The quality of care in Norwegian nursing homes

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study

BACKGROUND

Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs.

METHODS

A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience.

RESULTS

The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids.

CONCLUSIONS

Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

Intended, Unintended, Unanticipated? Consequences of Social Distancing Measures for Nursing Home Residents During the Covid-19 Pandemic

During the outbreak of the COVID-19 pandemic, Norwegian health authorities introduced social distancing measures in nursing homes. The aim was to protect vulnerable residents from contracting the potentially deadly infection. Drawing on individual interviews with nursing home managers and physicians, and focus groups with nursing staff, we explore and describe consequences the social distancing measures had on nursing home residents' health and wellbeing. The analysis indicates that most residents became socially deprived, while some became calmer during the nursing home lockdown. Nursing home staff, physicians and managers witnessed that residents' health and functional capacity declined when services to maintain health, such as physiotherapy, were put on hold. In conclusion, we argue that although Norwegian health authorities managed to keep the infection rates low in nursing homes, this came at a high price for the residents however, as the social distancing measures also negatively impacted their health and wellbeing.

Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial

OBJECTIVES

To investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia.

METHODS

Baseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care.

MEASUREMENTS

The primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio.

RESULTS

Generalized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed.

CONCLUSION

For nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers' engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT02238652.

Standards and quality of care for older persons in long term care facilities: a scoping review

BACKGROUND

Caring for older persons has become a global necessity to ensure functional ability and healthy ageing. It is of paramount importance that standards of care are monitored, especially for older persons who live in long term care facilities (LTCF). We, therefore, scoped and summarised evidence relating to standards and the quality of care for older persons in LTCFs in gerontological literature globally.

METHODS

We conducted a scoping review using Askey and O'Malley's framework, including Levac et al. recommendations. PubMed, CINAHL, Health Sources, Scopus, Cochrane Library, and Google Scholar were searched with no date limitation up to May 2020 using keywords, Boolean terms, and medical subject headings. We also consulted the World Health Organization website and the reference list of included articles for evidence sources. This review also included peer-reviewed publications and grey literature in English that focused on standards and quality of care for older residents in LTCFs. Two reviewers independently screened the title, abstract, and full-text of evidence sources screening stages and performed the data extraction. Thematic content analysis was used, and a summary of the findings are reported narratively.

RESULTS

Sixteen evidence sources published from 1989 to 2017 met this study's eligibility criteria out of 73,845 citations obtained from the broader search. The majority of the studies were conducted in the USA 56% (9/16), and others were from Canada, Hong Kong, Ireland, Norway, Israel, Japan, and France. The included studies presented evidence on the effectiveness of prompted voiding intervention for urinary incontinence in LTCFs (37.5%), the efficacy of professional support to LTCF staff (18.8%), and the prevention-effectiveness of a pressure ulcer programme in LTCFs (6.3%). Others presented evidence on regulation and quality of care (12.5%); nursing documentation and quality of care (6.3%); medical, nursing, and psychosocial standards on the quality of care (6.3%); medication safety using the Beer criteria (6.3%); and the quality of morning care provision (6.3%).

CONCLUSION

This study suggests most studies relating to standards and quality of care in LTCFs focus on effectiveness of interventions, few on people-centredness and safety, and are mainly conducted in European countries and the United States of America. Future studies on people-centerdness, safety, and geographical settings with limited or no evidence are recommended.

Nursing Students Explore Meaningful Activities for Nursing Home Residents: Enlivening the Residents by Cultivating Their Spark of Life

International research focuses on person-centered care, quality of life, and quality of care for people living in long-term care facilities, and that it can be challenging to improve the quality of life for residents with dementia. The aim of this study was to explore ways of developing appropriate person-centered activities for nursing home residents based on what would be meaningful for them. A qualitative explorative design was chosen. Twelve students each year over a three-year period participated in the study (altogether 36). Each student tailored joyful and meaningful activities for two nursing home residents and wrote eight reflection journals each (altogether 284). Additional data came from eight focus group interviews with the students. Data were analyzed using qualitative content analysis. The main theme was “Enlivening the residents by cultivating their spark of life”. Two main categories were identified: (1) “Journeying to meaningful and enlivening (enjoyable) activities”, and (2) “Expressions of enlivening”, It is possible to tailor meaningful and enlivening activities together with the individual person with dementia. Involvement and engagement are necessary to understand the verbal and nonverbal expressions and communicate with the individual resident.

Nursing home residents' ADL status, institution-dwelling and association with outdoor activity: a cross-sectional study

Introduction

The Norwegian regulations for nursing homes consider access to meaningful activities to be an indicator for the quality of nursing homes. Activities of daily living (ADL) provide important basic self-care skills for nursing home residents. Due to the physical changes caused by ageing and comorbidities, nursing home residents may experience functional decline over time, which may affect their ability to perform meaningful ADL, such as outdoor activity, which is considered a valuable and meaningful activity in Norwegian culture. This study aimed to investigate the association between ADL status, institution-dwelling and outdoor activity among nursing home residents.

Methods

This cross-sectional study included 784 residents aged >67 years living in 21 nursing homes in 15 Norwegian municipalities between November 2016 and May 2018. The Barthel Index was used to assess the nursing home residents' ADL status. Other variables collected were age, gender, body weight and height, visits per month, institution, ward, and participation in weekly outdoor activities. Descriptive statistics were used to provide an overview of the residents' characteristics. A Poisson regression model was used to test the association between the outdoor activity level as the dependent variable and ADL score, institution, and other control variables as independent variables.

Results

More than half (57%) of the nursing home residents in this sample did not go outdoors. More than 50% of the residents had an ADL score <10, which indicates low performance status. Further, we found that residents' ADL status, institution, ward, and number of visits had an impact on how often the residents went outdoors.

