Nursing staff intentions towards managing deteriorating health in nursing homes: A convergent parallel mixed-methods study using the theory of planned behaviour

Recognising and responding to acute deterioration in care home residents: a scoping review

BACKGROUND

Acute deterioration describes a rapid change in physical and/or mental health resulting from an acute illness - e.g., heart attack or infection. Older people in care homes are some of the frailest and vulnerable in society. They have complex health needs, experience multiple long-term conditions (MLTC) and have weakened immune systems due to the ageing process. They are more susceptible to acute deterioration and delayed recognition and response, is linked to poorer health outcomes, adverse events and death. Over the past five years, the need to manage acute deterioration in care homes and prevent hospital admissions has led to development and implementation of improvement projects, including the use of hospital derived practices and tools to identify and manage this condition. This is potentially problematic as care homes are different from hospitals-options to escalate care vary throughout the UK. Further, hospital tools have not been validated for use in care homes and have shown to be less sensitive in older adults living with frailty.

OBJECTIVES

To collate the available evidence on how care home workers recognise and respond to acute deterioration in residents using published primary research, non-indexed and grey literature, policies, guidelines and protocols.

METHODS

A systematic scoping review was conducted following Joanna Briggs Institute (JBI) scoping review methodology. Searches were conducted using: CINAHL (EBSCOhost), EMCARE (OVID), MEDLINE (OVID) and HMIC (OVID). Snowball searches of included studies' reference lists were conducted. Studies that featured care homes with or without nursing and provided 24/7 care to residents were included.

RESULTS

Three hundred and ninety-nine studies were identified. After reviewing all studies against inclusion criteria, n = 11 were included in the review. All studies used qualitative methods and were conducted in Australia, UK, South Korea, USA and Singapore. Four themes were generated from the review: identifying residents with acute deterioration; managing acute deterioration, care home policies and procedures, and factors affecting recognition and response to acute deterioration.

FINDINGS

Recognition and response to acute deterioration in residents is determined by multiple factors and is context sensitive. There are several interrelated factors within and external to the care home that contribute to how acute deterioration is recognised and managed.

CONCLUSIONS AND IMPLICATIONS

The available literature on how care home workers recognise and respond to acute deterioration is limited and often subtends other areas of interest. Recognising and responding to acute deterioration in care home residents is reliant on a complex and open system encompassing multiple interrelated components. The phenomenon of acute deterioration remains underexplored and further research is required to examine contextual factors that accompany identification and management of this condition in care home residents.

Protocol for a process evaluation of a stepped wedge randomised controlled trial to reduce unnecessary hospitalisations of older people from residential aged care: the EDDIE+ study

INTRODUCTION

The Early Detection of Deterioration in Elderly residents (EDDIE+) programme is a theory-informed, multi-component intervention aimed at upskilling and empowering nursing and personal care staff to identify and manage early signs of deterioration in residents of aged care facilities. The intervention aims to reduce unnecessary hospital admissions from residential aged care (RAC) homes. Alongside a stepped wedge randomised controlled trial, an embedded process evaluation will be conducted to assess the fidelity, acceptability, mechanisms of action and contextual barriers and enablers of the EDDIE+ intervention.

METHODS AND ANALYSIS

Twelve RAC homes in Queensland, Australia are participating in the study. A comprehensive mixed-methods process evaluation, informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, will assess intervention fidelity, contextual barriers and enablers, mechanisms of action, and the acceptability of the programme from various stakeholder perspectives. Quantitative data will be collected prospectively from project documentation, including baseline context mapping of participating sites, activity tracking and regular check-in communication sheets. Qualitative data will be collected postintervention via semi-structured interviews with a range of stakeholder groups. The i-PARIHS constructs of innovation, recipients, context and facilitation will be applied to frame the analysis of quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the Bolton Clarke Human Research Ethics Committee (approval number: 170031) with administrative ethical approval granted by the Queensland University of Technology University Human Research Ethics Committee (2000000618). Full ethical approval includes a waiver of consent for access to residents' demographic, clinical and health services de-identified data. A separate health services data linkage based on RAC home addresses will be sought through a Public Health Act application. Study findings will be disseminated through multiple channels, including journal publications, conference presentations and interactive webinars with a stakeholder network.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trial Registry (ACTRN12620000507987).

Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program

BACKGROUND

Incomplete communication between staff and providers may cause adverse outcomes for nursing home residents. The Situation-Background-Assessment-Recommendation (SBAR) tool is designed to improve communication around changes in condition (CIC). An adapted SBAR was developed for the Centers for Medicare and Medicaid Services demonstration project, OPTIMISTIC, to increase its use during a resident CIC and to improve documentation.

