Local interaction Strategies and Capacity for Better Care in Nursing Homes: A Multiple Case Study

To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff. Methods: We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases. Results: Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these 'local interaction strategies'. We categorized these two sets of local interaction strategies as the 'common pattern' and the 'positive pattern' and summarize the results in two models of local interaction. Conclusions: The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.National Institutes of Health 2 R01NR003178-04A2Claude A. Pepper Older American's Independence Center AG-11268Paul A. Beeson Award NIA AG024787VA Health Services Research and Development EDU 08-417John A. Hartford Building Academic Geriatric Nursing Claire M. Fagin FellowshipBusiness Administratio

Cost-effectiveness of hip protectors in frail institutionalized elderly

A randomized controlled trial was performed to examine the cost-effectiveness of external hip protectors in the prevention of hip fractures. Since the hip protectors were not effective in preventing hip fractures in our study, the main objective became to examine whether the use of hip protectors results in lower average costs per participant in the hip protector group as compared with the control group. In addition, the average costs of a hip fracture and subsequent rehabilitation in frail, institutionalized elderly were calculated. Residents from apartment houses for the elderly, homes for the elderly and nursing homes with a high risk for hip fractures were randomized to the hip protector group (n = 276) or control group (n = 285). Costs were calculated for the hip fracture and subsequent rehabilitation until 1 year after the fracture. Six months after each hip fracture, a nurse was interviewed and after 12 months, a questionnaire was sent to the general practitioner or nursing home physician to determine the utilization of health care resources. Differences in costs between the groups were analyzed using non-parametric bootstrapping. Eighteen hip fractures occurred in the intervention group and 20 hip fractures (in 19 persons) in the control group (log rank P-value = 0.86). The average costs per participant, including the costs of the intervention, were €913 in the intervention group and 502 in the control group (cost difference of €-411; 95% confidence interval: -723; 57). The average costs of a hip fracture and subsequent rehabilitation were €8100 (95% CI: 6716-10,010). The use of hip protectors was not associated with lower costs. In addition, the average costs of a hip fracture and subsequent rehabilitation in the first year after the fracture were estimated at €8100 in institutionalized elderly. © International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Interprofessional communication with hospitalist and consultant physicians in general internal medicine : a qualitative study

This study helps to improve our understanding of the collaborative environment in GIM, comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of providers working with them. The implications of this research are globally important for understanding how to create opportunities for physicians and their colleagues to meaningfully and consistently participate in interprofessional communication which has been shown to improve patient, provider, and organizational outcomes

Connect for better fall prevention in nursing homes: Results from a randomized controlled pilot study

Session presented on: Thursday, July 25, 2013: Purpose: Studies show that nursing home (NH) fall rates drop when risk-factor reduction is performed by researchers, but programs implemented by existing NH staff have been less successful. We hypothesized that an intervention improving staff connections, communication, and problem solving (CONNECT) would improve uptake of a traditional falls education program (FALLS). Methods: Community (n=4) and VA NHs (n=4) were randomized to receive FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3-months. CONNECT was designed to help staff identify communication gaps, share information across disciplines to make sense of residents\u27 problems, and practice interaction strategies. FALLS used quality improvement approaches such as team in-services, teleconferences, academic detailing, and audit/feedback. Interdisciplinary staff participated in sessions (n=599; 49 %), and completed 3 waves of communication measures (n=470). A random sample of resident charts (n=481) was abstracted to measure fall-risk modification activities. The study outcome was change in facility fall-rates measured in the 6 months before and after the interventions. Results: Improvements in staff perceptions of communication quality, nurse aide participation in decision making, safety climate, care giving quality, and use of local interaction strategies were observed in intervention community NHs (treatment by time effect p=.01), but not in VA NHs. Fall-risk modification activities did not change significantly. In control facilities, fall rates were similar in pre- and post-intervention (2.61 and 2.64 falls/bed/yr), whereas they decreased by 12% in intervention facilities (2.34 to 2.06 falls/bed/yr); the effect of treatment on rate of change was 0.81 (0.55, 1.20). Conclusion: CONNECT improves measures of staff communication in community, but not VA nursing homes where we observed a ceiling effect in survey measures. Fall-risk modification activities measured by chart abstraction are insensitive to change; however, a trend toward improved fall rates occurred for the intervention group but requires confirmation in a larger study

