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Bagchus C, Zee MS, van der Steen JT, Klapwijk MS, Dekker NL, Onwuteaka-Philipsen BD, Pasman HRW. Challenges in recognizing and discussing changes in a resident's condition in the palliative phase: focus group discussions with nursing staff working in nursing homes about their experiences. BMC Palliat Care 2024; 23:144. [PMID: 38858719 PMCID: PMC11163817 DOI: 10.1186/s12904-024-01479-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 06/04/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Most nursing home residents have complex care needs, require palliative care and eventually die in these facilities. Timely recognition of changes in a resident's condition is crucial for providing appropriate care. Observations by nursing staff play a significant role in identifying and interpreting these changes. METHODS Focus group discussions were conducted with nursing staff from ten nursing homes in the Netherlands to explore their experiences and challenges in recognizing and discussing changes in a resident's condition. These discussions were analysed following the principles of thematic analysis. RESULTS The analysis of the challenges nursing staff face in identifying and interpreting changes in a resident's condition, resulted in three themes. First, that recognizing changes is considered complex, because it requires specialized knowledge and skills that is generally not part of their education and must partly be learned in practice. This also depends on how familiar the nursing staff is with the resident. Furthermore, different people observe residents through different lenses, depending on their relation and experiences with residents. This could lead to disagreements about the resident's condition. Lastly, organizational structures such as the resources available to document and discuss a resident's condition and the hierarchy between nursing home professionals often hindered discussions and sharing observations. CONCLUSION Nursing staff's experiences highlight the complexity of recognizing and discussing changes in nursing home residents' conditions. While supporting the observational skills of nursing staff is important, it is not enough to improve the quality of care for nursing home residents with palliative care needs. As nursing staff experiences challenges at different, interrelated levels, improving the process of recognizing and discussing changes in nursing home residents requires an integrated approach in which the organization strengthens the position of nursing staff. It is important that their observations become a valued and integrated and part of nursing home care.
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Affiliation(s)
- C Bagchus
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Faculty of Health, University of Applied Sciences Leiden, Leiden, the Netherlands
| | - M S Zee
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - J T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Primary and Community Care and Radboudumc Alzheimer center, Radboud university medical center, P.O. Box 9600, 6500 HB, Nijmegen, The Netherlands
| | - M S Klapwijk
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - N Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, the Netherlands
| | - B D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - H R W Pasman
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, the Netherlands.
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Gershater MA, Brenner J, Nordberg M, Hommel A. Nurse assistants' perception of caring for older persons who are dying in their own home : An interview study. BMC Palliat Care 2024; 23:70. [PMID: 38468298 DOI: 10.1186/s12904-024-01399-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 02/27/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND As the proportion of older persons in society increases, there is a growing trend towards providing end-of-life care in their homes. Palliative care is a complex and knowledge-demanding form of care, and nurse assistants are those who work closest to the older person at the end-of-life in their own homes. However, nurse assistants sometimes have low educational and insufficient levels of knowledge in palliative care, which can affect the quality of care they provide. Moreover, nurse assistants' experiences are relatively unexplored in this context. The purpose of the study was to illuminate nurse assistants' experiences in caring for dying older persons at home. METHOD An empirical, qualitative interview study was conducted with 14 nurse assistants with experience of palliative care in homecare. The material was analyzed using thematic content analysis. RESULTS From the nurse assistant's experiences, one main theme emerged: doing everything possible for the dying older person despite challenges. Moreover, three sub-themes emerged: making a difference at a crucial time, death awakens emotions, and balancing personal and professional relationships. The nurse assistants' saw their role primarily as relieving symptoms but also focusing on next of kin. The following are described as essential parts of their role: carrying out practical nursing tasks, focusing on the physical environment, working alone and seeking help from colleagues due to a physical distance to the other members of the multidisciplinary team. The nurse assistants experienced a lack of support as there was no structured guidance or debriefing available in difficult emotional situations. Furthermore, they disclosed that they were left alone to deal with their feelings. CONCLUSION This study demonstrates that nurse assistants strive to provide comprehensive care for dying older persons despite facing obstacles from their working conditions and work organization. They lack supervision and education in palliative care, but they rely on their experience-based knowledge to a large extent and provide care according to the four cornerstones of palliative care.
