Registered nurses in expanded roles improve care in nursing homes: Swiss perspective based on the modified Delphi method

Characteristics and Activities of Nurses in Expanded Roles Employed in Swiss Nursing Homes: A Cross-Sectional Study

BACKGROUND

As the number of nursing home residents with multiple healthcare needs grows, the demand for nursing expertise increases. The implementation of new care models involving nurses with expanded roles is crucial for ensuring quality care in nursing homes.

OBJECTIVES

To investigate the characteristics and activities of nurses employed in nursing homes in expanded roles and the factors associated with variation in the activities performed.

METHODS

This multicentre cross-sectional survey in Switzerland collected data from a convenience sample of 118 nursing homes between September 2018 and October 2019. From a subsample of 62 nursing homes, we analysed the characteristics and activities of 104 nurses in expanded roles. Associations between the activities performed and the educational background of the nurses in expanded roles, their direct supervisors' positions and the presence of physicians in the nursing homes were examined.

RESULTS

Most Registered Nurses in expanded roles were diploma educated (48%), with fewer having a bachelor's (35%) or master's degree (17%). Overall, direct clinical practice and guidance and coaching activities were conducted monthly to weekly; consultation, evidence-based practice, collaboration and ethical decision-making activities were conducted monthly. We saw variations where a higher educational background was associated with more frequent evidence-based practice activities (z = 3.47, p < 0.001), and if direct supervisors were ward managers, nurses in expanded roles worked more frequently below their scope of practice (z = 4.10, p < 0.001).

CONCLUSION

This is the first study to use Hamric's integrative Advanced Practice Nursing model to examine the activities of nurses in expanded roles in nursing homes. We found considerable variation in their activities, where nursing homes seem to adapt their roles to their educational background and the local context.

IMPLICATIONS FOR PRACTICE

Our findings show the importance of clarifying role expectations for Registered Nurses in expanded roles, allowing them to practice at the top of the licence to meet residents' complex healthcare needs.

Relationship between perceived organisational support, self-efficacy, proactive personality and career self-management among nurses: a moderated mediation analysis

OBJECTIVES

Career self-management is believed to be a critical behaviour in the new career era. However, the underlying mechanisms that stimulate nurses' career self-management are unclear. The aim of this study was to examine the mediating effect of self-efficacy and the moderating effect of proactive personality on the relationship between perceived organisational support and career self-management among nurses.

DESIGN

This was a cross-sectional survey.

SETTING AND PARTICIPANTS

A total of 1866 nurses from 15 hospitals across 15 cities in China were recruited for this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Perceived Organizational Support Scale, General Self-efficacy Scale, Proactive Personality Scale and Individual Career Management Questionnaire were used. Data were analysed using moderated mediation regressions with Hayes' PROCESS macro in SPSS version 26.0.

RESULTS

General self-efficacy mediated the relationship between perceived organisational support and career self-management. Proactive personality moderated the direct (B=0.043, p<0.001, 95% CI 0.026 to 0.060) and indirect relationship (B=0.098, p<0.001, 95% CI 0.074 to 0.123) between perceived organisational support and career self-management. Further, the positive effects of perceived organisational support on general self-efficacy and career self-management were stronger for nurses with a high level of proactive personality. The model explained 47.2% of the variance in career self-management.

CONCLUSION

The findings highlight the crucial benefits of self-efficacy and important conditional effects of perceived organisational support on nurses' career self-management.

The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries

BACKGROUND

The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing.

AIMS

We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support.

MATERIAL AND METHODS

A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts.

RESULTS AND DISCUSSION

Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses.

CONCLUSION

Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.

The role of qualification and quality management in the prescription of antipsychotics and potentially inappropriate medication (PIM) in nursing home residents in Germany: results of the HIOPP-3-iTBX study

BACKGROUND

Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants.

AIMS

Evaluation of structure quality as part of a cluster-randomized controlled intervention study.

METHODS

Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression.

RESULTS

The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed.

CONCLUSIONS AND DISCUSSION

The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

Assessing the implementation of nurse practitioner-led huddles in long-term care using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

The COVID-19 pandemic created major challenges in long-term care (LTC) homes across Canada and globally. A nurse practitioner-led interdisciplinary huddle intervention was developed to support staff wellbeing in two LTC homes in Ontario, Canada. The objective of this study was to identify the constructs strongly influencing the process of implementation of huddles across both sites, capturing the overall barriers and facilitators and the intervention's intrinsic properties.