Discussion

The nursing home residents in this study rarely went outdoors, which is interesting because Norwegians appreciate this activity. Differences in the number of visits might explain why some residents went outdoors more often than other residents did. Our findings also highlight that the institutions impact the outdoor activity. How the institutions are organized and how important this activity is considered to be in the institutions determine how often the activity is performed.

Conclusion

The low frequency of the outdoor activities might be explained by a low ADL score. More than 50% of the residents had an ADL score <10, which indicates low performance status. Despite regulations for nursing home quality in Norway, this result suggests that organizational differences matter, which is an important implication for further research, health policy and practice.

Determinants of nursing home choice: Does reported quality matter?

Quality report cards addressing information asymmetry in the health care market have become a popular strategy used by policymakers to improve the quality of care for older people. Using individual level data from the largest German sickness fund merged with institutional level data, we examine the relationship between reported nursing home quality, as measured by recently introduced report cards, nursing home prices, nursing home's location, and the individual choice of nursing homes. Report cards were stepwise introduced as of 2009, and we use a sample of 2010 that includes both homes that had been evaluated at that time and that had not yet been. Thus, we can distinguish between institutions with above and below average ratings as well as nonrated nursing homes. We find that the probability of choosing a nursing home decreases in distance and price. However, we find no economically significant effect of reported quality on individuals' choice of nursing homes.

Stakeholder Engagement in Practice Change: Enabling Person-Centred Mealtime Experiences in Residential Care Homes

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Staff experiences with implementing a case conferencing care model in nursing homes: a focus group study

Background

A majority of nursing home residents have dementia, and many develop neuropsychiatric symptoms. These symptoms are often caused by neuropathological changes in the brain, but modifiable factors related to quality of care also have an impact. A team-based approach to care that include comprehensive geriatric assessments to facilitate clinical decision-making and structured case conference meetings could improve quality of care and quality of life for the residents. Despite recommendations to adopt this approach, dementia care does not reach standards of evidence-based practice. Better implementation strategies are needed to improve care. A cluster randomised controlled trial with a 12-month intervention was conducted, and the experiences of staff from the intervention nursing homes were explored in a qualitative study after the trial was completed. The aim of the present study was to describe: (i) staff’s experiences with the intervention consisting of comprehensive geriatric assessments of nursing home residents and case conferencing, and (ii) enablers and barriers to implementing and sustaining the intervention.

Methods

Four focus groups with a total of 19 healthcare staff were interviewed, representing four out of eight intervention nursing homes. Thematic content analysis was used to interpret the transcribed data.

Results

Two major themes emerged: 1) learning experiences and 2) enablers and barriers to implementation. The participants had experienced learning both on an organisational level: improvements in care and an organisation that could adjust and facilitate change; and on an individual level: becoming more conscious of residents’ needs and acquiring skills in resident assessments. Participants described important enabling factors such as managerial support, drivers for change, and feasibility of the intervention for the local nursing home. Barriers to implementing and sustaining the intervention were time constraints, lack of staff training, unsuitable electronic patient record system for care planning and high complexities of care and instabilities that are present in nursing homes.

Conclusions

Quality improvements in nursing homes are difficult to sustain. In order to offer residents high quality of care that meet their individual needs, it is important for management and nursing home staff to be aware of and understand factors that enable or constrain change.

The Best Day of the Week: New Technology Enhancing Quality of Life in a Care Home

Older people living in residential aged care facilities tend to be physically as well as socially inactive, which leads to poorer health and reduced wellbeing. A lack of recognition of the importance of social support, limited resources, lack of training and task-oriented work routines leave little time for staff to meet the social needs of residents. Through qualitative ethnographic fieldwork, this study investigates the potential for new technologies to enhance quality of life and facilitate meaningful engagement in physical and social activities among culturally and linguistically diverse residents and staff in care facilities. A continuum from nonparticipation to full participation among residents was observed when Touch Screen Technology activities were implemented. Data indicate that resident’s engagement is impacted by five interdependent factors, including environmental, organisational, caregiver, patient, and management- &government-related. Findings show that new technologies can be used to increase meaningful physical and social engagement, including transcending language and cultural barriers. However, the successful application of new technologies to enhance quality of life is dependent on their integration into the daily routine and social relationships of staff and residents, with the full support of management. Guidelines governing the use of new technologies to support meaningful engagement of older people in residential care are lacking: this project highlights the importance of attention to the social relational dimensions of technology interventions to support best practice in their use.

Nursing home prices and quality of care - Evidence from administrative data

There is widespread concern about the quality of care in nursing homes. On the basis of administrative data of a large health insurance fund, we investigate whether nursing home prices are associated with relevant quality of care indicators at the resident level. Our results indicate negative associations between price and both inappropriate and psychotropic medication. In contrast, we do not find any relationship between the price and impairments of physical health.

The relationships between the combination of person- and organization-related conditions and patients' perceptions of palliative care quality

BACKGROUND

Little is known about the combination of person- and organization- related conditions and the relationships with patients' perspectives of care quality. Such a combination could contribute knowledge reflecting the complexity of clinical practice, and enhance individualized care. The aim was to investigate the relationships between the combination of person- and organization-related conditions and patients' perceptions of palliative care quality.

METHODS

A cross-sectional study, including 191 patients in the late palliative phase (73% response rate) admitted to hospice inpatient care (n = 72), hospice day care (n = 51), palliative units in nursing homes (n = 30) and home care (n = 38), was conducted between November 2013 and December 2014, using the instrument Quality from the Patients' Perspective specific to palliative care (QPP-PC). Data were analysed, using analysis of covariance, to explore the amount of the variance in the dependent variables (QPP-PC) that could be explained by combination of the independent variables - Person- and organization-related conditions, - while controlling for differences in covariates.