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Affiliation(s)
- Magdalena Annersten Gershater
- Department of Care Science, Faculty of Health and Society, Malmö University, Jan Waldenströms gata 25, Malmö, 206 05, Sweden.
| | - Josefin Brenner
- Department of Health and Social Care, Home Care Kungsparken, Malmö Municipality, Västra Kanalgatan 4, Malmö, 211 41, Sweden
| | - Malin Nordberg
- Department of Health and Social Care, Malmö Municipality, Villa Vikhem, Vikhems bygata 100, Staffanstorp, 245 46, Sweden
| | - Ami Hommel
- Department of Care Science, Faculty of Health and Society, Malmö University, Jan Waldenströms gata 25, Malmö, 206 05, Sweden
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Singh YP, Kumar N, Chauhan BS, Garg P. Carbamate as a potential anti-Alzheimer's pharmacophore: A review. Drug Dev Res 2023; 84:1624-1651. [PMID: 37694498 DOI: 10.1002/ddr.22113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
Alzheimer's disease (AD) is a progressive age-related neurodegenerative brain disorder, which leads to loss of memory and other cognitive dysfunction. The underlying mechanisms of AD pathogenesis are very complex and still not fully explored. Cholinergic neuronal loss, accumulation of amyloid plaque, metal ions dyshomeostasis, tau hyperphosphorylation, oxidative stress, neuroinflammation, and mitochondrial dysfunction are major hallmarks of AD. The current treatment options for AD are acetylcholinesterase inhibitors (donepezil, rivastigmine, and galantamine) and NMDA receptor antagonists (memantine). These FDA-approved drugs mainly provide symptomatic relief without addressing the pathological aspects of disease progression. So, there is an urgent need for novel drug development that not only addresses the basic mechanisms of the disease but also shows the neuroprotective property. Various research groups across the globe are working on the development of multifunctional agents for AD amelioration using different core scaffolds for their design, and carbamate is among them. Rivastigmine was the first carbamate drug investigated for AD management. The carbamate fragment, a core scaffold of rivastigmine, act as a potential inhibitor of acetylcholinesterase. In this review, we summarize the last 10 years of research conducted on the modification of carbamate with different substituents which primarily target ChE inhibition, reduce oxidative stress, and modulate Aβ aggregation.
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Affiliation(s)
- Yash Pal Singh
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Navneet Kumar
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER), S.A.S. Nagar, Punjab, India
| | | | - Prabha Garg
- Department of Pharmacoinformatics, National Institute of Pharmaceutical Education and Research (NIPER), S.A.S. Nagar, Punjab, India
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Morrison-Koechl J, Liu SH, Banerjee A, Heckman G, Keller H. Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review. J Multidiscip Healthc 2023; 16:2823-2837. [PMID: 37750163 PMCID: PMC10518155 DOI: 10.2147/jmdh.s417344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023] Open
Abstract
Purpose Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death. Patients and Methods A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal. Results Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death. Conclusion This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.
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Affiliation(s)
- Jill Morrison-Koechl
- Department of Kinesiology & Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Sheng Han Liu
- Department of Kinesiology & Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Albert Banerjee
- Department of Gerontology, St. Thomas University, Fredericton, New Brunswick, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Heather Keller
- Department of Kinesiology & Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
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Ahlström G, Rosén H, Persson EI. Quality of Life among Next of Kin of Frail Older People in Nursing Homes: An Interview Study after an Educational Intervention concerning Palliative Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052648. [PMID: 35270339 PMCID: PMC8909579 DOI: 10.3390/ijerph19052648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/14/2022] [Accepted: 02/22/2022] [Indexed: 11/30/2022]
Abstract
One cornerstone of palliative care is improving the family’s quality of life (QoL). The principles of palliative care have not been sufficiently applied in nursing homes. The aim of this study was to investigate the experiences of QoL of next of kin of frail older persons in nursing homes after an educational intervention concerning palliative care. This qualitative interview study with 37 next of kin used an abductive design with deductive and inductive content analysis. The deductive analysis confirmed the three themes of QoL from the study before the implementation: (1) orientation to the new life-situation, (2) challenges in the relationship, and (3) the significance of the quality of care in the nursing home. The inductive analysis resulted in the sub-theme “Unspoken palliative care”. Being the next of kin of an older person living in a nursing home can be distressing despite round-the-clock care, so staff need to apply a more explicitly palliative care perspective. Future research needs to evaluate the influence of meaning-focused coping on next of kin’s QoL and integrate this knowledge in psychosocial interventions. Clinical Trial Database for Clinical Research: KUPA project NCT02708498.