METHODS

Nineteen participants were interviewed about their experiences, pre-, post-, and during huddle implementation. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. CFIR rating rules and a cross-comparison analysis was used to identify differentiating factors between sites. A novel extension to the CFIR analysis process was designed to assess commonly influential factors across both sites.

RESULTS

Nineteen of twenty selected CFIR constructs were coded in interviews from both sites. Five constructs were determined to be strongly influential across both implementation sites and a detailed description is provided: evidence strength and quality; needs and resources of those served by the organization; leadership engagement; relative priority; and champions. A summary of ratings and an illustrative quote are provided for each construct.

CONCLUSION

Successful huddles require long-term care leaders to consider their involvement, the inclusion all team members to help build relationships and foster cohesion, and the integration of nurse practitioners as full-time staff members within LTC homes to support staff and facilitate initiatives for wellbeing. This research provides an example of a novel approach using the CFIR methodology, extending its use to identify significant factors for implementation when it is not possible to compare differences in success.

Revealing a gap in the clinical competence of nursing staff in nursing homes: a cross-sectional study with the Ms. Olsen test

BACKGROUND

Nursing staff, caring for frail older people in long-term care, needs to have a certain level of clinical competence to identify diseases at an early stage and to assess and provide good nursing care. In Finland, nursing care is based on evidence-based and high-quality nursing care. However, earlier inspections by the National Supervisory Authority for Welfare and Health showed many discrepancies between the nursing staff's clinical competence and adequate and continuous education.

AIM

This study aimed to explore nursing staff, i.e. the clinical competence and decision-making skills of registered and practical nurses in nursing homes for older people in Finland and to analyse the association between nurses' clinical competence and fundamental background factors.

METHODS

We conducted a cross-sectional study of 337 participants in 50 nursing homes in the western part of Finland, between December 2020 and January 2021. The instrument used was the validated Ms. Olsen test, an extraction of NOP-CET. Statistical analyses were conducted with descriptive statistics and correlations and a cut-off for clinical competence.

RESULTS

This study with the Ms. Olsen test revealed that only one-fourth of the RNs and a third of the PNs passed the clinical competence test. In the self-evaluation, almost all participants evaluated themselves with good clinical competence. The Finnish Current Care Guidelines were used on a daily basis by 7.4% and weekly by 30%. Significant correlation was found between Swedish as a working language and mother tongue and the score for clinical competence.

CONCLUSION

The clinical competence test, the Ms. Olsen test, was used in Finland for the first time to evaluate the nursing staffs´ clinical competence in nursing homes. We found gaps in the clinical competence in Finnish nursing homes, both for PNs and RNs. The result differed remarkably from their self-assessments and the staff did not use the national nursing guidelines as required to develop their nursing skills and knowledge. Gaps in the clinical competence have been identified and can be used to develop targeted continuous education.

Attitudes and knowledge of nurses working at night and sleep promotion in nursing home residents: multicenter cross-sectional survey

BACKGROUND

Sleep disturbances are common in nursing home residents and challenging for their nurses. Knowledge about sleep and sleep promoting factors is essential to provide adequate sleep management, where nurses play a key role. Therefore, nurses' knowledge and attitudes towards sleep and sleep promoting interventions is important as enabling or inhibiting factor for successful sleep management.

METHODS

A multicenter cross-sectional study was conducted among nurses working wholly or partially at night in nursing homes in Germany. Data were collected between February and April 2021 via online or paper and pencil questionnaires, comprising 56 items. Nursing homes were recruited through existing cooperation with the study centers as well as via nursing home registers.

RESULTS

Finally, 138 nursing homes participated and 271 nurses completed the survey. Nurses agreed that sleep disturbances are an important topic with important impact on resident' health. Although, the assessment of sleep was seen as nurses' responsibility, only 40 nurses (14.7%) stated that residents' sleep was always documented. Only 21.7% reported the availability of policy documents providing guidance regarding the management of sleep disturbances. The vast majority (93.2%) reported never having received training about sleep and management of sleep disturbances after their basic nursing training.

CONCLUSIONS

Our results indicate that nurses working at night can play an important role in residents' sleep promotion. The findings indicate nurses' educational needs regarding sleep and sleep promotion. Nursing homes should implement institutional guidelines in order to promote residents' sleep based on adequate evidence-based non-pharmacological interventions.

