Multidisciplinary team, working with elderly persons living in the community: a systematic literature review

Cumulative Anticholinergic Burden and its Predictors among Older Adults with Alzheimer's Disease Initiating Cholinesterase Inhibitors

BACKGROUND

Cumulative anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. However, concomitant use of cholinesterase inhibitors (ChEIs) and anticholinergic burden can nullify the benefit of the treatment and worsen Alzheimer's disease (AD). A literature gap exists regarding the extent of the cumulative anticholinergic burden and associated risk factors in AD. Therefore, this study evaluated the prevalence and predictors of cumulative anticholinergic burden among patients with AD initiating ChEIs.

METHODS

A retrospective longitudinal cohort study was conducted using the Medicare claims data involving parts A, B, and D from 2013 to 2017. The study sample included older adults (65 years and older) diagnosed with AD and initiating ChEIs (donepezil, rivastigmine, or galantamine). The cumulative anticholinergic burden was calculated based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using the defined daily dose over the 1 year follow-up period after ChEI initiation. Incremental anticholinergic burden levels were dichotomized into moderate-high (sum of standardized daily anticholinergic exposure over a year (TSDD) score ≥ 90) versus low-no (score 0-89). The Andersen Behavioral Model was used as the conceptual framework for selecting the predictors under the predisposing, enabling, and need categories. A multivariable logistic regression model was used to evaluate the predictors of high-moderate versus low-no cumulative anticholinergic burden. A multinomial logistic regression model was also used to determine the factors associated with patients having moderate and high burdens compared to low/no burdens.

RESULTS

The study included 222,064 older adults with AD with incident ChEI use (mean age 82.24 ± 7.29, 68.9% females, 83.6% White). Overall, 80.48% had some anticholinergic burden during the follow-up, with 36.26% patients with moderate (TSDD scores 90-499), followed by 24.76% high (TSDD score > 500), and 19.46% with low (TSDD score 1-89) burden categories. Predisposing factors such as age; African American, Asian, or Hispanic race; and need factors included comorbidities such as dyslipidemia, syncope, delirium, fracture, pneumonia, epilepsy, and claims-based frailty index were less likely to be associated with the moderate-high anticholinergic burden. The factors that increased the odds of moderate-high burden were predisposing factors such as female sex; enabling factors such as dual eligibility and diagnosis year; and need factors such as baseline burden, behavioral and psychological symptoms of dementia, depression, insomnia, urinary incontinence, irritable bowel syndrome, anxiety, muscle spasm, gastroesophageal reflux disease, heart failure, and dysrhythmia. Most of these findings remained consistent with multinomial logistic regression.  CONCLUSION: Four out of five older adults with AD had some level of anticholinergic burden, with over 60% having moderate-high anticholinergic burden. Several predisposing, enabling, and need factors were associated with the cumulative anticholinergic burden. The study findings suggest a critical need to minimize the cumulative anticholinergic burden to improve AD care.

Factors and interventions determining the functioning of health care teams in county-level hospitals in less affluent areas of China: a qualitative study

Background

Teamwork is essential for the quality and safety of care, and research on teamwork in health care has developed rapidly in many countries. However, evidence from less affluent, non-Western countries is scarce, while improving teamwork may be especially relevant to be able to increase the quality of care in these settings. This study aims to understand the main factors that influence, and interventions used to improve, the functioning of health care teams in the context of county-level hospitals in less affluent areas of China.

Methods

We conducted semistructured interviews to explore the factors that influence team functioning and the interventions implemented to improve team functioning in these hospitals. 15 hospital presidents and 15 team leaders were selected as respondents.

Results

From the interviews, we have identified five main factors that influence team functioning in these hospitals: "stuck in the middle", local county setting, difficulty in attracting and retaining talent, strong focus on task design, and strong focus on leadership. The interventions for improving team functioning can mostly be categorized as the following: 1) measures to attract and retain talent (e.g., increase salary, train talent in national or provincial level hospitals, and provide fast-track promotions), 2) interventions focused on monodisciplinary teams (e.g., changing the team structure and leadership, and skill training), and 3) interventions to establish and improve multidisciplinary teams (e.g., simulation training and continuous team process improvements).

Conclusion

With the introduction of multidisciplinary teams, interventions into team processes have started to receive more attention. The findings depict an overview of the main factors and interventions as specifically relevant for team functioning in county-level hospitals in less affluent areas of China and may help these hospitals benefit from additional process interventions to improve teamwork and the quality of care.

Technology-based interprofessional collaboration in primary care for home rehabilitation of the older adults: A dutch exploratory study

Primary healthcare professionals face an increasing number of geriatrics patients, and patient care often involves different disciplines. eHealth offers opportunities to support interprofessional collaboration (IPC). This exploratory study aimed to gain insight in 1) IPC in community-based rehabilitation, 2) facilitators and barriers for technology-based IPC and 3) technological IPC solutions envisioned by the primary healthcare professionals An focus group with six primary healthcare professionals and a design thinking session with four participants were conducted. Data analysis was based upon an IPC model. Results indicate that facilitators and barriers for IPC can be clustered in three categories: human, organization and technology, and provide some requirements to develop suitable IPC technological solutions Primary healthcare professionals recognise the urgency of working collaboratively. Current barriers are understanding each other's professional vocabulary, engaging the older adults, and using technology within the patient's environment. Further research is needed to integrate IPC components in a technological solution.

Improving Multidisciplinary Team Working to Support Integrated Care for People with Frailty Amidst the COVID-19 Pandemic

Multidisciplinary team (MDT) working is essential to optimise and integrate services for people who are frail. MDTs require collaboration. Many health and social care professionals have not received formal training in collaborative working. This study investigated MDT training designed to help participants deliver integrated care for frail individuals during the Covid-19 pandemic. Researchers utilised a semi-structured analytical framework to support observations of the training sessions and analyse the results of two surveys designed to assess the training process and its impact on participants knowledge and skills. 115 participants from 5 Primary Care Networks in London attended the training. Trainers utilised a video of a patient pathway, encouraged discussion of it, and demonstrated the use of evidence-based tools for patient needs assessment and care planning. Participants were encouraged to critique the patient pathway, reflect on their own experiences of planning and providing patient care. 38% of participants completed a pre-training survey, 47% a post-training survey. Significant improvement in knowledge and skills were reported including understanding roles in contributing to MDT working, confidence to speak in MDT meetings, using a range of evidence-based clinical tools for comprehensive assessment and care planning. Greater levels of autonomy, resilience, and support for MDT working were reported. Training proved effective; it could be scaled up and adopted to other settings.