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Sopcheck J, Tappen RM. Communicating With Nursing Home Residents About End of Life. Am J Hosp Palliat Care 2021; 39:1257-1265. [PMID: 34967673 DOI: 10.1177/10499091211064835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Approximately 33% of the 1.2 million older individuals residing in nursing homes have the capacity to discuss their preferences for end-of-life care, and 35% will die within their first year in the nursing home. These conversations necessary to promote care consistent with the resident's preferences are often limited and most often occur when the resident is actively dying. The purpose of this secondary analysis was to understand the resident's perspectives on end-of-life communication in the nursing home and suggest approaches to facilitate this communication. We interviewed 46 participants (16 residents, 10 family members, and 20 staff) in a Southeast Florida nursing home from January to May 2019. The data were analyzed using descriptive and pattern coding and matrices to decipher preliminary categories and thematic interpretation within and across each participant group. Two themes emerged from this secondary analysis that residents assume others know their end-of-life preferences, and past experiences may predict future end-of-life choices. Residents and family members were willing to discuss end-of-life care. Study findings also suggested that past experiences with the end-of-life and critical illness of another could impact residents' and family members' end-of-life care decisions, and that nurses' recognition of subtle signs of a resident's decline may trigger provider-initiated end-of-life conversations. Future research should focus on strategies to promote earlier end-of-life discussions to support independent decision-making about end-of-life care in this relatively dependent population of older adults.
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Affiliation(s)
| | - Ruth M Tappen
- 1782Florida Atlantic University, Boca Raton, FL, USA
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Åvik Persson H, Ahlström G, Ekwall A. Professionals' Expectations and Preparedness to Implement Knowledge-Based Palliative Care at Nursing Homes before an Educational Intervention: A Focus Group Interview Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18178977. [PMID: 34501567 PMCID: PMC8431503 DOI: 10.3390/ijerph18178977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
The provision of knowledge-based palliative care is rare in nursing homes. There are obstacles to practically performing this because it can be difficult to identify when the final stage of life begins for older persons. Educational interventions in palliative care in nursing homes are a challenge, and joint efforts are needed in an organisation, including preparedness. The aim was to explore professionals' expectations and preparedness to implement knowledge-based palliative care in nursing homes before an educational intervention. This study has a qualitative focus group design, and a total of 48 professionals working in nursing homes were interviewed with a semi-structured interview guide. Qualitative content analysis with an inductive approach was used for the analysis. One major theme was identified: professionals were hopeful yet doubtful about the organisation's readiness. The main categories of increased knowledge, consensus in the team, and a vision for the future illustrate the hopefulness, while insufficient resources and prioritisation illustrate the doubts about the organisation's readiness. This study contributes valuable knowledge about professionals' expectations and preparedness, which are essential for researchers to consider in the planning phase of an implementation study. The successful implementation of changes needs to involve strategies that circumvent the identified obstacles to organisations' readiness.
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Tjernberg J, Bökberg C. Older persons' thoughts about death and dying and their experiences of care in end-of-life: a qualitative study. BMC Nurs 2020; 19:123. [PMID: 33327960 PMCID: PMC7739469 DOI: 10.1186/s12912-020-00514-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/03/2020] [Indexed: 01/10/2023] Open
Abstract
Background Few studies have focused on how older persons living in nursing homes perceive their last period of life. Furthermore, previous research on older persons’ perceptions of death and dying is limited. Hence, there is an urgent need to explore their experiences during their final period in life. Aim To explore thoughts about death and dying and experiences of care in end-of-life among older persons living in nursing homes. Methods This study employed a qualitative approach including individual interviews with 36 older persons living in Swedish nursing homes. Questions related to quality of life; physical health; thoughts about death, dying, and the future; and experiences related to the living condition and environment were asked. The interview transcripts were analysed through content analysis. The study was approved by the Regional Ethics Review Board (reference number: 2015/4). Results The analysis resulted in the identification of three main thematic categories: The unavoidable and unknown end of life, Thoughts on control and Living your last period of life at a nursing home. The older persons did not fear death itself but had some worries about dying. Spending the last stage of life at a nursing home contributed to different thoughts and feelings among the older persons. With a few exceptions, older persons characterized life at the nursing home as boring and felt they were surrounded by people who did not belong there. Conclusions This study indicates a need for older persons to talk about death, dying and end-life issues. Furthermore, this study highlighted that the co-residence of cognitively healthy persons and persons with dementia in the same ward adversely affected cognitively healthy persons. This situation resulted in there being not enough time to both handle the care needs of persons with dementia and have the conversations that cognitively healthy persons desired, such as conversations about thoughts about existence, that could have improved their quality of life. Trial registration NCT02708498 Date of registration 16 February 2016.