RESULTS

Patients scored the care received and the subjective importance as moderate to high. The combination of person- and organization - related conditions revealed that patients with a high sense of coherence, lower age (person - related conditions) and being in a ward with access to and availability of physicians (organization-related condition) might be associated with significantly higher scores for the quality of care received. Gender (women), daily contact with family and friends, and low health-related quality of life (person-related conditions) might be associated with higher scores for subjective importance of the aspects of care quality.

CONCLUSION

Healthcare personnel, leaders and policy makers need to pay attention to person- and organization-related conditions in order to provide person-centered palliative care of high quality. Further studies from palliative care contexts are needed to confirm the findings and to investigate additional organizational factors that might influence patients' perceptions of care quality.

Theoretical Perspectives of Hospitalized Older Patients and Their Health-Related Problems and Quality of Care: Systematic Literature Review

Introduction:

The proportion of aged people is growing worldwide. Older persons are affected by a number of physical, psychological and social factors that influence their health and quality of life. These factors are usually multiple and are often masked by sensory and cognitive impairments.

Purpose:

The purpose of this study was to examine the available literature emphasizing older persons’ care, care-related problems, and older persons’ quality of healthcare. Also, the paper aimed at exploring the future direction of research needs.

Results:

Good quality older patients’ care involves safety, professional interventions, recognition and management of physical and emotional wellbeing. Care of older patients requires addressing the aging process itself, the expected decrease in functionality, and diminished cognitive ability. Little statistical data were found to address the quality of hospitalized elderly patients in particular as well as study on healthcare facilities and nursing homes. Literature does not provide much guidance to the effectiveness of care strategies.

Conclusion:

The results assert that elderly health care is a priority. However, health care systems are not specific about elderly patients’ needs, leading to low quality of elderly care. There is a need to use an integrated model of care to improve the quality of life and quality of care provided to hospitalized older patients.

Organisational and environmental characteristics of residential aged care units providing highly person-centred care: a cross sectional study

BACKGROUND

Few studies have empirically investigated factors that define residential aged care units that are perceived as being highly person-centred. The purpose of this study was to explore factors characterising residential aged care units perceived as being highly person-centred, with a focus on organisational and environmental variables, as well as residents' and staff' characteristics.

METHODS

A cross-sectional design was used. Residents (n = 1460) and staff (n = 1213) data from 151 residential care units were collected, as well as data relating to characteristics of the organisation and environment, and data measuring degree of person-centred care. Participating staff provided self-reported data and conducted proxy ratings on residents. Descriptive and comparative statistics, independent samples t-test, Chi² test, Eta Squared and Phi coefficient were used to analyse data.

RESULTS

Highly person-centred residential aged care units were characterized by having a shared philosophy of care, a satisfactory leadership, interdisciplinary collaboration and social support from colleagues and leaders, a dementia-friendly physical environment, staff having time to spend with residents, and a smaller unit size. Residential aged care units with higher levels of person-centred care had a higher proportion of staff with continuing education in dementia care, and a higher proportion of staff receiving regular supervision, compared to units with lower levels of person-centred care.

CONCLUSIONS

It is important to target organisational and environmental factors, such as a shared philosophy of care, staff use of time, the physical environment, interdisciplinary support, and support from leaders and colleagues, to improve person-centred care in residential care units. Managers and leaders seeking to facilitate person-centred care in daily practice need to consider their own role in supporting, encouraging, and supervising staff.

Nursing home care quality: a cluster analysis

Purpose The purpose of this paper is to explore potential differences in how nursing home residents rate care quality and to explore cluster characteristics. Design/methodology/approach A cross-sectional design was used, with one questionnaire including questions from quality from patients' perspective and Big Five personality traits, together with questions related to socio-demographic aspects and health condition. Residents ( n=103) from four Norwegian nursing homes participated (74.1 per cent response rate). Hierarchical cluster analysis identified clusters with respect to care quality perceptions. χ² tests and one-way between-groups ANOVA were performed to characterise the clusters ( p<0.05). Findings Two clusters were identified; Cluster 1 residents (28.2 per cent) had the best care quality perceptions and Cluster 2 (67.0 per cent) had the worst perceptions. The clusters were statistically significant and characterised by personal-related conditions: gender, psychological well-being, preferences, admission, satisfaction with staying in the nursing home, emotional stability and agreeableness, and by external objective care conditions: healthcare personnel and registered nurses. Research limitations/implications Residents assessed as having no cognitive impairments were included, thus excluding the largest group. By choosing questionnaire design and structured interviews, the number able to participate may increase. Practical implications Findings may provide healthcare personnel and managers with increased knowledge on which to develop strategies to improve specific care quality perceptions. Originality/value Cluster analysis can be an effective tool for differentiating between nursing homes residents' care quality perceptions.