Implementation and impacts of virtual team-based care planning for older persons in formal care settings: A scoping review

Objective

This scoping review aimed to summarize current knowledge about the implementation, impacts, facilitators and barriers of virtual team-based care planning for older persons in formal care settings (e.g. home and community, primary, long-term and acute care).

Methods

The Joanna Briggs Institute (JBI) methodology was used. The Arksey and O'Malley and Levac, Colquhoun, and O'Brien methodologies provided additional frameworks. Databases accessed included PubMed, EMBASE, CINAHL, AgeLine, PsycInfo and Scopus. Reference lists of selected articles and grey literature retrieved through Google and Google Scholar were also reviewed. Three researchers screened titles, abstracts and conducted full-text reviews. Extracted data were mapped in a table and analysed for summative themes. Older persons and family partners assisted in interpreting findings based on their lived experiences.

Results

A total of 27 studies were included. Virtual team-based care planning led to many positive outcomes for older persons (e.g. decreased depression, reduced falls and improved medication management) and their families (e.g. reduced caregiver stress and improved caregiving skills). Only four studies reported the involvement of older persons and/or families in virtual team-based care planning. Multiple barriers to adopting virtual team-based care planning were found including lack of education/training for older persons and families in using technology.

Conclusion

Despite the multiple advantages that virtual team-based care planning offers for older persons and families, it is important to ensure that this care can be offered to all. There is a need to ensure that health equity is addressed to promote access to care and respond to social determinants of health.

Scoping review to identify strategies and interventions improving interprofessional collaboration and integration in primary care

OBJECTIVE

To identify strategies and interventions used to improve interprofessional collaboration and integration (IPCI) in primary care.

DESIGN

Scoping review DATA SOURCES: Specific Medical Subject Headings terms were used, and a search strategy was developed for PubMed and afterwards adapted to Medline, Eric and Web of Science.

STUDY SELECTION

In the first stage of the selection, two researchers screened the article abstracts to select eligible papers. When decisions conflicted, three other researchers joined the decision-making process. The same strategy was used with full-text screening. Articles were included if they: (1) were in English, (2) described an intervention to improve IPCI in primary care involving at least two different healthcare disciplines, (3) originated from a high-income country, (4) were peer-reviewed and (5) were published between 2001 and 2020.

DATA EXTRACTION AND SYNTHESIS

From each paper, eligible data were extracted, and the selected papers were analysed inductively. Studying the main focus of the papers, researchers searched for common patterns in answering the research question and exposing research gaps. The identified themes were discussed and adjusted until a consensus was reached among all authors.

RESULTS

The literature search yielded a total of 1816 papers. After removing duplicates, screening titles and abstracts, and performing full-text readings, 34 papers were incorporated in this scoping review. The identified strategies and interventions were inductively categorised under five main themes: (1) Acceptance and team readiness towards collaboration, (2) acting as a team and not as an individual; (3) communication strategies and shared decision making, (4) coordination in primary care and (5) integration of caregivers and their skills and competences.

CONCLUSIONS

We identified a mix of strategies and interventions that can function as 'building blocks', for the development of a generic intervention to improve collaboration in different types of primary care settings and organisations.

Detect, trace and react: Danish senior centre staffs' awareness of and response to signs of deteriorating health or well-being among senior centre users - An ethnographic field study

Senior centre staff members seemingly have an important organisational and administrative role, as well as engage in outreach activities, referral and follow-up in relation to health issues among senior centre users. However, their role in health promotion and illness prevention is easily overlooked and under researched. This study aimed to explore municipal senior centre staffs' awareness of and response to signs of deteriorating health or well-being among users. A multisite ethnographic field study was conducted at seven municipal senior centres in Denmark from November 2019 to February 2020. Data were obtained from participant observation and semi-structured individual interviews with 16 staff members. A thematic analysis strategy helped identify themes of importance. Senior centre staff followed a process of three steps when remaining aware of and responding to signs of deteriorating health and well-being among users: detecting, tracing and reacting. Three themes with corresponding subthemes were identified: Establishing close and trusting relationships, facilitating a community feeling and utilising joint collaboration. Each subtheme was linked to some or all of the three steps in the process. The municipal senior centre staff had a strong and explicit focus on detecting, tracing and reacting to signs of deteriorating health and well-being among senior centre users. This makes the senior centres a promising arena for illness prevention and health promotion.

What is needed for continuity of care and how can we achieve it? - Perceptions among multiprofessionals on the chronic care trajectory

Background

Continuity of care (CoC) implies delivery of services in a coherent, logical and timely fashion. Continuity is conceptualized as multidimensional, encompassing three specific domains – relational, management and informational continuity – with emphasis placed on their interrelations, i.e., how they affect and are affected by each other. This study sought to investigate professionals’ perceptions of the prerequisites of CoC within and between organizations and how CoC can be realized for people with complex care needs.

Methods

This study had a qualitative design using individual, paired and focus group interviews with a purposeful sample of professionals involved in the chain of care for patients with chronic conditions across healthcare and social care services from three different geographical areas in Sweden, covering both urban and rural areas. Transcripts from interviews with 34 informants were analysed using conventional content analysis.

Results

CoC was found to be dependent on professional and cross-disciplinary cooperation at the micro, meso and macro system levels. Continuity is dependent on long-term and person-centred relationships (micro level), dynamic stability in organizational structures (meso level) and joint responsibility for cohesive care and enabling of uniform solutions for knowledge and information exchange (macro level).

Conclusions

Achieving CoC that creates coherent and long-term person-centred care requires knowledge- and information-sharing that transcends disciplinary and organizational boundaries. Collaborative accountability is needed both horizontally and vertically across micro, meso and macro system levels, rather than a focus on personal responsibility and relationships at the micro level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08023-0.

A systematic review of interventions to reduce anticholinergic burden in older people with dementia in primary care

OBJECTIVE

This systematic review aimed to assess the types and effectiveness of interventions that sought to reduce anticholinergic burden (ACB) in people with dementia (PwD) in primary care.