High morbid-mortability and reduced level of osteoporosis diagnosis among elderly people who had hip fractures in São Paulo City

OBJECTIVE: To know the morbid-mortality following an osteoporotic hip fracture in elderly patients living in São Paulo. PATIENTS AND METHODS: This study evaluated prospectively all patient over 60 years admitted in 2 school-hospitals in the city of São Paulo in a following 6-month period due to a osteoporotic proximal femur fracture. All of them filled up the Health Assessment Questionnaire (HAQ) and had their chart reviewed. After 6 months they were re-interviewed. Linear regression analysis was utilized to determine the factors related to functional ability. RESULTS: 56 patients were included (mean age 80.7 ± 7.9 years old, 80.4% females). After the 6-month follow up the mortality rate was 23.2%. Only 30% of the patients returned to their previous activities, and 11.6% became totally dependent. Factors related to worse functional ability after fracture were HAQ before fracture, institutionalization after fracture and age (r² 0.482). The diagnosis of osteoporosis was informed only by 13.9% of them, and just 11.6% received any treatment for that. CONCLUSION: Our results showed the great impact of these fractures on mortality and in the functional ability of these patients. Nevertheless, many of our physicians do not inform the patients about the diagnosis of osteoporosis and, consequently, the treatment of this condition is jeopardized.As fraturas osteoporóticas de fêmur proximal trazem graves conseqüências quanto à morbimortalidade e à qualidade de vida, mas desconhece-se este impacto no Brasil. OBJETIVO: Conhecer a morbimortalidade decorrente deste tipo de fraturas em idosos na cidade de São Paulo. MÉTODOS: Foram incluídos todos os pacientes com mais de 60 anos internados por fraturas de fêmur proximal durante seis meses, em dois hospitais de São Paulo. Os pacientes preencheram o questionário de capacidade funcional (HAQ), tiveram seu prontuário examinado e foram reavaliados após seis meses. Utilizou-se a análise de regressão linear para determinar os fatores relacionados à capacidade funcional. RESULTADOS: Cinqüenta e seis pacientes foram incluídos no estudo (80,7 ± 7,9 anos; 80,4% mulheres). A mortalidade em seis meses foi de 23,2%. Apenas 30% retornaram plenamente às suas atividades prévias e 11,6% tornaram-se completamente dependentes. Os fatores que mais bem conseguiram prever pior capacidade funcional após a fratura foram HAQ pré-fratura, institucionalização pós-fratura e idade (r² 0,482). Somente 13,9% receberam o diagnóstico de osteoporose e 11,6% iniciaram algum tratamento. CONCLUSÕES: Os resultados do presente estudo demonstram o impacto deste tipo de fraturas sobre a mortalidade e a capacidade funcional. Entretanto, a falha médica no diagnóstico e na orientação de tratamento da osteoporose permanece elevada.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaSanta Casa de Misericórdia de São Paulo Departamento de OrtopediaUNIFESP-EPM EPMUNIFESP, EPM, EPMSciEL

Neglecting the Importance of the Decision Making and Care Regimes of Personal Support Workers: A Critique of Standardization of Care Planning Through the RAI/MDS

Purpose: The Resident Assessment Instrument–Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process. Design and Methods: This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada. Results: PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care. Implications: Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents’ preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs’ nascent occupational identity and their role as interprofessional brokers in long-term care

CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes

<p>Abstract</p> <p>Background</p> <p>Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.</p> <p>Methods/design</p> <p>Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.</p> <p>Discussion</p> <p>By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00636675">NCT00636675</a></p

What are the beliefs, attitudes and practices of front-line staff in long-term care (LTC) facilities related to osteoporosis awareness, management and fracture prevention?

