COSMOS—improving the quality of life in nursing home patients: protocol for an effectiveness-implementation cluster randomized clinical hybrid trial

Background: Nursing home patients have complex mental and physical health problems, disabilities and social needs, combined with widespread prescription of psychotropic drugs. Preservation of their quality of life is an important goal. This can only be achieved within nursing homes that offer competent clinical conditions of treatment and care. COmmunication, Systematic assessment and treatment of pain, Medication review, Occupational therapy, Safety (COSMOS) is an effectiveness-implementation hybrid trial that combines and implements organization of activities evidence-based interventions to improve staff competence and thereby the patients’ quality of life, mental health and safety. The aim of this paper is to describe the development, content and implementation process of the COSMOS trial. Methods/Design: COSMOS includes a 2-month pilot study with 128 participants distributed among nine Norwegian nursing homes, and a 4-month multicenter, cluster randomized effectiveness-implementation clinical hybrid trial with follow-up at month 9, including 571 patients from 67 nursing home units (one unit defined as one cluster). Clusters are randomized to COSMOS intervention or current best practice (control group). The intervention group will receive a 2-day education program including written guidelines, repeated theoretical and practical training (credited education of caregivers, physicians and nursing home managers), case discussions and role play. The 1-day midway evaluation, information and interviews of nursing staff and a telephone hotline all support the implementation process. Outcome measures include quality of life in late-stage dementia, neuropsychiatric symptoms, activities of daily living, pain, depression, sleep, medication, cost-utility analysis, hospital admission and mortality. Discussion: Despite complex medical and psychosocial challenges, nursing home patients are often treated by staff possessing low level skills, lacking education and in facilities with a high staff turnover. Implementation of a research-based multicomponent intervention may improve staff’s knowledge and competence and consequently the quality of life of nursing home patients in general and people with dementia in particular

Efectos de un programa de eliminación de sujeciones físicas sobre personas mayores con demencia en residencias

Objetivo: Analizar los resultados de eliminar las sujeciones físicas en mayores con demencia que viven en residencias. Este objetivo se enmarca en un proceso más amplio de modificación del modelo de atención residencial. Método: Estudio cuasi experimental en dos residencias desde mayo de 2010 hasta mayo de 2012. Se recoge información en 7 momentos temporales y se efectúa un análisis longitudinal. Tras formar al personal se retiraron progresivamente las sujeciones físicas en el centro El Puig, mientras que en el centro Conarda se mantuvieron las sujeciones. Las variables principales medidas fueron: caídas, psicofármacos administrados, así como diversos indicadores de estado mental y funcional (Norton, NPI, Minimental,Tinetti, Barthel).Resultados: En el centro en el que se eliminan todas las sujeciones físicas (El Puig), se observa una ligera mejoría en el número de caídas y sus consecuencias mejoran levemente, aunque no son estadísticamente significativas. Los ANOVA mostraron mejoras significativas en el centro que ha eliminado las sujeciones respecto a la prescripción de psicofármacos, al deterioro cognitivo y a las alteraciones de conducta.Discusión: Se constata que retirar sujeciones físicas no repercute negativamente en las caídas y sin embargo mejora ciertos aspectos del bienestar y la autonomía de los mayores (alteraciones de conducta y deterioro mental). Además, se evidencia que este programa debe ser complementado con un programa de desatar químico (retirada de psicofármacos)