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations

BACKGROUND

Implementation fidelity assesses the degree to which an intervention is delivered as it should be. Fidelity helps to determine if the outcome(s) of an intervention are attributed to the intervention itself or to a failure of its implementation. Little is known about how fidelity impacts the intended outcome(s) and what elements or moderators can affect the fidelity trajectory over time. We exemplify the meaning of implementation fidelity with INTERCARE, a nurse-led care model that was implemented in eleven Swiss nursing homes (NHs) and showed effectiveness in reducing unplanned hospital transfers. INTERCARE comprises six core elements, including advance care planning and tools to support inter- and interprofessional communication, which were introduced with carefully developed implementation strategies.

METHODS

A mixed-methods convergent/triangulation design was used to investigate the influence of implementation fidelity on unplanned transfers. A fidelity questionnaire measuring the degree of fidelity to INTERCARE's core components was fielded at four time points in the participating NHs. Two-monthly meetings were conducted with NHs (September 2018-January 2020) and structured notes were used to determine moderators affecting fidelity (e.g., participant responsiveness). We used the fidelity scores and generalized linear mixed models to analyze the quantitative data. The Framework method was used for the qualitative analysis. The quantitative and qualitative findings were integrated using triangulation.

RESULTS

A higher overall fidelity score showed a decreasing rate of unplanned hospital transfers post-intervention (OR: 0.65 (CI = 0.43-0.99), p = 0.047). A higher fidelity score to advance care planning was associated with lower unplanned transfers (OR = 0.24 (CI 0.13-0.44), p = < 0.001) and a lower fidelity score for communication tools (e.g., ISBAR) to higher rates in unplanned transfers (OR = 1.69 (CI 1.30-2.19), p = < 0.003). In-house physicians with a collaborative approach and staff's perceived need for nurses working in extended roles, were important moderators to achieve and sustain high fidelity.

CONCLUSION

Implementation fidelity is challenging to measure and report, especially in complex interventions, yet is crucial to better understand how such interventions may be tailored for scale-up. This study provides both a detailed description of how fidelity can be measured and which ingredients highly contributed to reducing unplanned NH transfers.

TRIAL REGISTRATION

The INTERCARE study was registered at clinicaltrials.gov Protocol Record NCT03590470.

Core components of an effective pain management education programme for surgical nurses: A Delphi study*

The critical reason for this study is the inadequate training received by surgical nurses in acute and chronic pain management nursing services for patients.

Wie Pflegeexpert_innen in Deutschschweizer Pflegeheimen ihre Rollenentwicklung gestalten

Zusammenfassung. Hintergrund: Die Entwicklung und Aufrechterhaltung der Pflegequalität wird in Schweizer Pflegeheimen oft von Pflegeexpert_innen übernommen. Dabei handelt es sich um diplomierte Pflegefachpersonen mit heterogenem Bildungshintergrund und langjähriger Berufserfahrung. Wie diese ihre Rollenentwicklung in den Pflegeheimen gestalten, ist nicht bekannt. Fragestellung/Ziel: Ziel der Studie ist es darzulegen, wie Pflegeexpert_innen in Pflegeheimen ihre berufliche Rollenentwicklung gestalten. Methode: Wir führten eine qualitative, konstruktivistische Sekundärdatenanalyse von 14 semistrukturierten Interviews mit Pflegeexpert_innen aus Deutschschweizer Pflegeheimen durch. Die Daten wurden induktiv mit einer reflexiven thematischen Analyse ausgewertet. Ergebnisse: Aus den Berichten der 14 Pflegeexpert_innen konnten wir das konstituierende Thema „Vision als Motivation“ und drei Phasen der Rollenentwicklung ableiten. Die Vision, eine gute Pflegequalität für die Bewohner_innen sicherzustellen, motiviert Pflegeexpert_innen zum Rollenaufbau und zur Weiterentwicklung in drei Phasen: 1) „Rolle sukzessive gestalten“; 2) „Rolle kontinuierlich weiterentwickeln“; 3) „Rolle neu ausrichten“. Schlussfolgerungen: Pflegeexpert_innen passen ihre Rolle kontinuierlich an den sich verändernden Kontext an, um an der Pflegequalität arbeiten zu können. Zum Gelingen benötigen sie eine gemeinsame Vision mit ihren Vorgesetzten für die Pflegequalität.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations

BACKGROUND

Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care.