Stakeholders' roles and responsibilities regarding quality of care

Purpose The purpose of this paper is to describe how different stakeholders (society, managers, employees and clients) can together ensure the quality of care. Design/methodology/approach Qualitative data were collected from four focus group interviews conducted in three countries. All interviewees were pursuing a master's degree in social and/or health care management and had begun working in their field after completing their bachelor's degree. The data were analysed using inductive content analysis. Findings The society and managers are responsible for the care system as a whole and must apply system-oriented, rather than sector-oriented, thinking. Employees are responsible for ensuring the continuity of client services in their work, and managers and employees share the responsibility of achieving the organisational goals and quality standards. The clients are responsible for acting as responsible service users and providing the required information to obtain care. Communication was strongly emphasised in the data, and it necessitates cross-professional and organisational boundaries, professional and political boundaries, as well as boundaries between the professional and the client. Research limitations/implications Since the interviewees were all pursuing a master's degree in social and/or health care management, when reflecting on their work experience, they may have also been reflecting what they had learned in university. Practical implications This study emphasises the importance of collaboration and communication between stakeholders in ensuring the quality of care. Unpredictable economies, the ageing population and the ongoing integration and reorganisation of health and social care services in Europe highlight systematic and strategic approach in quality of care. Originality/value This paper claims that communication between different care stakeholders gives a more systematic and coherent framework for the quality of care. Quality of care is a strategic choice and part of the strategic decision making at the societal, political, organisational and managerial levels.

Understanding organizational and cultural premises for quality of care in nursing homes: an ethnographic study

BACKGROUND

Internationally, there are concerns about the quality of care in nursing homes. The concept of 'corporate culture' as an internal variable could be seen as the means to improve quality of care and quality of life for the residents. The aim of this article was to describe the nursing home culture from the staff's perspective and to include how the residents describe quality of care.

METHODS

An ethnographic design was employed. A purposive sample of four municipal public nursing homes in Norway with long-term care residents was included in the study. Data were collected by participant observation including informal conversation with the staff, and in-depth interviews with 15 residents using a narrative approach.

RESULTS

The main findings were that organizational cultures could be seen as relatively stable corporate cultures described as 'personalities' with characteristics that were common for all nursing homes (conformity) and typical traits that were present in some nursing homes, but that they were also like no other nursing home (distinctiveness). Conformity ('Every nursing home is like all other nursing homes') meant that nursing home organizations formed their services according to a perception of what residents in general need and expect. Trait ('Every nursing home is like some other nursing homes') expressed typologies of nursing homes: residency, medical, safeguard or family orientation. The distinctness of each nursing home ('Every nursing home is like no other nursing home') was expressed in unique features of the nursing home; the characteristics of the nursing home involved certain patterns of structure, cultural assumptions and interactions that were unique in each nursing home. Nursing home residents experienced quality of care as 'The nursing home as my home' and 'Interpersonal care quality'. The resident group in the different types of nursing homes were unique, and the experience of quality of care seemed to depend on whether their unique needs and expectations were met or not.

CONCLUSION

In order to create a sustainable nursing home service the service needs to be characterized by learning and openness to change and must actually implement practices that respond to the resident and his or her family's values.

An examination of quality of care in Norwegian nursing homes - a change to more activities?

BACKGROUND

Studies on Norwegian nursing homes have shown that the general care is at a relatively high level, while the level of physical and social activities is relatively low. As a response to these findings, the Norwegian government has stressed the importance of activities in various white papers and circulars and, in recent years, has launched several campaigns specifically aimed at increasing the level of activities.

AIM

The aim of the study was to examine the following: (i) how the government has succeeded in increasing the level of physical and social activities in Norwegian nursing homes; (ii) how the level of activities compares to the general care; and (iii) how the level of activities and the general care are influenced by the following facility characteristics: residents' mobility level, total staffing levels, ratio of RNs, ratio of unlicensed staff and ward size.

METHOD

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data.

RESULTS

On a scale ranging from 1 to 7, the staff members assess the activity dimension to be 4.31 and the general care dimension to be 5.66. The activity dimension was significantly negatively correlated with the ratio of unlicensed staff, the ratio of Registered Nurses and the residents' mobility level, while the general care dimension was significantly negatively correlated with the ratio of unlicensed staff.

CONCLUSION

The study shows that the level of physical and social activities offered to the residents is relatively low, while the general care level is significantly higher, in line with earlier studies. Consequently, the government has not succeeded with its current policy to increase the level of activities in nursing homes. The relationship between the two quality dimensions and the explanatory variables shows that nursing home quality is a complicated phenomenon.

Ethical challenges in care for older patients who resist help

Background:

Situations where patients resist necessary help can be professionally and ethically challenging for health professionals, and the risk of paternalism, abuse and coercion are present.

Research question:

The purpose of this study was to examine ethical challenges in situations where the patient resists healthcare.

Research design:

The method used was clinical application research. Academic staff and clinical co-researchers collaborated in a hermeneutical process to shed light on situations and create a basis for new action.

Participants and research context:

Four research groups were established. Each group consisted of six to eight clinical co-researchers, all employees with different health profession backgrounds and from different parts of the municipal healthcare services, and two scientific researchers.

Ethical considerations:

The study was conducted in compliance with ethical guidelines and principles. Participants were informed that participation was voluntary and that confidentiality would be maintained. They signed a consent form.

Findings:

The findings showed that the situations where patients opposed help related to personal hygiene, detention in an institution and medication associated with dental treatment. The situations were perceived as demanding and emotionally stressful for the clinicians.

Discussion:

The situations can be described as everyday ethics and are more characterised by moral uncertainty and moral distress than by being classic ethical dilemmas.

Conclusion:

Norwegian legislation governing the use of force seems to provide decision guidance with the potential to reduce uncertainty and moral stress if the clinicians’ legal competence had been greater.

Relatives’ participation in everyday care in special care units for persons with dementia

Background:

Research concerning relatives’ participation in the everyday care related to persons living in special care units for persons with dementia is limited.

Research questions:

To examine relatives’ participation in their near one’s everyday care, the level of burden experienced and important factors for participation, in this special context.

Design:

The study had a cross-sectional design, and data collection was carried out by means of a study-specific questionnaire.

Participants and context:

A total of 233 relatives from 23 different special care units participated.

Ethical consideration:

The study was approved by the Norwegian Social Science Data Services.

