Improving the Quality of Long-Term Care

Quality of Municipal Long-Term Care in Different Models of Care: A Cross-Sectional Study From Norway

The quality of care remains a critical concern for health systems around the globe, especially in an era of unprecedented financial challenges and rising demands. Previous research indicates large variation in several indicators of quality in the long-term care setting, highlighting the need for further investigation into the factors contributing to such disparities. As different ways of delivering long-term care services likely affect quality of care, the objectives of our study is to investigate (1) variation in structure, process and outcome quality between municipalities, and (2) to what extent variation in quality is associated with municipal models of care and structural characteristics. The study had a cross-sectional approach and we utilized data on the municipal level from 3 sources: (1) a survey for models of care (2) Statistics Norway for municipal structural characteristics and (3) the National Health Care Quality Indicator System. Descriptive statistics showed that the Norwegian long-term care sector performs better (measured as percentage or probability) on structure (85.53) and outcome (84.86) quality than process (37.85) quality. Hierarchical linear regressions indicated that municipal structural characteristics and model of care had very limited effect on the quality of long-term care. A deeper understanding of variation in service quality may be found at the micro level in healthcare workers' day-to-day practice.

Effective Chronic Disease Interventions in Nursing Homes: A Scoping Review Based on the Knowledge-to-Action Framework

Objectives: The purpose of this scoping review was two-fold: 1) to identify effective intervention studies addressing chronic disease for seniors living in nursing homes (e.x. chronic heart failure, diabetes, dementia, etc.), and 2) to describe how consistently the studies' reported their stages of the Knowledge-to-Action framework (2006).Methods: This scoping review involved a systematic search of CINAHL, EMBASE, PubMed and Scopus of intervention studies, published in English and French between 1997 and 2018, that focused on the development, implementation and/or evaluation of a chronic disease management guideline or best practice for older adults 65+ residing within a nursing home (NH). Authors abstracted information specific to the seven stages of the Knowledge-to-Action framework (identifying problem, tailoring to local context, barriers and facilitators to intervention delivery, implementation, monitoring, outcome criteria, and sustainability).Results: Six studies met the inclusion criteria. Procedures for monitoring knowledge use and outcome evaluation were thoroughly described. Other stages of the Knowledge-to-Action framework were not consistently reported, including problem identification related to older adults' needs and within the context of NHs, intervention implementation, evaluation, and sustainability. Of the six studies included, only two met all the pre-defined evaluation outcomes.Conclusions: Given the need for chronic disease management in NHs, researchers are encouraged to report on intervention studies using the Knowledge-to-Action framework to optimize the likelihood that interventions will be suitable for the context of their delivery and introduce sustainable change.Clinical implications: To answer what interventions should be introduced to residents in long-term care, research must clearly demonstrate efficacy, provide enough detail for methods to be reproducible in applied contexts, and consider strategies for sustainability and the holistic needs of residents.

Residents' and Relatives' Experiences of Acute Situations: A Qualitative Study to Inform a Care Model

Background and Objectives

As new models of care aiming to reduce hospitalizations from nursing homes emerge, their implementers must consider residents’ and relatives’ needs and experiences with acute changes in the residents’ health situations. As part of the larger INTERCARE implementation study, we explored these persons’ experiences of acute situations in Swiss nursing homes.

Research Design and Methods

3 focus groups were conducted with residents and their relatives and analyzed via reflexive thematic analysis.

Results

The first theme, the orchestra plays its standards, describes experiences of structured everyday care in nursing homes, which functions well despite limited professional and competency resources. The second theme, the orchestra reaches its limits, illustrates accounts of acute situations in which resources were insufficient to meet residents’ needs. Interestingly, participants’ perceptions of acute situations went well beyond our own professional view, that is, changes in health situations, and included situations best summarized as “changes that might have negative consequences for residents if not handled adequately by care workers.” Within the third theme, the audience compensates for the orchestra’s limitations, participants’ strategies to cope with resource limitations in acute situations are summarized.

Discussion and Implications

Our findings suggest differences between care providers’ and participants’ perspectives regarding acute situations and care priority setting. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning and meeting individual residents’ and relatives’ needs. Implications for the development and implementation of a new nurse-led model of care are discussed.

Expert nurse response to workforce recommendations made by the coronavirus commission for safety and quality in nursing homes

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents’ care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.