METHODS

Four Plan-Do-Study-Act (PDSA) cycles to develop and refine successive protocol implementation of the OPTIMISTIC SBAR were deployed in four Indiana nursing homes. Use of SBAR, documentation quality, and participant surveys were assessed pre- and post-intervention implementation.

RESULTS

OPTIMISTIC SBAR use and documentation quality improved in three of the four buildings. Participants reported improved collaboration between nurses and providers after SBAR intervention.

CONCLUSION

Successive PDSA cycles implementing changes in an OPTIMISTIC SBAR protocol for resident CIC led to an increase in SBAR use, improved documentation, and better collaboration between nursing staff and providers.

Identifying the core components of a nursing home hospital avoidance programme

BACKGROUND

Nursing home hospital avoidance programmes have contributed to a reduction in unnecessary emergency transfers but a description of the core components of the programmes has not been forthcoming. A well-operationalised health-care programme requires clarity around core components to evaluate and replicate the programme. Core components are the essential functions and principles that must be implemented to produce expected outcomes.

OBJECTIVES

To identify the core components of a nursing home hospital avoidance programme by assessing how the core components identified at one nursing home (Site One) translated to a second nursing home (Site Two).

METHODS

Data collected during the programme's implementation at Site Two were reviewed for evidence of how the core components named at Site One were implemented at Site Two and to determine if any additional core components were evident. The preliminary updated core components were then shared with seven evaluators familiar with the hospital avoidance programme for consensus.

RESULTS

The updated core components were agreed to include the following: Decision Support Tools, Advanced Clinical Skills Training, Specialist Clinical Support and Collaboration, Facility Policy and Procedures, Family and Care Recipient Education and Engagement, Culture of Staff Readiness, Supportive Executive and Facility Management.

CONCLUSION

This study launches a discussion on the need to identify hospital avoidance programme core components, while providing valuable insight into how Site One core programme components, such as resources, education and training, clinical and facility support, translated to Site Two, and why modifications and additions, such as incorporating the programme into facility policy, family education and executive support were necessary, and the ramifications of those changes. The next step is to take the eight core component categories and undertake a rigorous fidelity assessment as part of formal process evaluation where the components can be critiqued and measured across multiple nursing home sites. The core components can then be used as evidence-based building blocks for developing, implementing and evaluating nursing home hospital avoidance programmes.

Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review

PURPOSE

To identify the clinical indicators of acute deterioration in residents and the factors that influence residential aged care facility staff's identification of these.

DESIGN

Rapid review and narrative synthesis.

METHODS

The WHO and Cochrane Rapid Review Methods Group recommendations guided the review processes. CINAHL, Medline, PubMed, and the Cochrane Library were searched from 2000 to January 2022. Data related to clinical indicators of deterioration were categorized using the Airway, Breathing, Circulation, Disability, Exposure assessment framework, and factors influencing detection were grouped as consumer (resident and family), aged care workforce, and organization factors.

RESULTS

Twenty publications were included of which 14 informed clinical indicators; nine highlighted factors that influence staff's identification of these and three informed both. Included article were collectively below moderate quality. Most clinical indicators were grouped into the 'Disability' category with altered level of consciousness, behavior, and pain identified most frequently. Few studies reported more traditional indicators of deterioration used in the general population - changes in vital signs. The most common factors influencing the detection of acute deterioration were organizational and workforce-related including resource, knowledge, and confidence deficits.

CONCLUSION

Findings suggest subtle changes in resident's health status, rather than focusing primarily on physiologic parameters used in early warning tools for acute care settings, should be recognized and considered in the design of early warning tools for residential aged care facilities.

CLINICAL RELEVANCE

Early warning tools sensitive to the unique needs of residents and support for aged care facility staff are recommended to improve the capacity of aged care facility care staff to identify and manage acute deterioration early to avoid hospitalization.

Detecting Acute Deterioration in Older Adults Living in Residential Aged Care: A Scoping Review

OBJECTIVES

To explore models, processes, or tools implemented in residential aged care (RAC) to support registered nurses (RNs) to identify and respond to the acute deterioration of residents.

DESIGN

Scoping literature review of English Language articles published in peer reviewed journals.

SETTINGS AND PARTICIPANTS

Studies were conducted in RAC facilities providing long-term 24-hour medical, nursing, and social care for people age 65 years or older with age-related disability.

METHODS

We completed a MESH term and key word search of MEDLINE, Embase, CINAHL, PubMed, and Google Scholar. Included studies had (1) part of the intervention based in RAC; (2) had a direct impact on RAC day to day practice; and (3) contained or provided access to the detail of the intervention. Data was charted by author, date, country, study design and the components, genesis, and efficacy of the methods used to identify and respond to acute deterioration.