METHODS

One trial registry and eight electronic databases were systematically searched to identify eligible English language studies from inception until December 2021. To be eligible for inclusion, studies had to be randomised controlled trials (RCTs) or non-randomised studies (NRS), including controlled before-and-after studies and interrupted time-series studies, of interventions to reduce ACB in PwD aged ≥65 years (either community-dwelling or care home residents). All outcomes were to be considered. Quality was to be assessed using the Cochrane Risk of Bias tool for RCTs and ROBINS-I tool for NRS. If data could not be pooled for meta-analysis, a narrative synthesis was to be conducted.

RESULTS

In total, 1880 records were found, with 1594 records remaining after removal of duplicates. Following title/abstract screening, 13 full-text articles were assessed for eligibility. None of these studies met the inclusion criteria for this review. Reasons for exclusion were incorrect study design, ineligible study population, lack of focus on reducing ACB, and studies conducted outside the primary care setting.

CONCLUSIONS

This 'empty' systematic review highlights the lack of interventions to reduce ACB in PwD within primary care, despite this being highlighted as a priority area for research in recent clinical guidance. Future research should focus on development and testing of interventions to reduce ACB in this patient population through high-quality clinical trials.

Virtual team-based care planning with older persons in formal care settings: a scoping review protocol

INTRODUCTION

COVID-19 has necessitated greater adoption of virtual care (eg, telephone (audio), videoconference) delivery models. Virtual care provides opportunities for innovative practice in care planning with older persons and meaningful family engagement by synchronously involving multiple care providers. Nevertheless, there remains a paucity of summarising evidence regarding virtual team-based care planning for older persons. The purpose of this scoping review is to summarise evidence on the utilisation of virtual team-based care planning for older persons in formal care settings. Specifically, (1) what has been reported in the literature on the impact or outcomes of virtual team-based care planning? (2) What are the facilitators and barriers to implementation?

METHODS AND ANALYSIS

This scoping review will follow a rigorous and well-established methodology by the Joanna Briggs Institute, supplemented by the Arksey & O'Malley and Levac, Colquhoun, & O'Brien frameworks. A three-step search strategy will be used to conduct a search on virtual team-based care planning for older persons in formal care settings. Keywords and index terms will be identified from an initial search in PubMed and AgeLine, and used to conduct the full search in the databases PubMed, EMBASE, CINAHL, AgeLine, PsycInfo and Scopus. Reference lists of included articles and grey literature retrieved through Google and Google Scholar will also be reviewed. Three researchers will screen titles and abstracts, and will conduct full-text review for inclusion. Extracted data will be mapped in a table.

ETHICS AND DISSEMINATION

Research ethics approval is not required for data collection from publicly accessible information. Findings will be presented at conferences, submitted for open-access publication in a peer-reviewed journal and made accessible to multiple stakeholders. The scoping review will summarise the literature on virtual team-based care planning for the purpose of informing the implementation of a virtual PIECES™ intervention (Physical/Intellectual/Emotional health, Capabilities, Environment, and Social).

Deprescribing to reduce polypharmacy: study protocol for a randomised controlled trial assessing deprescribing of anticholinergic and sedative drugs in a cohort of frail older people living in the community

BACKGROUND

Targeted deprescribing of anticholinergic and sedative medications in older people may improve their health outcomes. This trial will determine if pharmacist-led reviews lead to general practitioners deprescribing anticholinergic and sedative medications in older people living in the community.

METHODS AND ANALYSIS

The standard protocol items: Recommendations for Interventional Trials (SPIRIT) checklist was used to develop and report the protocol. The trial will involve older adults stratified by frailty (low, medium, and high). This will be a pragmatic two-arm randomized controlled trial to test general practitioner uptake of pharmacist recommendations to deprescribe anticholinergic and sedative medications that are causing adverse side effects in patients.

STUDY POPULATION

Community-dwelling frail adults, 65 years or older, living in the Canterbury region of New Zealand, seeking publicly funded home support services or admission to aged residential care and taking at least one anticholinergic or sedative medication regularly.

INTERVENTION

New Zealand registered pharmacists using peer-reviewed deprescribing guidelines will visit participants at home in the community, review their medications, and recommend anticholinergic and sedative medications that could be deprescribed to the participant's general practitioner. The total use of anticholinergic and sedative medications will be quantified using the Drug Burden Index (DBI).

OUTCOMES

The primary outcome will be the change in total DBI between baseline and 6-month follow-up. Secondary outcomes will include entry into aged residential care, prolonged hospitalization, and death.

DATA COLLECTION POINTS

Data will be collected at the time of interRAI assessments (T0), at the time of the baseline review (T1), at 6 months following the baseline review (T2), and at the end of the study period, or end of study participation for participants admitted into aged residential care, or who died (T3).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human, Disability and Ethics Committee: ethical number (17CEN265).

TRIAL REGISTRATION

ClinicalTrials.gov ACTRN12618000729224 . Registered on May 2, 2018, with the Australian New Zealand Clinical Trials Registry.

Barriers and facilitators to interprofessional collaborative practice for community-dwelling older adults: An integrative review

AIMS AND OBJECTIVES

The aim of this integrative review was to synthesise empirical reports of interprofessional collaborative practice (IPCP) for community-dwelling older adults and uncover barriers and facilitators related to its success as a model of care for this population.

BACKGROUND

IPCP is a model of care that has demonstrated positive outcomes for community-dwelling older adults. However, a summary of barriers and facilitators to IPCP models has not been presented.

METHODS

An integrative review using the method posited by Whittemore and Knafl was completed to identify barriers and facilitators to IPCP for community-dwelling older adults. The literature search was reported following PRISMA guidelines.

RESULTS

Four themes emerged as barriers to IPCP: (1) A (Potential) Logistical Nightmare, (2) All About the Money, (3) If We Can't Test It, Can We Recommend It? and (4) Challenging for the Team, Challenging for the Client. Three themes emerged as facilitators to IPCP: (1) Reducing Resource Waste, (2) The "C" in IPCP and (3) What Matters Most.

CONCLUSIONS

IPCP models for community-dwelling older adults must adapt to the setting of care and client needs. Interprofessional education opportunities for team members facilitate effective IPCP. Healthcare policies and funding structures need to address IPCP for community-dwelling older adults for this model to be successful and sustainable.

RELEVANCE TO CLINICAL PRACTICE

Nurses participate on and lead IPCP teams caring for community-dwelling older adults and, therefore, need to be aware of barriers and facilitators to this model of care.