Results:

A great majority of relatives reported that they visited weekly and were the resident’s spokesperson, but seldom really participated in decisions concerning their everyday care. Participation was seldom reported as a burden.

Discussion:

This study indicated that relatives were able to make a difference to their near one’s everyday life and ensure quality of care based on their biographical expertise, intimate knowledge about and emotional bond with the resident. Since knowing the resident is a prerequisite for providing individualised care that is in line with the resident’s preferences, information concerning these issues is of utmost importance.

Conclusion:

This study prompts reflection about what it is to be a spokesperson and whether everyday care is neglected in this role. Even though relatives were satisfied with the care provided, half of them perceived their participation as crucial for the resident’s well-being. This indicated that relatives were able to offer important extras due to their biographical expertise, intimate knowledge about and emotional bond with the resident. Good routines securing that written information about the residents’ life history and preferences is available and used should be implemented in practice.

Real teams and their effect on the quality of care in nursing homes

BACKGROUND

Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes.

METHODS

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships.

RESULTS

The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave.

CONCLUSIONS

The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

How do persons with dementia participate in decision making related to health and daily care? a multi-case study

BACKGROUND

Many countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities.The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making.

METHODS

This Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate.A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach.

RESULTS

Professional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered.

CONCLUSIONS

Persons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context.

Leadership, staffing and quality of care in nursing homes

Background

Leadership and staffing are recognised as important factors for quality of care. This study examines the effects of ward leaders' task- and relationship-oriented leadership styles, staffing levels, ratio of registered nurses and ratio of unlicensed staff on three independent measures of quality of care.

Methods

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilised: self-report questionnaires to 444 employees, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, telephone interviews with 378 relatives and 900 hours of field observations. Separate multi-level analyses were conducted for quality of care assessed by relatives, staff and field observations respectively.

Results

Task-oriented leadership style had a significant positive relationship with two of the three quality of care indexes. In contrast, relationship-oriented leadership style was not significantly related to any of the indexes. The lack of significant effect for relationship-oriented leadership style was due to a strong correlation between the two leadership styles (r = 0.78). Staffing levels and ratio of registered nurses were not significantly related to any of the quality of care indexes. The ratio of unlicensed staff, however, showed a significant negative relationship to quality as assessed by relatives and field observations, but not to quality as assessed by staff.

Conclusions

Leaders in nursing homes should focus on active leadership and particularly task-oriented behaviour like structure, coordination, clarifying of staff roles and monitoring of operations to increase quality of care. Furthermore, nursing homes should minimize use of unlicensed staff and address factors related to high ratios of unlicensed staff, like low staff stability. The study indicates, however, that the relationship between staffing levels, ratio of registered nurses and quality of care is complex. Increasing staffing levels or the ratio of registered nurses alone is not likely sufficient for increasing quality of care.

Are the barriers to good oral hygiene in nursing homes within the nurses or the patients?

OBJECTIVE

To explore nursing home patients' oral hygiene and their nurses' assessments of barriers to improvement.

BACKGROUND

In nursing homes, nurses are responsible for patients' oral hygiene.

MATERIALS AND METHODS

This study assessed the oral hygiene of 358 patients in 11 Norwegian nursing homes. 494 nurses in the same nursing homes participated in a questionnaire study.

RESULTS

More than 40% of patients had unacceptable oral hygiene. 'More than 10 teeth' gave OR = 2, 1 (p = 0.013) and 'resist being helped' OR = 2.5 (p = 0.018) for unacceptable oral hygiene. Eighty percent of the nurses believed knowledge of oral health was important, and 9.1% often considered taking care of patients' teeth unpleasant. Half of the nurses reported lack of time to give regular oral care, and 97% experienced resistant behaviour in patients. Resistant behaviour often left oral care undone. Twenty-one percent of the nurses had considered making legal decisions about use of force or restraints to overcome resistance to teeth cleaning.

CONCLUSION

Oral hygiene in the nursing homes needed to be improved. Resistant behaviour is a major barrier. To overcome this barrier nurses' education, organisational strategies to provide more time for oral care, and coping with resistant behaviour in patients are important factors.

Functional level, physical activity and wellbeing in nursing home residents in three Nordic countries

BACKGROUND AND AIMS

The main aim of this study was to describe physical and cognitive function and wellbeing among nursing home residents in three Nordic countries. A second aim was to compare groups of differing ages, levels of dependency in daily life activities (ADL), degree of fall-related self-efficacy, wellbeing and cognitive function.

METHODS

322 residents from nursing homes in Sweden, Norway and Denmark were included. Physical and cognitive function, level of physical activity and wellbeing were assessed by means of reliable and valid instruments.

RESULTS

The mean age of participants was 85 years. Sixty percent could rise from a chair and 64% could walk independently. Men were younger and more physically active than women. Participants with a high level of dependency in ADL had lower physical and cognitive functions, were less physically active, and had lower fall-related self-efficacy than participants less dependent in ADL. Participants with low cognitive function had high fall-related self-efficacy.

CONCLUSIONS

These data demonstrate that elderly residents in nursing homes in Sweden, Norway and Denmark are frail but heterogeneous. Significant differences in physical activity, physical function and dependency in ADL were seen in relation to age, fall-related self-efficacy, wellbeing and cognitive function.

Diagnostic accuracy of three types of fall risk methods for predicting falls in nursing homes

AIMS

To determine the diagnostic accuracy of three different methods for identifying individuals at high risk of falling. The St- Thomas Risk Assessment tool (STRATIFY- modified for nursing homes), staff judgment of fall risk, and previous falls remembered by the staff were evaluated. We also examined whether a combination of two of the methods would increase accuracy.