Moving Online: A Pilot Clinical Trial of the Changing Talk Online (CHATO) Communication Education for Nursing Home Staff

BACKGROUND AND OBJECTIVES

Staff-resident communication is a critical part of nursing home (NH) care. Reducing elderspeak and increasing person-centered communication has been shown to reduce behavioral symptoms experienced by persons living with dementia. An online version of a successful classroom-based communication-training program that reduced staff elderspeak and resident behavioral symptoms was evaluated. The objective of this study was to establish feasibility and determine the preliminary effects of the online program in preparation for a national pragmatic clinical trial.

RESEARCH DESIGN AND METHODS

Seven NHs were randomized to immediate intervention or wait-list control conditions. The NHs were provided with the web-based training program that staff individually accessed. Primary outcomes were knowledge scores and communication ratings of a video-recorded interaction, using pre- to post-training comparisons.

RESULTS

Knowledge increased from a mean pretest score of 61.9% (SD=20.0) to a mean posttest score of 84.6% (SD=13.5) for the combined group. Knowledge significantly improved between Time 1 and Time 2 for the immediate intervention participants (p<.001), but not for the wait-list control participants (p=.091), and this difference was statistically significant (p<.001). Ability to recognize ineffective, inappropriate, non-person-centered, and elderspeak communication improved after training (p<.001). The magnitude of improvement in communication recognition was comparable to that of the original classroom format.

DISCUSSION AND IMPLICATIONS

The adapted communication intervention was feasible and improved knowledge and communication. Online instruction can improve access to quality education and is an effective means to improve dementia care by overcoming barriers to in-person training.

Skin tear prevalence and incidence in the long-term care population: a prospective study

Objective:

The World Health Organization estimates that between 2015 and 2050 the proportion of the world's population over 60 years old will nearly double from 12% to 22%. An often overlooked byproduct of ageing is the skin changes associated with it, which heighten the risk of developing skin tears. Despite this presumed increased risk, the true impact of skin tears across age groups and care settings is poorly understood. The purpose of the present study was to establish the prevalence and incidence of skin tears in the Ontario long-term care population.

Method:

A prospective study design was used to explore the prevalence and incidence of skin tears. Individuals from four long-term care facilities in Ontario were followed over four weeks. The participants were examined for skin tears at the beginning of the study and at week four to determine whether skin tears had occurred and to record the skin tear type and location.

Results:

A total of 380 individuals, aged 65 years and over, took part. The study found a skin tear prevalence of 20.8% and an incidence of 18.9% within four weeks. These results provide much needed data on the burden of skin tears in the long-term care population. Conclusion: The present study is an important first step towards developing a prevention programme targeting individuals at risk for skin tears in long-term care.

Transitioning Communication Education to an Interactive Online Module Format

BACKGROUND

The Changing Talk intervention improves nursing home staff communication by reducing elderspeak. To facilitate dissemination, interactive online modules were created, maintaining the original content. This article reports on the process of transitioning and the results of pilot testing the modules.

METHOD

Interactive online modules were developed, pilot tested, and the evaluated in comparison to outcomes from the classroom format training.

RESULTS

Online participants (N = 9) demonstrated pre to posttest knowledge gain (scores improved from M = 82.4% to M = 91.2%). Rating of a staff-resident interaction showed improved recognition of elderspeak and person-centered communication after training. Online and original participants reported similar intentions to use learned skills and rated the program highly.

CONCLUSION

Evidence-based interventions can be translated from traditional classroom to online format maintaining effects on increasing staff knowledge and intentions to use learned skills in practice. However, the modules should be tested in a larger and more representative sample. J Contin Educ Nurs. 2017;48(7):320-328.

The meaning of slow nursing in dementia care

Research literature in the dementia field lacks examples of ‘best-practices’ demonstrating concretely how it is possible to support the sense of coherence in people with dementia. The purpose of this study was to elucidate the nurses’ views concerning a caring approach that may support the sense of coherence in people with dementia. The data were collected through participant observation and focus group interviews during a four-month period in 2011. Sixteen registered nurses recruited from two Norwegian nursing homes participated in this study. The data were interpreted using a phenomenological-hermeneutical method. Three themes were identified: ‘being in the moment’, ‘doing one thing at a time’, and ‘creating joy and contentment’. An overall interpretation of these themes is described by the metaphor ‘slow nursing’, a caring approach that may lead to supporting the sense of coherence in people with dementia.