METHODS

The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective.

RESULTS

Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate.

CONCLUSIONS

As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03590470 ).

Contextual factors influencing advance care planning in home care: process evaluation of the cluster-randomised controlled trial STADPLAN

Background

The STADPLAN study is a cluster-randomised controlled trial including 27 home care services in Germany. It assesses the effect of an advance care planning (ACP) intervention delivered by trained nurses to older care-dependent patients. Patients received two ACP conversations and an information brochure. Nurses were educated through a two-day programme and topic guides structuring the conversations.

Objectives of the process evaluation were to determine: [1] whether the intervention was implemented as planned, [2] which change mechanisms were observed, [3] whether targeted process outcomes were achieved and [4] in which way contextual factors influenced the implementation process.

Methods

The process evaluation is based on a mixed methods approach following the recommendations of the UK-MRC framework for the development and evaluation of complex interventions. Qualitative and quantitative assessments were developed and analysed guided by a logic model comprising intervention, participants, mechanisms of change and context factors. The results of the main trial will be published elsewhere.

Results

Educational programme and topic guides were mostly implemented as planned and resulted in motivation, knowledge, and perceived competencies to facilitate ACP conversations in nurses. Deviances in the performance of ACP conversations indicated patients’ varied individual needs, but also obstacles like reluctance of patients and caregivers to participate actively and time constraints of nurse facilitators. Patients and caregivers reported increased awareness of ACP, planning and other activities indicating that targeted process outcomes could be achieved. The relevance of multifaceted contextual factors acting as barriers or facilitators for the engagement in ACP interventions on the individual, organisational and macro level was evident.

Conclusions

The process evaluation elicits obstacles and achievements of the ACP intervention. The logic model organised a plethora of mixed methods data into a holistic picture of multifaceted results. Nurses as ACP facilitators in home care can fulfil a crucial initiating role based on a trusting relationship with their patients. To support older care-dependent people’s ACP engagement, access should be simplified.

Furthermore, education for nurse facilitators and sufficient resources for service provision are needed. Independent of monetary reimbursement, healthcare providers must respect patients’ choice for or against any ACP intervention.

Ethics and trial registration

Approved by the Ethics Committees of Martin Luther University Halle-Wittenberg (Ref.-No. 2019–045), Carl von Ossietzky University Oldenburg (Ref.-No. 2019–024), and University of Lübeck (Ref.-No. 19–080).

German Clinical Trials Register: DRKS00016886. Registered retrospectively 04/06/2019, first participant included 29/05/2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03026-2.

Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes

Background | objective

To evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents.

Design

Convergent mixed-method design within a hybrid type-2 effectiveness-implementation study.

Setting

Eleven nursing homes in the German-speaking region of Switzerland.

Participants

Quantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes.

Intervention

Three intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used.

Methods

The quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention’s acceptability, feasibility and uptake were assessed using validated and self-developed scales.

Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach.

Results

The ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users’ perceived ease of using the intervention and its adaptations, and the intervention’s usefulness, appeared to influence the implementation’s success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation.

Conclusions

Our findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly.

Trial registration

This study was registered at clinicaltrials.gov (NCT03590470) on the 18/06/2018.

Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design

Background

Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse‐led models of care focusing on improving in‐house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse‐led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals.

Methods

A multicenter nonrandomized stepped‐wedge design within a hybrid type‐2 effectiveness‐implementation study was implemented in 11 NHs in German‐speaking Switzerland. The first NH enrolled in June 2018 and the last in November 2019. The study lasted 18 months, with a baseline period of 3 months for each NH. Inclusion criteria were 60 or more long‐term care beds and 0.8 or more hospitalizations per 1′000 resident care days. Nine hundred and forty two long‐term NH residents were included between June 2018 and January 2020 with informed consent. Short‐term residents were excluded. The primary outcome was unplanned hospitalizations. A fully anonymized dataset of overall transfers of all NH residents served as validation. Analysis was performed with segmented mixed regression modeling.

Results

Three hundred and three unplanned and 64 planned hospitalizations occurred. During the baseline period, unplanned transfers increased over time (β₁ = 0.52), after which the trend significantly changed by a similar but opposite amount (β₂ = −0.52; p = 0.0001), resulting in a flattening of the average transfer rate throughout the postimplementation period (β₁ + β₂ ≈ 0). Controlling for age, gender, and cognitive performance did not affect these trends. The validation set showed a similar flattening trend.