MATERIALS AND METHODS

A prospective observational cohort study was carried out for 18 months. One thousand one hundred and forty-eight participants were included and assessed for fall risk. Falls among these residents were recorded from the date of inclusion to the date of death, transfer, or end of observation time. Diagnostic accuracy was evaluated in terms of sensitivity, specificity, predictive values and likelihood ratios, as well as Kaplan-Meier estimates and the Cox proportional hazard model, with time to the first fall as the dependent variable. Sensitivity, specificity, predictive value and likelihood ratios were calculated for falls within 30, 90 and 180 days of assessment for fall risk.

RESULTS

Five hundred and seventy (49.6%) of the 1148 residents had one or more falls during the observation period. One thousand one hundred had more than 30 days of observation, 987 more than 90 days, and 867 more than 180 days. For falls within 30 days of assessment for fall risk, sensitivity varied from 65% to 72%, specificity from 69% to 75%, positive predictive value from 31% to 35% and negative predictive value from 91% to 92%. Sensitivity and negative predictive value decreased for falls within 90 days and decreased further for falls within 180 days, whereas specificity and positive predictive value increased for all three assessment methods. Staff judgment of fall risk was the single method having the highest sensitivity but the lowest specificity. A combination of either two of them increased sensitivity to more than 80%, but decreased specificity. The positive Likelihood ratio varied from 2.24 to 2.70 and the negative Likelihood ratio from 0.41 to 0.49 for falls within 30 days. The relative risk of sustaining a fall was 2.4, 2.9 and 3.0 times higher for those assessed to be at high risk of falls compared with those assessed to be at low risk, according to STRATIFY, staff judgment of fall risk and previous falls remembered by the staff, respectively.

CONCLUSIONS

The diagnostic accuracy of the three methods did not differ markedly. However, staff judgment had the highest sensitivity and the lowest specificity after 30, 90 and 180 days. A combination of either two of the methods showed the highest sensitivity but the lowest specificity.

Experiences of relocation in dementia care from the perspective of six care workers

BACKGROUND

Relocation of persons with dementia might be considered when quality of care cannot be sustained due to increasing needs. Relocation has been studied from the aspects of mortality and morbidity. AIM. To explore the thoughts and experiences of care workers when relocating a person with dementia within municipal sheltered housing.

METHOD

This qualitative study was conducted in Sweden and based on interviews with six care workers involved in the relocation of two persons with dementia. Latent content analysis was applied.

RESULTS

The findings of one narrative are summarised in the theme 'Walking the tightrope: trying to balance conflicting needs'. In the other narrative the theme 'Balancing closeness and distance' emerged. Eight sub-themes were identified illustrating the relocation time-line.

CONCLUSION

Relocation from the care workers' perspective is a complex process with conflicting values and practical issues that hinder the provision of good care and security.

IMPLICATIONS FOR PRACTICE

Supporting next of kin in the relocation decision-making process presupposes time for reflection in dialogue with staff. The risk of moral distress should be observed and support for care workers could be provided in the form of supervision, ethical consultations and local guidelines.

Elderly people who committed suicide--their contact with the health service. What did they expect, and what did they get?

OBJECTIVE

Contact between elderly patients and healthcare professionals may be crucial for suicide prevention if suicidal tendencies are revealed and help is to be provided. The objective of the study was to investigate how elderly suicide cases had perceived the health service and what characterised their contact with it.

METHOD

This is a psychological autopsy study based on qualitative interviews with people who had known 1 of the total of 23 suicide cases aged over 65. The 63 informants were relatives, general practitioners (GPs) and home-based care workers. The systematic text condensation method was applied to analyse interviews.

RESULTS

Many of the elderly expressed distrust of health service once their functional decline began. They feared losing their autonomy if they became dependent on help, and many therefore refused health service provisions. Communication between them and helpers failed. As they gradually became more dependent on medical care, many experienced that they were not given the desired help, which confirmed their distrust.

CONCLUSION

Contact between these people and the health service must inspire confidence for it to prevent suicide. Elderly people at risk of suicide are vulnerable: they feel degraded if their autonomy is threatened by health personnel. The structure and organisation of the health service, and each worker's contact with the elderly, must preserve their dignity. Dignity must be evinced through the healthcare professionals' treatment of elderly people and a system that meets their needs.

Health and well-being in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes

OBJECTIVE

The aim of this study is to investigate the association of psychosocial factors and patient factors with stress in care staff in nursing homes.

METHODS

In this cross-sectional survey, 197 care staff from 13 dementia wards from four nursing homes in the Stavanger region, Norway, participated. Stress in care staff was measured by Perceived Stress Scale, Hopkins Symptom Check List, and subjective health complaints. Agitation in patients was measured with the Cohen-Mansfield Agitation Inventory. Work-related psychosocial factors were measured by General Nordic Questionnaire for Psychosocial and Social Factors at Work (QPSNordic). Data were analyzed using multivariate regression analyses.

RESULTS

Psychosocial factors (QPS Nordic) were significantly associated with all the three outcome measures of stress in care staff, whereas agitation was associated with subjective health complaints only. QPS Nordic subscales significantly associated with stress in care staff were those associated with leadership.

CONCLUSIONS

Psychosocial factors were more important predictors of carer stress than patient-related factors such as dementia severity and agitation. The findings provide key background information in the planning of interventions to improve conditions for care staff and ultimately for nursing home residents.