Multispecialty Interprofessional Team Memory Clinics: Enhancing Collaborative Practice and Health Care Providers' Experience of Dementia Care

This study explored whether working within Multispecialty INterprofessional Team (MINT) memory clinics has an impact on health care professionals' perceptions of the challenges, attitudes, and level of collaboration associated with providing dementia care. Surveys were completed by MINT memory clinic members pre- and 6-months post-clinic launch. A total of 228 pre-and-post-training surveys were matched for analysis. After working in the MINT memory clinics for 6 months, there were significant reductions in mean ratings of the level of challenge associated with various aspects of dementia care, and significant increases in the frequency with which respondents experienced enthusiasm, inspiration, and pride in their work in dementia care and in ratings of the extent of collaboration for dementia care. This study provides some insights into the effect of collaborative, interprofessional approaches on health care professionals' perceptions of the challenges and attitudes associated with providing dementia care and level of collaboration with other health professionals.

A concept analysis of interprofessional collaborative practice for community-dwelling older adults

Models of interprofessional collaborative practice have demonstrated improved outcomes for community-dwelling older adults. However, the concept of interprofessional collaborative practice for community-dwelling older adults needs clarification and a clear definition. A concept analysis based on the method posited by Walker and Avant was conducted to formulate an operational definition of this concept. Defining attributes, antecedents, consequences and empirical referents were identified from a review of the literature. A model case and contrary case were selected to further clarify the concept of interprofessional collaborative practice for community-dwelling older adults. Nurses are ideal leaders of interprofessional teams caring for older adults and can utilize this concept in practice, education and research.

Nurses' perceptions of their role in functional focused care in hospitalised older people: An integrated review

AIM

The aim of this integrative review was to identify nurses' perspectives of their role in influencing the functional status of hospitalised older people.

METHODS

An integrative review using Whittemore and Knafls' method was conducted using EBSCOhost CINAHL, Ovid MEDLINE(R), EBSCOhost, Social Gerontology, Cochrane Database of Systematic Reviews and ProQuest Dissertations & Theses data bases. Only studies with nurses' perspectives, or beliefs about their role in function-focused care were included. Content analysis was used to develop the themes nurses' role in function-focused care and barriers to functional care.

RESULTS

The review found 12 relevant articles. Nurses believed that they were responsible for function-focused care, yet functional care tasks were often missed. Organisational contexts created many barriers to providing function-focused care for patients. Nurses felt powerless to address these overarching problems in their organisations.

CONCLUSION

Nurses understand the importance of functional care yet often fail to carry out functional care interventions. Lack of organisational support creates a workplace that is short on staff, time and equipment and does not prioritise functional care needs. Nurse leaders and healthcare organisations need to reprioritise function-focused care for the good of patients, families and healthcare budgets.

Multidisciplinary approach to degenerative cervical myelopathy

INTRODUCTION

Degenerative cervical myelopathy (DCM) is a prevalent condition causing significant impairment spanning several domains of health. A multidisciplinary approach to the care of DCM would be ideal in utilizing complex treatments from different disciplines to address broad patient needs.

AREAS COVERED

In this article the authors will discuss the importance of multidisciplinary care and establish a general framework for its use. The authors will then highlight the potential role of a multidisciplinary team in each aspect of DCM care including assessment, diagnosis, decision-making, surgical intervention, non-operative therapy, monitoring, and postoperative care.

EXPERT OPINION

In order to provide comprehensive personalized care to DCM patients, it is necessary to have a multidisciplinary team composed by a combination of the patient, surgeon, primary care practitioner, neurologist, anesthesiologist, radiologist, physiatrist, nurses, physiotherapist, occupational therapist, pain specialist, and social workers all functioning independently and communicating to achieve a common goal.

A qualitative study of care coordination in community physical rehabilitation

Introduction

This study explored the factors influencing effective care coordination in a community physical rehabilitation service. The two research questions answered were “What was effective care coordination?” and “What were the barriers and enablers?”

Methods

This qualitative study, influenced by an interprofessional skill framework, was conducted in a regional service in Australia. Participants were 35 allied health, nursing, and client administration team members. Individual interviews, group observations, and focus groups generated data. This article will present the descriptive thematic analysis method and results.

Results

Care coordination resulted from a suite of informal and formal tools that smoothed the client’s rehabilitation journey. Effectiveness and efficiency were sought alongside client-centred, holistic, and flexible yet consistent approaches to care coordination. All staff undertook care coordination relevant to their managerial, clinical, or administration support roles. The involvement of many people and processes required effective teamwork, notably communication, collaboration, coordination, and navigation of stakeholder differences. The barriers to and enablers of care coordination were the service’s resources including integrated workspaces, transport and communication systems, and the individuals’ resources including clinical reasoning skills in, and familiarity and buy in with care coordination and rehabilitation.

Discussion

Staff viewed care coordination as an integral and valued part of rehabilitation, with some responsibilities shared by all staff. Additional time and support were required for stakeholders to enact their assigned care coordination roles. Effective care coordination required staff to be trained and competent in interprofessional collaboration. Systems that were efficient to use and encouraged accountability were desired.

Perspectives about Interprofessional Collaboration and Patient-Centred Care

Interprofessional collaboration is understood to improve efficiencies and quality of care but is associated with challenges such as professionals' differing routines, knowledge, and identities, as well as professional hierarchies and time constraints. Given these challenges, there is limited understanding of how professionals collaborate effectively in providing patient-centred care. This study, with a convergence triangulation mixed-methods study design, explored interprofessional staffs' perceptions of interprofessional collaboration and patient-centred care when working with hospitalized older adults. Thirty-six staff responded to a survey which included the Patient-Centred Care measure and the Modified Index of Interdisciplinary Collaboration; we also interviewed 14 nursing staff. Although all scores suggested a high value was placed on interprofessional collaboration, scores were low related to activities that facilitated team processes. We identified three themes from the data: knowing the patient/family, functional needs, and communication processes. Staff identified daily rounds with interprofessional teams as supportive of interprofessional collaboration and patient-centred-care.