De-escalation techniques for managing non-psychosis induced aggression in adults

Background: Aggression occurs frequently within health and social care settings. It can result in injury to patients and staff and can adversely affect staff performance and well-being. De-escalation is a widely used and recommended intervention for managing aggression, but the efficacy of the intervention as a whole and the specific techniques that comprise it are unclear. Objectives: To assess the effects of de-escalation techniques for managing non-psychosis-induced aggression in adults in care settings, in both staff and service users. Search methods: We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and 14 other databases in September 2017, plus three trials registers in October 2017. We also checked references, and contacted study authors and authorities in the field to identify additional published and unpublished studies. Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing de-escalation techniques with standard practice or alternative techniques for managing aggressive behaviour in adult care settings.We excluded studies in which participants had psychosis. Data collection and analysis: We used the standard methodological procedures expected by Cochrane. Main results: This review includes just one cluster-randomised study of 306 older people with dementia and an average age of 86 years, conducted across 16 nursing homes in France. The study did not measure any of our primary or secondary outcomes but did measure behavioural change using three measurement scales: the Cohen-Mansfield Agitation Inventory (CMAI; 29-item scale), the Neuropsychiatric Inventory (NPI; 12-item scale), and the Observation Scale (OS; 25-item scale). For the CMAI, the study reports a Global score (29 items rated on a seven-point scale (1 = never occurs to 7 = occurs several times an hour) and summed to give a total score ranging from 29 to 203) and mean scores (evaluable items (rated on the same 7-point scale) divided by the theoretical total number of items) for the following four domains: Physically Non-Aggressive Behaviour, such as pacing (13 items); Verbally Non-Aggressive Behaviour, such as repetition (four items); Physically Aggressive Behaviour, such as hitting (nine items); and Verbally Aggressive Behaviour, such as swearing (three items). Four of the five CMAI scales improved in the intervention group (Global: change mean difference (MD) −5.69 points, 95% confidence interval (CI) −9.59 to −1.79; Physically Non-Aggressive: change MD −0.32 points, 95% CI −0.49 to −0.15; Verbally Non-Aggressive: change MD −0.44 points, 95% CI −0.69 to −0.19; and Verbally Aggressive: change MD −0.16 points, 95% CI −0.31 to −0.01). There was no difference in change scores on the Physically Aggressive scale (MD −0.08 points, 95% CI −0.37 to 0.21). Using GRADE guidelines, we rated the quality of this evidence as very low due to high risk of bias and indirectness of the outcome measures. There were no differences in NPI or OS change scores between groups by the end of the study. We also identified one ongoing study. Authors’ conclusions: The limited evidence means that uncertainty remains around the effectiveness of de-escalation and the relative efficacy of different techniques. High-quality research on the effectiveness of this intervention is therefore urgently needed

Health Care Personnel’s Perspective on Potential Electronic Health Interventions to Prevent Hospitalizations for Older Persons Receiving Community Care: Qualitative Study

Background: The use of electronic health (eHealth) interventions is suggested to help monitor and treat degenerative and chronic diseases through the use of sensors, alarms, and reminders and can potentially prevent hospitalizations for home-dwelling older persons receiving community care. It is increasingly recognized that the health care personnel’s acceptance of a technological application remains a key challenge in adopting an intervention, thus interventions must be perceived to be useful and fit for purpose by the actual users. Objective: The aim of this study was to identify and explore the perspectives of managers and health care personnel in community care regarding the use of eHealth interventions in terms of prevention of hospitalizations for home-dwelling older persons receiving community care. Methods: A case study with a qualitative approach was carried out in community care in a Norwegian municipality, comprising individual interviews and focus group interviews. A total of 5 individual interviews and 2 focus group interviews (n=12) were undertaken to provide the health care personnel’s and managers’ perspective regarding the use of eHealth interventions, which could potentially prevent hospitalizations for home-dwelling older persons receiving community care. Data were analyzed by way of systematic text condensation, as described by Malterud. Results: The data analysis of focus group interviews and individual interviews resulted in 2 categories: potential technological applications and potential patient groups. Discussions in the focus groups generated several suggestions and wishes related to technical applications that they could make use of in their day-to-day practice. The health care personnel warranted tools and measures to enhance and document their clinical observations in contact with patients. They also identified patient groups, such as patients with chronic obstructive pulmonary disease or dehydration or urinary tract infections, for whom hospitalizations could potentially have been prevented. Conclusions: We have shown that the health care personnel in community care warrant various technological applications that have the potential to improve quality of care and resource utilization in the studied municipality. We have identified needs and important matters in practice, which are paramount for acceptance and adoption of an intervention in community care.publishedVersio

What are the key contextual factors when preparing for successful implementation of assistive living technology in primary elderly care? A case study from Norway