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Affiliation(s)
- Johanna Tjernberg
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden
| | - Christina Bökberg
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden.
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Bökberg C, Behm L, Ahlström G. Quality of life of older persons in nursing homes after the implementation of a knowledge-based palliative care intervention. Int J Older People Nurs 2019; 14:e12258. [PMID: 31298499 PMCID: PMC6900068 DOI: 10.1111/opn.12258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The goals of palliative care are to relieve suffering and promote quality of life. Palliative care for older persons has been less prioritised than palliative care for younger people with cancer, which may lead to unnecessary suffering and decreased quality of life at the final stage of life. AIM To evaluate whether a palliative care intervention had any influence on the perceived quality of life of older persons (≥65 years). METHODS This study was conducted as a complex intervention performed with an experimental crossover design. The intervention was implemented in 20 nursing homes, with a six-month intervention period in each nursing home. Twenty-three older persons (≥65 years) in the intervention group and 29 in the control group were interviewed using the WHOQOL-BREF and WHOQOL-OLD questionnaires at both baseline and follow-up. The collected data were analysed using the Wilcoxon signed-rank test to compare paired data between baseline and follow-up. RESULTS In the intervention group, no statistically significant increases in quality of life were found. This result contrasted with the control group, which revealed statistically significant declines in quality of life at both the dimension and item levels. Accordingly, this study showed a trend of decreased health after nine months in both the intervention and control groups. CONCLUSION It is reasonable to believe that quality of life decreases with age as part of the natural course of the ageing process. However, it seems that the palliative care approach of the intervention prevented unnecessary quality of life decline by supporting sensory abilities, autonomy and social participation among older persons in nursing homes. From the ageing perspective, it may not be realistic to strive for an increased quality of life in older people living in nursing homes; maybe the goal should be to delay or prevent reduced quality of life. Based on this perspective, the intervention prevented decline in quality of life in nursing home residents. IMPLICATIONS FOR PRACTICE The high number of deaths shows the importance to identify palliative care needs in older persons at an early stage to prevent or delay deterioration of quality of life.
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Affiliation(s)
- Christina Bökberg
- Department of Health Sciences, Faculty of MedicineLund UniversityLundSweden
| | - Lina Behm
- Department of Health Sciences, Faculty of MedicineLund UniversityLundSweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of MedicineLund UniversityLundSweden
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The Development of a Digital Dysphagia Guide with Care Homes: Co-Production and Evaluation of a Nutrition Support Tool. Geriatrics (Basel) 2019; 4:geriatrics4030048. [PMID: 31443170 PMCID: PMC6787745 DOI: 10.3390/geriatrics4030048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 07/25/2019] [Accepted: 08/09/2019] [Indexed: 12/03/2022] Open
Abstract
Good nutrition is a recognised outcome in the health and well-being of older care home residents and dysphagia is a known risk factor associated with under nutrition and poor outcomes. The study co-produced a digital Dysphagia Guide with Care Homes using a consensus method with interviews and focus groups to prioritise the need for information and explore acceptability of an educational tool for care home workers. Evaluation of use, acceptability of design, and content of the guide were completed via remote monitoring. The workforce prioritised the need for training as well as the knowledge and skills in relation to planning resident-centred care and advice on textured diets. The technology was a means of offering ‘bite-size’ learning to enhance planning for nutrition across the whole organisation including managers, kitchen staff, and care workers. The Guide to Dysphagia was produced on a tablet and piloted in four care homes over 12 weeks, by 57 staff. Integrated analytics allowed user activity to be monitored. Findings showed that 73% of respondents reported the guide helped them in their job. Additionally, 88% of respondents stated they would recommend the guide to other staff, with 90% reporting it was easy to use. Engagement with staff and managers in four homes resulted in a co-designed, dysphagia guide.
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