Comprehensive geriatric assessments in integrated care programs for older people living at home: A scoping review

In many integrated care programs, a comprehensive geriatric assessment (CGA) is conducted to identify older people's problems and care needs. Different ways for conducting a CGA are in place. However, it is still unclear which CGA instruments and procedures for conducting them are used in integrated care programs, and what distinguishes them from each other. Furthermore, it is yet unknown how and to what extent CGAs, as a component of integrated care programs, actually reflect the main principles of integrated care, being comprehensiveness, multidisciplinarity and person-centredness. Therefore, the objectives of this study were to: (a) describe and compare different CGA instruments and procedures conducted within integrated care programs for older people living at home, and (b) describe how the principles of integrated care were applied in these CGAs. A scoping review of the scientific literature on CGAs in the context of integrated care was conducted for the period 2006-2018. Data were extracted on main characteristics of the identified CGA instruments and procedures, and on how principles of integrated care were applied in these CGAs. Twenty-seven integrated care programs were included in this study, of which most were implemented in the Netherlands and the United States. Twenty-one different CGAs were identified, of which the EASYcare instrument, RAI-HC/RAI-CHA and GRACE tool were used in multiple programs. The majority of CGAs seemed to reflect comprehensiveness, multidisciplinarity and person-centredness, although the way and extent to which principles of integrated care were incorporated differed between the CGAs. This study highlights the high variability of CGA instruments and procedures used in integrated care programs. This overview of available CGAs and their characteristics may promote (inter-)national exchange of CGAs, which could enable researchers and professionals in choosing from the wide range of existing CGAs, thereby preventing them from unnecessarily reinventing the wheel.

[Autonomy and Participation As Common Goals of Nursing, Therapy and Social Medicine: Proposal for an Organizational Configuration Model on the Basis of Service Blueprinting]

BACKGROUND

Every person who is in the need of long-term care (according to German Social Code SGB XI §14) fulfills the requirements of disability according to German Social Code SGB IX, § 2. The right of participation and autonomy must be specially protected and realized for persons with long-term care needs because these persons have a limited capacity to advance their interests. The rights of people in the need of long-term care or assistance are protected not only by the national constitution but also by the UN Disability Rights Convention. Participation is an important principle of these extra-statutory regulations and has an extraordinary significance and individual meaning for quality of life. For concretizing the aim of participation and for realizing participation in daily practice, the following question arises: How must organizations be configured to achieve individual aims of participation for persons with long-term care need, complex health care needs and with potential for rehabilitation across sectoral, disciplinary and professional borders? This analysis focuses on people older than 70 years with geriatric-relevant multimorbidity and with potential for rehabilitation.

AIM

The aim of this study was to create a configuration model for the organization of interdisciplinary cooperation in rehabilitation out of a case study and on the basis of the service blueprinting method [1]. In a next step this configuration model can be evaluated concerning its effectiveness for achieving individual participation goals and quality of life of persons with long-term care need and with potential for rehabilitation.

METHOD

For creating the configuration model, the service blueprinting method [1] on the basis of Dervin's sense making theory [11] was applied to a case vignette of geriatric rehabilitation against a background of organization theories and nursing science concepts. With the case study the configuration model can be applied exemplarily at the setting of restorative care, therapy and rehabilitation. With the service blueprinting method, the rehabilitation process is aligned onto the geriatric patient's individual health care needs, perceptions of participation and quality of life.

RESULTS

As a result of the sequencing and service blueprinting process we offer a dynamic model for the coordination of responsibility of interdisciplinary rehabilitation teams with a user-centered alignment. Its effectiveness (and side-effects) for interdisciplinary cooperation and for patient's individual goals of participation and quality of life must be evaluated in further studies. A mixed-method design should be used to evaluate objective outcome parameters such as dependency on nursing care, hospital admission rates and subjective outcome parameters such as patient's perception of participation, autonomy and quality of life.

IMPLICATIONS FOR HEALTHCARE PRACTICE

The configuration model can be used for evaluating already implemented geriatric rehabilitation processes and organizations. The configuration model can be used in health care research or organizational research. After more evidence for desirable effects, it can be implemented into the health care system. Side effects should be monitored.This paper was written in cooperation with the working group "Nursing", department "Practical Social Medicine and Rehabilitation" of the German Society of Social Medicine and Prevention (Deutsche Gesellschaft für Sozialmedizin und Prävention DGSMP e.V.).

The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia

This paper examines the healthcare needs of community-dwelling older people living in Porto, Portugal, diagnosed with moderate or severe dementia, linked to functional dependency, cognitive decline, limitations in the activities of daily life, and frailty levels. A sample of 83 participants was recruited. Data were collected between 2013 and 2017. A sociodemographic questionnaire, the Clinical Dementia Rating (CDR), the Barthel Index (BI), the Lawton and Brody Instrumental Activities of Daily Living (IADL) Scale, and the Edmonton Frail Scale (EFS) were used. A set of 26 healthcare needs was defined to support the assessment. The Pearson chi-square or Fisher's exact test (as appropriate) was used to examine the association of the needs (unmet and met) with the levels of dementia and frailty. Participants were diagnosed previously with moderate or severe dementia and benefited from a structured home-care program. There was a high number rated as "severe dementia," "fully dependent," "severely or fully dependent in the activities of daily living (ADL)," and "severe frailty." There were statistically significant differences among needs identified in people with moderate or severe dementia and moderate or severe frailty. The most prevalent healthcare needs in the sample were food preparation, medication/taking pills, looking after their home, toilet use, sensory problems, communication/interaction, bladder, bowels, eating and drinking, memory, sleeping, and falls prevention. In particular, the study identifies a set of needs that are present simultaneously in both frailty and dementia stages. This study underlines that despite well-structured home-care programs for people with dementia, unmet health needs remain. Timely healthcare needs assessment may help professionals to avoid fragmented care and to tailor quality-integrated interventions, including the emotional and psychological balance of the caregiver.