Inadequate care in Norwegian nursing homes--as reported by nursing staff

Studies have shown that inadequate care, also referred to as abuse, violence, neglect and maltreatment occur in nursing homes in many countries. The aim of this study was to describe the frequency and types of inadequate care committed by staff in nursing homes. Another aim was to investigate if nursing staff reported differently depending on age, education level and years of experience working at nursing homes. A questionnaire survey was conducted among nursing staff (n = 616) in 16 nursing homes in the central part of Norway. Twenty items concerned staff behaviour in forms of acts of inadequate care. The respondents were asked to report how often they had observed colleagues commit acts and how often they themselves had committed such acts. The response rate was 79%. All in all, 91% of the nursing staff reported that they had observed at least one act of inadequate care and 87% reported that they had committed at least one act of inadequate care. Acts of negligent and emotional character were most frequently reported, both as observed and committed. Depending on the higher educational level that the nursing staff had more acts of all types were observed and committed. The oldest staff and those with longest experience at the present nursing home reported more observed and committed acts of physical character than did the others. The extent of inadequate care confirms that this is a common part of activities in nursing homes. Because emotional and negligent acts can be just as harmful as physical acts, more knowledge is needed about the reasons in order to take preventive actions.

Staff attitudes towards institutionalised dementia residents

AIM

To explore the attitudes of staff caring for institutionalised dementia residents and the variables associated with these attitudes.

METHODS

Fourteen nursing homes and one hospital-based geriatric ward in Bergen, Norway were surveyed, using the translation of an Approach to Dementia Questionnaire. The study population (n = 291) was a mixture of registered nurses, auxiliary nurses, nursing assistants and non-trained aides.

DESIGN

Survey.

RESULTS

Significant differences in hope and person-centred attitudes were identified in this study. Nursing assistants, compared with registered nurses (p = 0.02), had significantly lower hope attitudes. Staff over 50 years of age reported significantly lower hope attitudes (p = 0.01) than those under 40 years of age. Staff with 10 and fewer years of work experience reported significantly lower hope attitudes (p = 0.02) than those with more than 10 years of experience. Nurses with specialised training in geriatrics, psychiatry or dementia care had significantly higher hope attitudes, compared with nurses without any special training (p = 0.04). The person-centred attitude was lower among participants who were over 50 years old, compared with their counterparts under the age of 40 (p < or = 0.01).

DISCUSSION

Education, age, work experience, care unit size and specialised training are associated with differences in attitudes. We recommend that employers be proactive in encouraging and facilitating staff development by offering further training that aims to impart more positive attitudes.

RELEVANCE TO CLINICAL PRACTICE

Improvements in staff competency levels will be more important in the future, as a result of the forecasted increase in the percentage of the population who will suffer from dementia and reside in nursing homes.

Carers' and nurses' appraisals of needs of nursing home placement for frail older in Norway

AIMS AND OBJECTIVES

The aim of this paper was to explore carers' and nurses' appraisals concerning if and when nursing home placement for frail older people awaiting placement was needed and to illuminate ethical issues involved in decisions regarding nursing home placement.

BACKGROUND

Requesting nursing home placement can be a complicated decision for carers, causing feelings of failure, anxiety and guilt. After the necessity of nursing home care is determined, the names of the older people are put on waiting lists. While waiting, home health care provides support services. Even with this care, many of the older people and their carers face difficult life situations.

DESIGN

This is a descriptive and comparative cross-sectional study using qualitative methods.

METHODS

The convenience sample (n = 36) comprised 11 carers of older people on a nursing home placement waiting list in Norway and 11 nurses caring for these older people. Every one willingly participated in interviews that were transcribed and analysed by qualitative content analysis.

RESULTS

Various similarities and differences between nurses' and carers' appraisals were found. Complex ethical issues of justice, equality, autonomy, beneficence and justifiability in nursing were involved in decision making concerning nursing home placement. Four categories constructed were: 'appraising nursing home to be the level of care needed', 'appraising the older people as able to continue living at home', 'being ambivalent about nursing home placement' and 'being sceptical about use of coercion regarding nursing home placement'.

CONCLUSIONS

Not all of the older people awaiting nursing home placements could be placed in nursing homes when beds became available. The situations were complex and involved ethical issues.

RELEVANCE TO CLINICAL PRACTICE

Despite insufficient resources in home health care, providing appropriate support for older people and their carers means that nurses have to consider individual concerns in each situation, cooperate with carers, respect their appraisals of needs and argue for the timely nursing home placement of older people.

Sense of coherence as a resource in relation to health-related quality of life among mentally intact nursing home residents - a questionnaire study

BACKGROUND

Sense of coherence (SOC) is a strong determinant of positive health and successful coping. For older people living in the community or staying in a hospital, SOC has been shown to be associated with health-related quality of life (HRQOL). Studies focusing on this aspect among nursing home (NH) residents have been limited. This study investigated the relationship between SOC and HRQOL among older people living in NHs in Bergen, Norway.

METHODS

Based on the salutogenic theoretical framework, we used a descriptive correlation design using personal interviews. We collected data from 227 mentally intact NH residents for 14 months in 2004-2005. The residents' HRQOL and coping ability were measured using the SF-36 Health Survey and the Sense of Coherence Scale (SOC-13), respectively. We analyzed possible relationships between the SOC-13 variables and SF-36 subdimensions, controlling for age, sex, marital status, education and comorbidity, and investigated interactions between the SOC and demographic variables by using multiple regression.

RESULTS

SOC scores were significantly correlated with all SF-36 subscales: the strongest with mental health (r = 0.61) and the weakest with bodily pain (r = 0.28). These did not change substantially after adjusting for the associations with demographic variables and comorbidity. SOC-13 did not interact significantly with the other covariates.

CONCLUSION

These findings suggest that more coping resources improve HRQOL. This may indicate the importance of strengthening the residents' SOC to improve the perceived HRQOL. Such knowledge may help the international community in developing nursing regimens to improve HRQOL for older people living in NHs.