Conclusion

A complex intervention with six evidence‐based components demonstrated effectiveness in significantly reducing unplanned transfers of NH residents to hospitals. INTERCARE's success was driven by registered nurses in expanded roles and the use of tools for clinical decision‐making.

See related Editorial by Kaehr et al. in this issue.

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.

Facilitators and barriers to implement nurse-led interventions in long-term dementia care: a qualitative interview study with Swiss nursing experts and managers

Background

To support the implementation of nurse-led interventions in long-term dementia care, in-depth knowledge of specific supporting factors and barriers is required. Conditions and structures of caring for people with dementia differ widely, depending on the country and the care context. Our study aimed to describe the experiences and opinions of nursing experts and managers with regard to facilitators and barriers to the implementation of nurse-led interventions in long-term dementia care.

Methods

We conducted a qualitative descriptive study using individual interviews based on qualitative vignettes as a useful stimulus to generate narrations allowing to study peoples’ perceptions and beliefs. The study took place in nursing homes in the German-speaking part of Switzerland and in the Principality of Liechtenstein using purposive sampling. We intended to conduct the interviews face-to-face in a quiet room according to the participant’s choice. However, due to the lockdown of nursing homes during the COVID-19 pandemic in spring 2020, we performed interviews face-to-face and by video. We analysed data thematically following Braun and Clarke to achieve a detailed, nuanced description. To verify our interpretation and to ensure congruence with participants’ perspectives, we conducted member checks. The Standards for Reporting Qualitative Research (SRQR) served to structure our manuscript.

Results

Six dyads of nursing home managers and nursing experts from six nursing homes took part in our study (n = 12). Our thematic analysis yielded seven themes reflecting facilitators and barriers to implementing nurse-led interventions in long-term dementia care: «A common attitude and cohesion within the organization», «Commitment on several levels», «A needs-oriented implementation», «The effect and the public perception of the intervention», «A structured and guided implementation process», «Supporting knowledge and competencies», as well as «Resources for implementing the intervention».

Conclusions

To support the implementation of nurse-led interventions in long-term dementia care, active commitment-building seems essential. It is necessary that the value of the intervention is perceptible.Commitment-building is the precondition to reach the persons involved, such as nursing home managers, nursing staff, residents and relatives. Furthermore, nurses should precisely inform about the intervention. It is necessary that the value of the intervention is perceptible. In addition, nurses should adjust the interventions to the situational needs of people with dementia, thus. Therefore, it is important to support dementia-specific competencies in long-term care. Findings indicate that the barrier is determined by the intervention and its implementation – and not by the behaviour of the person with dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02120-1.

Registered nurses in expanded roles improve care in nursing homes: Swiss perspective based on the modified Delphi method

AIM

To define both competencies and envisaged outcomes for registered nurses in expanded roles in Swiss nursing homes to be implemented and evaluated within a new model of care.

BACKGROUND

In regions where Advanced Practice Nurses are rare or absent, registered nurses take up clinical leadership and expanded roles. To allow effective implementation, monitoring and evaluation of these nurses, stakeholders need a shared understanding of the competencies they require and what outcomes they should achieve.

DESIGN

RAND/UCLA Appropriateness Method - a modified Delphi method.

METHODS

A critical literature review and case studies were conducted to identify possible competencies and outcomes for registered nurses in expanded roles. In 2017, a two-round rating process and an in-person panel discussion was completed by a group of multi-professional stakeholders.

FINDINGS

Two rounds generated 190 competencies and 72 outcomes relevant to registered nurses in expanded roles.

CONCLUSION

The relevant competencies and outcomes of registered nurses in expanded roles indicate their support for care teams and development of nursing care in nursing homes. Their geriatric expertise allows them to function as role models and innovators, reinforcing overall perceptions of nursing as a profession. These nurses are especially important in countries and settings where Advanced Practice Nurses are scarce or unavailable.

IMPACT

The identified competencies clarify the duties of expanded-role registered nurses, thereby differentiating them from other care providers. Although conducted in the Swiss healthcare system, our methods and findings can be adapted to other healthcare settings. The results of this study will guide the development of an educational programme in a multi-centre study to reduce avoidable hospitalizations, while the defined outcomes guide the evaluation of their impact.