'Best fit' caring skills of an interprofessional team in short-term goal-directed reablement: older adults' perceptions

This paper reports a study conducted to illuminate older adults' perceptions of multiproffesional team's caring skills as success factors for health support in short-term goal-directed reablement. The fact that older adults are given perquisites to live in their own homes puts great demands on the professional care given them at home. An option offered could be short-term goal-directed reablement delivered by an interprofessional team. This means after periods in hospitals to strengthen their multidimensional health, older adults' reablement processes are supported to return to their daily life as soon as possible. Crucial in making these intentions a reality seems to be identifying the professional's approach that works as success factors for health support in the reablement process. A descriptive qualitative design with a phenomenographic approach based on interviews with 23 older persons who had received short-term goal-directed reablement at home after a period at hospital was used. The study was approved by an ethical board. The analysis revealed four major referential aspects of multiproffesional team's caring skills as success factors for health-support in short-term goal-directed reablement: a motivating caregiver, a positive atmosphere-creating caregiver, a human fellowship-oriented caregiver and a caregiver that goes beyond the expected. In this study, all caring skills in the continuum are perceived as positively loaded necessities in different situations during the reablement process. Caring skills as success factors are initially shown at a practical level, such as how the professional caregivers encourage and motivate the older persons in different training situations. At a deeper level, the caregivers open their hearts and have the capacity to go beyond the expected in the professional caregiver-patient relationship. The multiproffesional team's best fit caring skills during the home reablement process need to be addressed as evidence base in the area of elderly home care.

The educational needs of nursing staff when working with hospitalised older people

OBJECTIVES

To examine nursing staffs' geriatric knowledge, perceptions about interprofessional collaboration and patient-centred care, and perceived learning needs related to working with hospitalised older people.

METHOD

A triangulation mixed methods design was used. A survey was administered to nursing staff that contained the Knowledge About Older Patients Quiz, the patient-centered Care measure and the Modified Index of Interdisciplinary Collaboration measure. Interviews were conducted to understand nursing staffs' learning needs. Survey data were analysed using descriptive statistics. Interview data were analysed using content analysis. Survey and interview data were then compared and contrasted.

RESULTS

Twenty-two nursing staff (response rate 26%) completed surveys and 14 participated in interviews. The mean knowledge about older patients score was 22.95, indicating moderately high gerontological knowledge. The mean scores on the patient-centered Care measure and Modified Index of Interdisciplinary Collaboration were moderately high at 3.75 and 3.86, respectively. Themes developed from analysis of the interview data were as follows: complex vulnerable population, clinical care concerns and working as a team. In spite of scores on knowledge surveys, nursing staff identified learning needs related to managing the responsive behaviours of older patients with cognitive impairment, chemical and physical restraints, mobility and continence.

CONCLUSIONS

There was an incongruence between survey and interview data as nursing staff reported gaps in their knowledge despite moderately high scores on the Knowledge about Older People Quiz. Further research is needed to understand additional factors that influence nurses' educational needs.

Effectiveness of early assessment and intervention by interdisciplinary teams including health and social care professionals in the emergency department: protocol for a systematic review

INTRODUCTION

Finding cost-effective strategies to improve patient care in the emergency department (ED) is an increasing imperative given growing numbers of ED attendees. Encouraging evidence indicates that interdisciplinary teams including health and social care professionals (HSCPs) enhance patient care across a variety of healthcare settings. However, to date no systematic reviews of the effectiveness of early assessment and/or interventions carried by such teams in the ED exist. This systematic review aims to explore the impact of early assessment and/or intervention carried out by interdisciplinary teams including HSCPs in the ED on the quality, safety and cost-effectiveness of care, and to define the content of the assessment and/or intervention offered by HSCPs.

METHODS AND ANALYSIS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standardised guidelines, we will conduct a systematic review of randomised controlled trials (RCTs), non-RCTs, controlled before-after studies, interrupted time series and repeated measures studies that report the impact of early assessment and/or intervention provided to adults aged 18+ by interdisciplinary teams including HSCPs in the ED. Searches will be carried in Cumulative Index of Nursing and Allied Health Literature, Embase, Cochrane Library and MEDLINE from inception to March 2018. We will also hand-search the reference lists of relevant studies. Following a two-step screening process, two independent reviewers will extract data on the type of population, intervention, comparison, outcomes and study design. The quality of the studies will be appraised using the Cochrane Risk of Bias Tool. The findings will be synthesised in a narrative summary, and a meta-analysis will be conducted where appropriate.

ETHICS AND DISSEMINATION

Ethical approval will not be sought since it is not required for systematic reviews. The results of this review will be disseminated through publication in a peer-review journal and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42018091794.

Health care provider experiences in primary care memory clinics: a phenomenological study

BACKGROUND

There is a growing need for community-based services for persons with Alzheimer's disease and related dementias (ADRD). Memory clinic (MC) teams in primary care settings have been established to provide care to people with ADRD. To consider wider adoption of these MC teams, insight is needed into the experiences of practitioners working in these models. The purpose of the current study is to explore the experiences of health care providers (HCPs) who work in primary care Memory Clinic (MC) teams to provide care to persons with Alzheimer's disease and related dementias (ADRD).

METHODS

This study utilized a phenomenological methodology to explore experiences of 12 HCPs in two primary care MCs. Semi-structured interviews were completed with each HCP. Interviews were recorded and transcribed verbatim. Colaizzi's steps for analyzing phenomenological data was utilized by the authors.

RESULTS

Three themes emerged from the analysis to describe HCP experiences: supporting patients and family members during ADRD diagnosis and treatment, working in a team setting, and personal and professional rewards of caring for people with ADRD and their family members.

CONCLUSIONS

Findings provide insight into current practices in primary care MCs and on the motivation of HCPs working with persons with ADRD.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

The Care of Older Adults Experiencing Cognitive Challenges: How Interprofessional Teams Collaborate

We conducted a scoping study to examine how interprofessional health care teams improve the outcomes of older adults experiencing cognitive challenges. We searched Ovid, Medline 1946, and MEDLINE In-Process and other non-indexed citations, using the concepts multi or interdisciplinary care teams, confusion or cognitive impairment, and elderly adults. Of 4,554 articles the review yielded, 34 relevant to our inquiry, using Arksey and O'Malley's methodological framework. Twenty-nine per cent of authors reported on the processes interprofessional teams use to achieve positive outcomes for older adults. They highlighted the importance of communication, staff strategies, and education interventions in achieving outcomes with older adults and in supporting interprofessional collaboration. The review revealed knowledge gaps about the processes teams use to collaborate in caring for older adults experiencing cognitive challenges, and how to best incorporate older adults and their families' perspectives in team decisions. More research to understand processes interprofessional teams use is needed.

Deprescribing anticholinergic and sedative medicines: protocol for a Feasibility Trial (DEFEAT-polypharmacy) in residential aged care facilities

INTRODUCTION

Targeted deprescribing of anticholinergic and sedative medicines can lead to positive health outcomes in older people; as they have been associated with cognitive and physical functioning decline. This study will examine whether the proposed intervention is feasible at reducing the prescription of anticholinergic and sedative medicines in older people.