Psychiatric and behavioural symptoms and the use of psychotropic medication in Special Care Units and Regular Units in Norwegian nursing homes

BACKGROUND

In a number of countries Special Care Units (SCUs) have been established to meet the particular needs of patients with dementia. The criteria for SCUs are poorly defined and often not met.

AIM

To assess the frequency distributions of dementia, psychiatric and behavioural symptoms and the use of psychotropic medication in SCUs and Regular Units (RUs) across different regions.

METHODS AND MATERIAL

By means of a structured interview, comprising the Neuropsychiatric Inventory, the Clinical Dementia Rating Scale and Lawton's Physical Self-maintenance scale, a representative sample of 1163 nonselected nursing home patients was assessed. In addition, information was collected from the patients' records.

RESULTS

Overall SCU patients were significantly more likely to be younger, to have higher level of functioning, to have dementia, to exhibit clinically significant psychiatric and behavioural symptoms and to receive psychotropic medication. There were significant differences across regions in terms of psychiatric and behavioural symptoms and the use of psychotropic medication. The ratio of accommodation in SCUs to that in RUs varied across the regions.

CONCLUSION

Patients in SCUs and patients in RUs are distinct nursing home populations. Regional differences, which might be due to diverse ratios of SCUs, are evident.

Predictors of uptake and adherence to the use of hip protectors among nursing-home residents

The aim of the present study was to identify predictors for initial uptake and adherence with the use of hip protectors when offering hip protectors free of charge to nursing-home residents. An 18 months prospective follow up study was carried out in 18 Norwegian nursing homes. One thousand two hundred and thirty-six residents were included in the study of which 604 started to use a hip protector. A multivariate logistic regression model was used to identify predictors for the initial uptake. A Cox proportional hazard model was used to identify predictors for adherence. A stepwise backward strategy was used in both the logistic and in the Cox regression. The effect of nursing homes as clusters was adjusted for in the analysis. The uptake rate among all residents was 46% and the adherence was approximately 75% after 3 months, and approximately 60% after 18 months. Female gender [odds ratio (OR): 1.54, 95% CI: 1.06-2.24, P = 0.022], previous fractures (OR: 1.67, 95% CI: 1.02-2.75, P = 0.043), previous falls (OR: 2.08, 95% CI: 1.35-3.19, P < 0.001) and memory (not able to memorise: OR: 3.71, 95% CI: 2.09-6.59, P < 0.001, large problems with memorising: OR: 2.85, 95% CI: 1.81-4.49, P < 0.001, medium problems with memorising: OR: 2.45, 95% CI: 1.39-4.33, P = 0.002, some problems with memorising: OR: 1.99, 95% CI: 1.14-3.48, P = 0.016) seemed to be important predictors for uptake. Among those who took up the offer male gender (HR: 1.71, 95% CI: 1.00-2.91, P = 0.049), memory (not able to memorise: HR: 0.26, 95% CI: 0.14-0.50, P < 0.001, large problems with memorising: HR: 0.32, 95% CI: 0.22-0.45, P < 0.001, medium problems with memorising: HR: 0.46, 95% CI: 0.30-0.73, P < 0.001, some problems with memorising: HR: 0.49, 95% CI: 0.32-0.73, P = 0.001) and bowel incontinence (HR: 0.41, 95% CI: 0.25-0.66, P < 0.001) were predictors for a lower probability of ending hip protector use. Factors related to a high risk of falling were important predictors for both uptake and adherence. The fact that neither memory impairments nor incontinence (bowel) seemed to be barriers to hip protector use is important since these characteristics are common among nursing-home residents and tertiary prevention such as the use of hip protectors is probably the most feasible intervention to prevent hip fractures in this group.

The impact of social support and sense of coherence on health-related quality of life among nursing home residents--a questionnaire survey in Bergen, Norway

BACKGROUND AND OBJECTIVES

Few studies have examined the association between social support and health-related quality of life (HRQOL) among nursing home residents and whether the sense of coherence (SOC) modifies the effect of social support on health-related quality of life. The main aims of this study were to determine the relationship between social support and HRQOL and to investigate whether the SOC modifies the effect of social support on HRQOL.

DESIGN

A cross-sectional, descriptive, correlational design.

SETTINGS

All 30 nursing homes in Bergen in western Norway.

PARTICIPANTS

Two hundred and twenty-seven mentally intact long-term nursing home residents 65 years and older.

METHODS

Data were obtained through face-to-face interviews using the SF-36 Health Survey, Social Provisions Scale and Sense of Coherence Scale. Possible relationships between the Social Provisions Scale and the eight SF-36 subdimensions were analysed using multiple linear regression while controlling for age, sex, marital status, education and comorbid illness. Interactions between the Sense of Coherence Scale and Social Provisions Scale were investigated.

RESULTS

Attachment affected the mental health subdimension (p=0.001), opportunity for nurturance affected social functioning (p=0.003) and reassurance of worth affected vitality (p=0.001) after adjustment for demographic variables and comorbid illness. After the analysis included the sense of coherence, nurturance still significantly affected social functioning and reassurance of worth still significantly affected vitality. No interaction with sense of coherence was found, and sense of coherence significantly affected all SF-36 subdimensions.

CONCLUSIONS

The opportunity to provide nurturance for others appears to be important for social functioning, and sense of competence and sense of self-esteem appear to be important for vitality. Further, the residents' relationships with significant others comprise an important component of mental health. Finally, independent of the level of sense of coherence, social support is an important resource for better health-related quality of life. Clinical nurses should recognize that social support is associated with health-related quality of life and pay attention to the importance of social support for the residents in daily practice.