.

Relation to functional and nutritional status among hospitalized elderlies

Introduction: Adding years to life is a great achievement when this is accompanied by a good level of health and well-being and independence. Major indicators for prediction mortality risk in older adults are the nutrition status and physical functional ability. The aim of this study is to present the nutritive and functional status among institutionalized elderlies and the relatedness with certain risk factors. Material and methods: Cross-sectional study has been conducted at certain nursing homes with participation of individuals over 60 years old. As for the research Scale of Daily Living Activities (ADL) has been used to present the functional capacity of the elderly and MNA has been used to detect the nutrition status. Results: The results from the research conducted among elderlies have shown the following socio-demographic characteristics: out of 127 participants, most of them were females-77% and 69% at the age between 75 and 84. Most of the elderlies (in 68%) have completed secondary education. The results from MNA have shown that 69,2% are wellnourished, 27,6% are at risk for malnutrition and 3,2% are malnourished. There is a relatedness of the nutrition status with the gender (p < 0,001) and the level of education (p < 0,001).ADL scale among 127 elderly participants has shown that 37% are independent, 45% are with a moderate impairment and 18% are with severe functional impairment. In comparison with the females, the males show higher level of functional ability in all ADL components except the continence. Conclusion: The results from the research have shown that the nutrition status among elderlies is satisfactory, emphasizing the factors such as gender, education level and functional ability as key points for the level of nutrition status at the elderlies.

Challenging nurse student selection policy: Using a lifeworld approach to explore the link between care experience and student values

AIM

This study uses a lifeworld perspective to explore beginning students' values about nursing. Internationally, increasing care demand, a focus on targets and evidence of dehumanized care cultures have resulted in scrutiny of practitioner values. In England, selection policy dictates that prospective nursing students demonstrate person-centred values and care work experience. However, there is limited recent evidence exploring values at programme commencement or the effect of care experience on values.

DESIGN

Mixed method study.

METHODS

A total of 161 undergraduate nursing students were recruited in 2013 from one English university. Thematic content analysis and frequency distribution to reveal descriptive statistics were used.

RESULTS

Statistical analysis indicated that most of the values identified in student responses were not significantly affected by paid care experience. Five themes were identified: How I want care to be; Making a difference; The value of learning; Perceived characteristics of a nurse; and Respecting our humanity. Students readily drew on their experience of living to identify person-centred values about nursing.

Recognizing and Responding to the "Toxic" Work Environment: Worker Safety, Patient Safety, and Abuse/Neglect in Nursing Homes

This grounded theory study examined how the certified nursing assistant (CNA) understands and responds to bullying in the workplace. Constant comparative analysis was used to analyze data from in-depth telephone interviews with CNAs ( N = 22) who experienced bullying while employed in a nursing home. The result of the analysis is a multistep model describing CNA perceptions of how, over time, they recognized and responded to the "toxic" work environment. The strategies used in responding to the "toxic" environment affected their care provision and were attributed to the development of several resident and worker safety outcomes. The data suggest that the etiology of abuse and neglect in nursing homes may be better explained by institutional cultures rather than individual traits of CNAs. Findings highlight the relationship between worker and patient safety, and suggest worker safety outcomes may be an indicator of quality in nursing homes.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background

Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.

Objectives

To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.

Review methods

Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.

Design

ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.

Settings

ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.

Participants

ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.

Intervention

An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.

Main outcome measures

ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.

Results

ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.

Limitations

Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.

Conclusions

A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.

Future work

There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.

Trial registration

Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.