Objective To identify contextual factors at different organisational levels to guide the implementation of an assistive living technology intervention in Norwegian primary home care. Design A single embedded case study design was carried out in an urban municipality in Western Norway to get an overview of key contextual factors from the municipality’s perspective. Data collection and analysis The data collection was based on a triangulation of methods involving document analysis, semi-structured individual interviews and focus group interviews to get a broad insight when preparing for an intervention. Data were collected on three levels of the healthcare system: (1) national policy documents and regulations (macro), (2) five individual interviews with senior managers and municipal strategy documents (meso) and (3) two focus group interviews with nurses and nurse managers in direct patient care (micro). The Model for Understanding Success in Quality framework was used as a guide in the data analysis. Results The main contextual factors identified were external motivators and project sponsorship (macro level); leadership, workforce focus and maturity (meso level);and motivation to change and maturity (micro level). Strategies developed in policy documents affected upper management in the municipality, but healthcare personnel at the micro level were not so familiar with strategies and emphasis on assistive living technologies. Healthcare personnel in our study were motivated to use technological solutions, but lack of data infrastructure and resource availability hindered this. Conclusions Aligning interests across multiple stakeholders remain a challenge when planning for an assistive living technology intervention in primary care. In the studied municipality, integration of technological solutions into healthcare services was more a vision than a reality because of a low level of organisational readiness.publishedVersio

Health status of UK care home residents: a cohort study

Background: UK care home residents are often poorly served by existing healthcare arrangements. Published descriptions of residents’ health status have been limited by lack of detail and use of data derived from surveys drawn from social, rather than health, care records. Aim: to describe in detail the health status and healthcare resource use of UK care home residents Design and setting: a 180-day longitudinal cohort study of 227 residents across 11 UK care homes, 5 nursing and 6 residential, selected to be representative for nursing/residential status and dementia registration. Method: Barthel index (BI), Mini-mental state examination (MMSE), Neuropsychiatric index (NPI), Mini-nutritional index (MNA), EuroQoL-5D (EQ-5D), 12-item General Health Questionnaire (GHQ-12), diagnoses and medications were recorded at baseline and BI, NPI, GHQ-12 and EQ-5D at follow-up after 180 days. National Health Service (NHS) resource use data were collected from databases of local healthcare providers. Results: out of a total of 323, 227 residents were recruited. The median BI was 9 (IQR: 2.5–15.5), MMSE 13 (4–22) and number of medications 8 (5.5–10.5). The mean number of diagnoses per resident was 6.2 (SD: 4). Thirty per cent were malnourished, 66% had evidence of behavioural disturbance. Residents had contact with the NHS on average once per month. Conclusion: residents from both residential and nursing settings are dependent, cognitively impaired, have mild frequent behavioural symptoms, multimorbidity, polypharmacy and frequently use NHS resources. Effective care for such a cohort requires broad expertise from multiple disciplines delivered in a co-ordinated and managed way

A review of the literature on patient participation in transitions of the elderly

Patient participation is highlighted in healthcare policy documents as an important area to address in order to improve and secure healthcare quality. The literature on healthcare quality and safety furthermore reveals that transitional care carries a risk of adverse events. Elderly persons with co-morbidities are in need of treatment and healthcare from several care professionals and are transferred between different care levels. Patient-centered care, shared decision-making and user involvement are concepts of care that incorporate patient participation and the patients’ experiences with care. Even though these care concepts are highlighted in healthcare policy documents, limited knowledge exists about their use in transitions, and therefore points to a need for a review of the existing literature. The purpose of the paper is to give an overview of studies including patient participation as applied in transitional care of the elderly. The methodology used is a literature review searching electronic databases. Results show that participation from elderly in discharge planning and decision-making was low, although patients wanted to participate. Some tools were successfully implemented, but several did not stimulate patient participation. The paper has documented that improvements in quality of transitional care of elderly is called for, but has not been well explored in the research literature and a need for future research is revealed. Clinical practice should take into consideration implementing tools to support patient participation to improve the quality of transitional care of the elderly

A qualitative analysis of trainer/coach experiences of changing care home practice in the Well-being and Health in Dementia (WHELD) randomised control trial