<p>Abstract</p> <p>Background</p> <p>Compared to the general elderly population, those institutionalized in LTC facilities have the highest prevalence of osteoporosis and subsequently have higher incidences of vertebral and hip fractures. The goal of this study is to determine how well nurses at LTC facilities are educated to properly administer bisphosphonates. A secondary question assessed was the nurse's and PSW's attitudes and beliefs regarding the role and benefits of vitamin D for LTC patients.</p> <p>Methods</p> <p>Eight LTC facilities in Hamilton were surveyed, and all nurses were offered a survey. A total 57 registered nurses were surveyed. A 21 item questionnaire was developed to assess existing management practices and specific osteoporosis knowledge areas.</p> <p>Results</p> <p>The questionnaire assessed the nurse's and personal support worker's (PSWs) education on how to properly administer bisphosphonates by having them select all applicable responses from a list of options. These options included administering the drug before, after or with meals, given with or separate from other medications, given with juice, given with or without water, given with the patient sitting up, or finally given with the patient supine. Only 52% of the nurses and 8.7% of PSWs administered the drug properly, where they selected the options: (given before meals, given with water, given separate from all other medications, and given in a sitting up position). If at least one incorrect option was selected, then it was scored as an inappropriate administration. Bisphosphonates were given before meals by 85% of nurses, given with water by 90%, given separately from other medication by 71%, and was administered in an upright position by 79%. Only 52% of the nurses and 8.7% of PSWs surveyed were administering the drug properly. Regarding the secondary question, of the 57 nurses surveyed, 68% strongly felt their patients should be prescribed vitamin D supplements. Of the 124 PSWs who completed the survey, 44.4% strongly felt their patients should be prescribed vitamin D supplementation.</p> <p>Conclusion</p> <p>Bisphosphonates are quite effective in increasing the bone mineral density of LTC patients, and may reduce fracture rates, but it is only effective if properly administered. In our study, proper administration of bisphosphonate therapy was less than optimal. In summary, although the education of health providers has improved since the mid-1990's, this area still requires further attention and the subject of future quality assurance research.</p

Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results

OBJECTIVE: To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks. METHODS: An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity. RESULTS: From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P < .001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P < .001). CONCLUSIONS: Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened

Supportive hand feeding in dementia: Establishing evidence for three hand feeding techniques