METHODS AND ANALYSIS

The Standard Protocol Items: Recommendations for Interventional trials (SPIRIT checklist) was used to develop and report the protocol. Single group (precomparison and postcomparison) feasibility study design.

STUDY POPULATION

3 residential care homes have been recruited.

INTERVENTION

This will involve a New Zealand registered pharmacist using peer-reviewed deprescribing guidelines, to recommend to general practitioners (GPs), sedative and anticholinergic medicines that can be deprescribed. The cumulative use of anticholinergic and sedative medicines for each participant will be quantified, using the Drug Burden Index (DBI).

OUTCOMES

The primary outcome will be the change in the participants' DBI total and DBI PRN 3 and 6 months after implementing the deprescribing intervention. Secondary outcomes will include the number of recommendations taken up by the GP, participants' cognitive functioning, depression, quality of life, activities of daily living and number of falls.

DATA COLLECTION POINTS

Participants' demographic and clinical data will be collected at the time of enrolment, along with the DBI. Outcome measures will be collected at the time of enrolment, 3 and 6 months' postenrolment.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Human Disability and Ethics Committee. Ethical approval number (16/NTA/61).

TRIAL REGISTRATION NUMBER

Pre-results; ACTRN12616000721404.

Health team for the elderly: a feasibility study for preventive home visits

The aim was to describe the development, utilization and feasibility of a model of preventive home visits, in an urban and a rural municipality in Norway.

Background

Older people >65 years will rise significantly in coming years. Increased age is associated with risk of disability, illness and need for public health services. Preventive home visits is assumed to help older people to maintain their functional level longer, delaying disease and thus delaying the need for health care.

Method

Descriptive explorative design describing the development, utilization and feasibility of preventive home visits in two different settings. All 77-year-old persons living at home in an urban municipality and all 75 years and older in a rural municipality were invited to participate. A questionnaire including a substantial number of tests concerning; fall, nutrition, polypharmacy and cognitive impairment was used by Health Team Nurses as base for a risk assessment. Pilot studies were conducted to validate the questionnaire including an inter-rater reliability study of the risk assessment tool. A multiprofessional team, Health Team for the Elderly met each week to evaluate risk assessments and make recommendations to be sent to each respective general practitioner. Data were analysed using descriptive and inferential statistics. In total, 167 persons (109 from the urban municipality and 58 from the rural municipality) participated, corresponding to 60% of the approached individuals. The mean time for the visits was 108 minutes (SD 20). Missing data were identified for; Do you feel safe in your municipality (17.5%) and Are you looking forward to ageing (11.4%). In total, 36 persons (21.7%) were identified with increased risk for developing illness. We suggest that a structured model of preventive home visits and collaboration between highly specialized health care professionals are important factors for reliable health promoting risk assessments of elderly home dwellers.

Understanding interprofessional collaboration in the context of chronic disease management for older adults living in communities: a concept analysis

AIM

To report a concept analysis of interprofessional collaboration in the context of chronic disease management, for older adults living in communities.

BACKGROUND

Increasing prevalence of chronic disease among older adults is creating significant burden for patients, families and healthcare systems. Managing chronic disease for older adults living in the community requires interprofessional collaboration across different health and other care providers, organizations and sectors. However, there is a lack of consensus about the definition and use of interprofessional collaboration for community-based chronic disease management.

DESIGN

Concept analysis.

DATA SOURCES

Electronic databases CINAHL, Medline, HealthStar, EMBASE, PsychINFO, Ageline and Cochrane Database were searched from 2000 - 2013.

METHODS

Rodgers' evolutionary method for concept analysis.

RESULTS

The most common surrogate term was interdisciplinary collaboration. Related terms were interprofessional team, multidisciplinary team and teamwork. Attributes included: an evolving interpersonal process; shared goals, decision-making and care planning; interdependence; effective and frequent communication; evaluation of team processes; involving older adults and family members in the team; and diverse and flexible team membership. Antecedents comprised: role awareness; interprofessional education; trust between team members; belief that interprofessional collaboration improves care; and organizational support. Consequences included impacts on team composition and function, care planning processes and providers' knowledge, confidence and job satisfaction.

CONCLUSION

Interprofessional collaboration is a complex evolving concept. Key components of interprofessional collaboration in chronic disease management for community-living older adults are identified. Implications for nursing practice, education and research are proposed.

Awareness and Knowledge of Occupational Therapy among Nigerian Medical and Health Sciences Undergraduates

Objective/Background

Consequent to the introduction of occupational therapy (OT) training programmes in Nigeria in the past decade, this study sought to assess the awareness and knowledge of Nigerian medical and other health career undergraduates about OT.

Methods

Three hundred and eighty-one undergraduates and students of other health disciplines from the College of Health Sciences, Obafemi Awolowo University (OAU), Ile-Ife, Nigeria responded to a validated three section questionnaire assessing their awareness and knowledge about OT. The collected data were analysed using descriptive statistics of mean and percentages and inferential statistics of chi-square test of association.

Results

The mean age of the respondents was 20.96 ±2.88 years. Over 80% of the respondents were aware of the OT profession, with higher rates among male respondents (83.7%), students in the 2nd year of study (94.7%), and those in the medical rehabilitation programme (99.1%). Amongst the respondents, < 40% had good knowledge of OT while a majority had knowledge ranging from poor to moderate (62.7%). Respondents’ course of study and level of study were significantly associated with awareness and knowledge about OT.

Conclusion

Nigerian medical and health sciences undergraduates had high awareness, but poor to moderate knowledge about the OT profession, roles, and work settings. Level of awareness and knowledge about OT were significantly influenced by the rehabilitation-related course of study and lower level of study. Replication of similar studies in countries with different cultural backgrounds is suggested.

Longitudinal effects on self-determination in the RCT “Continuum of care for frail elderly people”

Purpose

– An intervention “Continuum of care for frail elderly people” was designed to create an integrated care from the hospital emergency department (ED) to home. The purpose of this paper is to evaluate longitudinal effects in terms of self-determination in daily life for community-living frail older persons.