This is the author accepted manuscript. The final version is available from SAGE Publications via the DOI in this recordObjectives This study explored the experiences of a range of health and social care professionals employed in the role of trainer/coaches to support care home staff to implement a psychosocial intervention for residents living with dementia. It aimed to identify the factors which are pertinent to these roles, in the context of a cascade model of training. Method A focus group was convened involving dementia trainer/coaches and supervisors who had worked on Well-being and Health for people with Dementia randomised control trial. Twelve participants explored their preparedness for and experiences of their role as 'Well-being and Health for people with Dementia therapists'. They reflected on their perceptions of the resources and support required. The data were transcribed verbatim and subjected to inductive thematic analysis. Results Three main themes emerged from the data. Within the theme of 'skills in relationship building' were two subthemes of developing trust and getting to know individual staff and each care home. In the second main theme of 'making use of tangible resources' two subthemes relating to using the Well-being and Health for people with Dementia manuals and the supervision of the therapists arose. The third theme, 'being an agent for change' contained three subthemes: effective training methods, creating opportunities for Dementia Champions to reflect and therapists' perceived rewards of their role. Conclusion The findings provide new insights into the trainer/coach role applicable to the practices of services recruiting, training and providing ongoing professional support to practitioners in-reaching into care homes.National Institute for Health Research (NIHR

Sosial kapital og stressrelaterte lidelser for ansatte i sykehjemssektoren i Norge

Bakgrunn: Den demografiske endringen i befolkningen vil medføre en utfordring for helsetjenestetilbudet generelt og innen innenfor sykehjemssektoren spesielt i tiden som kommer. I denne studien vil sammenhenger mellom sosial kapital og stressrelaterte helseplager blant ansatte innenfor sykehjemssektoren bli undersøkt. Metode: 197 helsepersonell fra fire ulike sykehjem inngikk i studien hvor stressrelaterte helseplager ble målt ved å anvende Hopkins Symtoms Check List (HSCL-10) og sosial kapital ved QPS-Nordic for psykososiale faktorer i arbeidslivet. Data ble analysert ved faktoranalyser(konstruksjon av sosial kapital), samt via korrelasjonsanalyse og multiple regresjonsanalyser.Resultat: Det foreligger en signifikant sammenheng mellom sosial kapital og stressrelaterte lidelser blant ansatte i sykehjemssektoren.  Den vertikale relasjonen (leder-ansatt) er nært knyttet til forekomsten av stressrelaterte lidelser blant sykehjemsansatte, og da slik at vertikal rettferdighet framstår som den sterkeste prediktoren.Konklusjon: Resultatene støtter ideen om i sterkere grad å vektlegge relasjonelle forhold generelt, og utvikling av gode vertikale relasjoner i organisasjonen spesielt, i organisasjonsutviklingen innenfor helsevesenet Norge

Current practice and challenges in night-time care for people with dementia living in care homes:a qualitative study

OBJECTIVE: To explore the current practices and challenges in night-time care for people with dementia living in care homes in the UK.METHODS: Focus group discussions (FGD) were held with care staff and family carers from five care homes in South London. To supplement the FGD data, an online survey was circulated to family carers (n = 16), and informal interviews were conducted with night-time care staff and nurses (n = 19). The questions for the online survey were designed to specifically explore the themes that emerged from the FGD.RESULTS: Thematic analysis revealed eight key themes in the management of sleep disturbance in people with dementia living in care homes: current night-time care practices, dissonance in perceived causes of sleep disturbances, inconsistencies in treatment options, insufficient staffing levels, working relationships between shifts, nurse burden and responsibility, communication as a critical challenge, connecting with residents and one overarching theme of balance.CONCLUSIONS: The findings of this study highlight the need for an evidence-based sleep disturbance management programme designed for use in care homes and informed by stakeholders. The key themes identified represent the major barriers to good quality care and areas which future programmes will need to address to improve the quality of night-time care in care homes. There are clearly opportunities for future examination of non-pharmacological night-time care management programmes for use in the population. Copyright © 2017 John Wiley &amp; Sons, Ltd.</p