Session presented on Sunday, July 24, 2016: Purpose: Providing nutritional support has been a cornerstone of nursing practice since its inception. Nightengale, 1859. Many things have changed since 1859: life expectancy has increased, and rates of dementia have increased exponentially. Although times have changed, nursing\u27s responsibility for basic nursing care has never been more important for persons with dementia (residents) in the nursing home (NH) setting. The establishment of an evidence-base for the complex basic care needs of this vulnerable population is critical for eradicating malnutrition. Feeding Assistants, often certified nursing assistants (CNAs), are faced daily with challenging, \u27aversive\u27 feeding behaviors (e.g., clamping mouth shut, turning head away). Alzhiemer\u27s Association, 2015 In fact, nearly 86% of residents in the nursing home (NH) setting will experience problems with food intake. Hanson, 2013. Due to an inadequate evidence base for practice and limited training in dementia care, many CNAs rely on personal beliefs and experiences, often misinterpreting these \u27aversive\u27 feeding behaviors as \u27resistance\u27 and they cease attempts to feed. Batchelor-Murphy, 2015 These factors perpetuate malnutrition; a pervasive, yet reversible problem in the long-term care setting on a global scale. Feeding assistants may encounter a wide range of difficulties when providing supportive hand feeding to a resident. These may be issues related to dysphagia, functional/ physical limitations, or feeding behaviors that are generally reflective of the neuropsychiatric symptoms of dementia. Yet, approaches to the actual act of using a particular technique in assisting a resident to eat are often overlooked and the complexity of a meal interaction minimized. Evidence to support use of any hand feeding technique is sparse - only one scientific study has ever designated a hand feeding technique (Over Hand) for use when providing feeding assistance. Simmons, 2004. The purpose of this study was to compare the efficacy of three supportive hand feeding techniques for persons with dementia (residents) in the nursing home (NH) setting: Direct Hand (DH), Over Hand (OH), Under Hand (UH). Batchelor-Murphy, 2015, Batchelor-Aselage, 2014 The UH technique is an innovative method of providing supportive hand feeding in dementia that taps into remaining sensory ability, and provides motor cues to residents for eating. Thus, UH was hypothesized to increase meal intake and decrease \u27aversive\u27 feeding behaviors because the resident is actively engaged in a movement associated with meal intake since early childhood. Primary outcomes were time spent providing feeding assistance, percent of meal intake, and frequency of feeding behaviors. Methods: A prospective, Latin-square experimental design was used to randomly assign a designated hand feeding technique to be used when providing feeding assistance to 30 residents. To limit sequence and carry over effect, each resident was randomly assigned to one of the three Latin-square sequences: (1) DH, OH, UH; (2) OH, UH, DH; or (3) UH, DH, OH. Working in pairs, 50 trained Research Assistants (RAs) provided 1:1 meal assistance and video-recorded the meal interactions. Assistance was provided for 3 daily meals over a two day period per hand feeding technique, according to the sequencing of the Latin-square randomization. This method yielded 6 meals per hand technique per resident, 18 meals per resident, and a total of 540 video-recorded meal interactions. One RA recorded outcome measures in \u27real time\u27, and the RA partner coded the video-recorded interaction. An independent, second RA rater coded the video to establish inter-rater reliability (IRR). All RAs completed field notes to detail reasons for needing to change from the designated hand feeding technique when the designated technique was not promoting meal intake. Formative debriefs were held with small groups of RAs quarterly to assess fidelity issues related to study design, training process and materials, intervention delivery, and receipt of treatment. Bellg, 2004 Primary study outcomes included (1) the amount of time spent providing feeding assistance, (2) percent of meal intake (based on tray weights and overall visual estimation), and (3) feeding behaviors as measured using the Edinburgh Feeding Evaluation in Dementia (EdFED) Scale. Hierarchical random coefficients regression models for repeated measures were used to evaluate hand feeding technique effects across meals on the feeding time and meal intake outcomes, with statistical significance set at 0.05. Results: Inter-rater reliability was high for feeding time (0.91-0.97) and meal intake (0.88-0.91). No significant differences between feeding methods for the mean amount of time spent providing feeding assistance were demonstrated: DH (42.4 min; SD = 9.2), UH (44.1 min; SD = 9.3), and OH (45.2 min; SD = 9.2). Mean meal intake (% eaten) was significantly higher (with a medium effect size) for DH (67%; SD = 15.2) and UH (65%; SD = 15.0) when compared to OH (59.9%: SD = 15.1; both p \u3c .002, Cohen d = 0.52 and 0.40, respectively). Subjective overall percentage estimations of meal intake (customary NH practice) consistently overestimated meal intake by 10% when compared to objective tray weights. IRR for the EdFED was poor with only 0.47-0.59 agreement. Raters struggled to differentiate \u27refusing to open mouth\u27 and \u27refusing to eat\u27. As designed, the EdFED is scored with 0-20 range (0 = no behaviors; 20 = high \u27aversive\u27 feeding behaviors). For this study, RAs also collected frequency scores for each behavior. While our IRR was lower than previously reported for the EdFED, the mean scores for \u27resistive\u27 feeding behaviors were more frequent with OH (8.3; SD = 1.8) when compared to DH (8.0; SD = 1.8, p = 0.0412, Cohen d = 0.17) and UH (7.7; SD = 1.8, p = 0.0014, Cohen d= 0.33). During a debrief, one of the RAs made the statement, \u27she (the resident) got a point for turning her head away, and a point for clamping her mouth shut, but she only did those things because she wanted me to give her a sip of water\u27. This revelation caused a shift in our thinking from the current paradigm of viewing these feeding behaviors as \u27resistive\u27, to viewing them as forms of communication. Field notes indicated residents responded differently to the UH technique with active participation in the meal, and one resident stated, \u27something about this feels powerful\u27. OH elicited more statements to \u27let go of my hand\u27 and pushing assistance away. Field notes also detailed rationales for needing to change techniques due to resident ability and individual preferences with the techniques. Conclusion: The findings from this study suggest a paradigm shift from viewing \u27aversive\u27 feeding behaviors as negative behaviors that should be extinguished into seeing them as forms of communication. Behavior is often the only form of control a resident has over a meal interaction to indicate preferences when language is lost. The DH and innovative UH techniques showed modest increases in meal intake and decreases in feeding behaviors. The OH technique resulted in the opposite effects, with decreased meal intake and increased feeding behaviors. Results are reported by \u27designated hand feeding technique\u27, but field notes detailed conditions under which alternative techniques were required based on the resident\u27s functional ability, energy level, position, or individual preferences for the meal. These results should be interpreted in light of having a dedicated RA who did not have competing demands on their time deliver the intervention, in contrast to a setting using NH staff. Future work is needed to determine the conditions under which each technique works best, in order to teach NH staff how and when to use each technique based on the resident\u27s individual preferences and abilities. In a time when a medical cure does not exist and feeding tubes are not recommended in advanced dementia, this research advances the repertoire of supportive hand feeding techniques to promote meal intake in residents, and offers a nursing care intervention until death