Design/methodology/approach

– A non-blinded, controlled trial with participants randomised to the intervention group or a control group with follow-ups at three, six and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the ED, the hospital wards and a multi-professional team in the community with a case manager as the hub. The intervention’s person-centred approach involved the older persons in all decisions. Inclusion criteria: 80 years and older or 65-79 years with at least one chronic disease and dependent in at least one daily activity. Analyses were made on the basis of the intention-to-treat principle and outcome measure experienced self-determination in daily life measured by Impact on Participation and Autonomy for Older persons (IPA-O). The analysis was made using Svenssons’ statistical method.

Findings

– There were significant differences in favour of the intervention at three months in self-determination concerning activities at home and at three and six months concerning social relationships.

Originality/value

– Self-determination seems to deteriorate over time in both groups, and the intervention “Continuum of care for frail elderly people” seemed to slow the rate of decline in two dimensions; activities in and around the house at three-month follow-up, and at three and six months concerning social relationship. Thus, the intervention has the means to support them in exercising self-determination and aging in place, a valuable benefit both for the individual and for society.

Home Help Service Staffs’ Descriptions of Their Role in Promoting Everyday Activities Among Older People in Sweden Who Are Dependent on Formal Care

The study aimed to explore how home help service staff described their role in improving the abilities of older people, in particular, older women with chronic pain who are dependent on formal care, to perform everyday activities. Three focus group interviews were conducted, and a qualitative inductive thematic content analysis was used. The analysis resulted in one theme: struggling to improve the care recipients’ opportunities for independence but being inhibited by complex environmental factors. By encouraging the care recipients to perform everyday activities, the staff perceived themselves to both maintain and improve their care recipients’ independence and quality of life. An important goal for society and health care professionals is to improve older people’s abilities to “age in place” and to enable them to age independently while maintaining their quality of life. A key resource is home help service staff, and this resource should be utilized in the best possible way.

Analyzing the Interprofessional Working of a Home-Based Primary Care Team

De plus en plus, les équipes interprofessionnelles sont chargées de fournir la prestation de services de soins de santé intégrés. Cependant, les équipes efficaces ne sont pas le fruit du hasard, mais nécessitent une planification minutieuse et une attention soutenue au processus de développer l’équipe. Basée sur une étude de cas portant sur des entretiens, l’observation participante, et une enquête, nous avons identifié les attributs clés pour le travail interprofessionnel efficace (TIE) dans le cadre de soins primaires à domicile (SPD). Reconnaissant l’importance d’un modèle théorique qui reflète la nature multi-dimensionnelle de la recherche sur l’efficacité de l’équipe, nous avons utilisé le modèle de l’efficacité de l’équipe integrée pour analyser nos résultats. Ces résultats indiquaient qu’une vision commune, des objectifs communs, le respect et la confiance entre les membres de l’équipe—ainsi que la communication continue, la direction efficace et des mécanismes de résolution des conflits—sont essentiels pour le développement d’une equipe de TIE qui fonctionne très bien. L’ambiguité et l’incertitude qui entoure le cadre de la prestation de services (à domicile), ainsi que la négociation des relations extérieures dans le domaine SPD, nécessitent la recherche plus approfondie.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

Care planning and decision-making in teams in Swedish elderly care: a study of interprofessional collaboration and professional boundaries

In front-line practice, joint working between different professionals in health/social care and rehabilitation is regarded as a means to reach a comprehensive assessment of the needs of the older care recipients, leading to decisions on appropriate care and services. The aim of this study was to examine professional collaboration and professional boundaries in interprofessional care planning teams. Two different care planning teams were studied, one performing care planning in the homes of older individuals and the other performing care planning for older people in hospital wards. The empirical data consisted of audio-recorded care planning meetings and interviews with the professionals in the teams. The integration between the professionals involved was most noticeable in the investigation and assessment phase, while it was lower in the planning phase and almost non-existent in decision-making. The home care planning team tended to work in a more integrated manner than the discharge planning team. The importance of clarifying the roles of all professions concerned with needs assessment and care planning for older people became evident in this study.

Healthcare personnel's experiences of situations in municipal elderly care that generate troubled conscience

Healthcare personnel may perceive troubled conscience when feeling inadequate and powerless. It is important to further explore healthcare personnel's descriptions of situations in daily work, which generate troubled conscience to increase the awareness of such situations. This study aimed to describe health care personnel's experiences of situations in municipal elderly care that generate troubled conscience. In this qualitative study, interviews were conducted with Registered and Enrolled nurses and nursing assistants (n = 20) working in municipal elderly care. The interviews were tape-recorded, transcribed verbatim and analysed with content analysis. Situations that generated troubled conscience was (i) Being caught between different demands, comprising being forced to prioritize between different residents' needs, being torn between residents'-/relatives'-/and co-workers' needs and expectations' and between work and private life, (ii) Being torn away from residents to other 'must do's', comprising stealing time from residents' to do housekeeping chore' and to 'obey' rules and recommendations, (iii) Feeling unable to relieve suffering, comprising falling short when striving to help, lacking knowledge, advice and support and time to ease residents' suffering and finally, (iv) Being part of providing care that is or feels wrong, comprising providing poor care and/or witnessing co-workers providing poor care, and being forced to give care that feels wrong. These findings identify important factors that generate stress of conscience (stress caused by troubled conscience), including difficulties with balancing priorities and following rules and recommendations that seem contrary to best care, and the need for interdisciplinary teamwork. Findings point to that sharing what conscience tells in the work team opens up possibilities for healthcare personnel to constructively deal with troubled conscience. Intervention studies are needed to explore whether such measures contribute to relieve the burden of troubled conscience and increase possibilities to provide high quality care.

Swedish Health Care Professionals’ View of Frailty in Older Persons

There is a paucity of research literature concerning frailty in older persons from the health care professionals’ perspective. Consequently, the purpose of this study was to elucidate health care professionals’ view of frailty in older persons. An explorative, qualitative design was selected and four focus groups comprising 21 health care professionals were conducted, audiotaped, transcribed verbatim, and analyzed. Frailty was found to consist of seven dimensions: “being bodily weak and ill,” “being negatively influenced by personal qualities,” “lacking balance in everyday activities,” “being dependent in everyday life,” “not being considered important,” “being hindered by the physical milieu and defective community service,” and “having an inadequate social network.” The results showed that health care professionals’ view of frailty in older persons differed from the current state of knowledge on frailty. This implies that the seven dimensions found to constitute frailty could contribute to a more comprehensive understanding of the concept.