RESULTS

We found 46 studies detailing models of care, clinical patterns of acute deterioration, and deterioration detection tools. It was not possible to determine which element of the models care had the greatest impact on RN decision making. The clinical patterns of acute deterioration painted a picture of acute deterioration in the frail. There was limited evidence to support the use of existing deterioration detection tools in the RAC population.

CONCLUSION AND IMPLICATIONS

We found no straight forward systematic method to support RAC RNs to identify and respond to the acute deterioration of residents. This is an important practice gap. The clinical pattern of acute deterioration described in the literature has the potential to be used for the development of a tool to support RAC RNs to identify and respond to the acute deterioration of residents.

Capacity of nurses working in long-term care: A systematic review qualitative synthesis

BACKGROUND

The United Nations calculates there were 703 million adults 65 years and older globally as of 2019 with this number projected to double by 2050. A significant number of older adults live with comorbid health conditions, making the role of a nurse in long-term care (LTC) complex. Our objective was to identify the challenges, facilitators, workload, professional development and clinical environment issues that influence nurses and nursing students to seek work and continue to work in LTC settings.

METHODS

Eligibility criteria included being a nurse in a LTC setting and research with a substantial qualitative component. Multiple databases (including Medline and CINAHL) were searched between 2013 and 2019 along with grey literature. Covidence was used to organise a team of 10 into a paired review of titles and abstracts to the final full text screening, extraction and appraisal with the CASP Qualitative Studies Checklist. Analysis involved a thematic synthesis approach. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist informed the writing of the review.

RESULTS

The search resulted in 18 articles and dissertations. Areas investigated included recruitment, resilience, employment and retention, how nurses perceived their professional work, rewards and difficulties, supervision, student preceptorship and career aspiration, nurses' perceptions of occupational status, along with leadership, education and development needs, and intentions to manage resident deteriorating health. The five themes were (1) perspectives of nursing influenced by the organisation, (2) pride in, and capacity to build relationships, (3) stretching beyond the technical skills, (4) autonomy, and (5) taking on the challenge of societal perceptions.

DISCUSSION

This review revealed what is required to recruit nursing students to careers in LTC and retain nurses. To be explored is how staff can work to their full scope of practice and the resultant impact on resident care, including how to maximise a meaningful life for residents and their families.

REGISTRATION

National Institute for Health Research UK (Prospero ID: CRD42019125214).

Nurse practitioners as antibiotic stewards: Examining prescribing patterns and perceptions

BACKGROUND

Advanced practice providers in the outpatient setting play a key role in antibiotic stewardship, yet little is known about how to engage these providers in stewardship activities and what factors influence their antibiotic prescribing practices.

METHODS

We used mixed methods to obtain data on practices and perceptions related to antibiotic prescribing by nurse practitioners (NP) and Veteran patients. We interviewed NPs working in the outpatient setting at one Veterans Affairs facility and conducted focus groups with Veterans. Emerging themes were mapped to the Systems Engineering Initiative for Patient Safety framework. We examined NP antibiotic prescribing data from 2017 to 2019.

RESULTS

We interviewed NPs and conducted Veteran focus groups. Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period.

CONCLUSION

Outpatient NPs focus on educating the patient while balancing organizational access challenges. Further research is needed to determine how to include both NPs and patients when implementing outpatient antibiotic stewardship strategies. Further research is also needed to understand factors associated with the decline in nurse practitioner antibiotic prescribing observed in this study.

The state of mixed methods research in nursing: A focused mapping review and synthesis

AIMS

To consider the scope and quality of mixed methods research in nursing.

DESIGN

Focused mapping review and synthesis (FMRS).

DATA SOURCES

Five purposively selected journals: International Journal of Nursing Studies, Journal of Nursing Scholarship, Journal of Advanced Nursing, Worldviews on Evidence-Based Nursing, and Journal of Mixed Methods Research.

REVIEW METHODS

In the target journals, titles and abstracts from papers published between 2015-2018 were searched for the words or derivative words 'mixed methods'. Additional keyword searches were undertaken using each journal's search tool. We included studies that investigated nursing and reported to use a mixed methods approach. Articles that met the inclusion criteria were read in full and information was extracted onto a predetermined pro forma. Findings across journals were then synthesized to illustrate the current state of mixed methods research in nursing.

RESULTS

We located 34 articles that reported on mixed methods research, conducted across 18 countries. Articles differed significantly both within and across journals in terms of conformity to a mixed methods approach. We assessed the studies for the quality of their reporting as regard the use of mixed methods. Nineteen studies were rated as satisfactory or good, with 15 rated as poorly described. Primarily, a poor rating was due to the absence of stating an underpinning methodological approach to the study and/or limited detail of a crucial integration phase.

CONCLUSIONS

Our FMRS revealed a paucity of published mixed methods research in the journals selected. When they are published, there are limitations in the detail given to the underpinning methodological approach and theoretical explanation.