Practice Change Interventions in Long-Term Care Facilities: What Works, and Why?

Gauging the stress of long-term care nursing assistants using ecological momentary assessment, wearable sensors and end of day reconstruction

BACKGROUND

Nursing assistants working in long-term care (LTC) often report that their job is stressful. To reduce their work stress, a better understanding of their stress profile is needed.

OBJECTIVE

We aimed to pilot test methods to identify and understand stressors that LTC nursing assistants experience.

METHODS

We asked each participant to provide wearable sensor/watch data, ecological momentary assessment (EMA) surveys and end of day review data over two eight-hour working shifts.

RESULTS

Eight nursing assistants participated. All participants worked in a common continuing care retirement community in Maryland, United States of America. Our stress assessment method revealed 83 stressful events that were classified under 10 categories. Most of the reported events were rated as having a mild to low-moderate intensity. The three most common causes of stress were work demands and pressure (28.35%), heavy workload and staffing (19.69%), and safety issues and COVID-19 concerns (17.32%). We also explored the difference between stress events and intensity among different shifts. Disrespect from residents (22.73%) was the most commonly reported stressor during day shifts. Feeling rushed was the most commonly reported stressor during the evening (22.47%) and the night (38.46%) shifts.

CONCLUSIONS

We found stress was commonly reported. Stress intensity conflicted with prior literature, and we explored possible explanations.

IMPLICATIONS FOR PRACTICE

We discuss potential implications for these findings, modification of our methods to increase feasibility, the utility of these data collection methods for future work and suggest next steps.

Partnering with social service staff to implement pragmatic clinical trials: an interim analysis of implementation strategies

BACKGROUND

With recent growth in the conduct of pragmatic clinical trials, the reliance on frontline staff to contribute to trial-related activities has grown as well. Active partnerships with staff members are often critical to pragmatic trial implementation, but rarely do research teams track and evaluate the specific "implementation strategies" used to support staff's involvement in trial procedures (e.g., participant recruitment). Accordingly, we adapted implementation science methodologies and conducted an interim analysis of the strategies deployed with social service staff involved in one multi-site pragmatic clinical trial.

METHODS

We used a naturalistic, observational study design to characterize strategies our research team deployed with staff during monthly, virtual meetings. Data were drawn from meeting notes and recordings from the trial's 4-month Preparation phase and 8-month Implementation phase. Strategies were mapped to the Expert Recommendations for Implementing Change taxonomy and categorized into nine implementation clusters. Survey data were also collected from staff to identify the most useful strategies the research team should deploy when onboarding new staff members in the trial's second year.

RESULTS

A total of 287 strategies were deployed. Strategies in the develop stakeholder interrelationships cluster predominated in both the Preparation (35%) and Implementation (31%) phases, followed by strategies in the use iterative and evaluative approaches cluster, though these were more prevalent during trial Preparation (24%) as compared to trial Implementation (18%). When surveyed on strategy usefulness, strategies in the provide interactive assistance, use financial approaches, and support staff clusters were most useful, per staff responses.

CONCLUSIONS

While strategies to develop stakeholder interrelationships were used most frequently during trial Preparation and Implementation, program staff perceived strategies that provided technical assistance, supported clinicians, and used financial approaches to be most useful and should be deployed when onboarding new staff members. Research teams are encouraged to adapt and apply implementation strategy tracking methods when partnering with social service staff and deploy practical strategies that support pragmatic trial success given staff needs and preferences.

TRIAL REGISTRATION

NCT05357261. May 2, 2022.

"I didn't know it was going to be like this.": unprepared for end-of-Life care, the experiences of care aides care in long-term care

BACKGROUND

Care aides provide up to 70-90% of the direct care for residents in long-term care (LTC) and thus hold great potential in improving residents' quality of life and end-of-life (EoL) care experiences. Although the scope and necessity of the care aide role is predicted to increase in the future, there is a lack of understanding around their perceptions and experiences of delivering EoL care in LTC settings. The aim of this study was to gain an understanding of the perspectives, experiences, and working conditions of care aides delivering end-of-life care in LTC in a rural setting, within a high-income country.

METHODS

Data were collected over ten months of fieldwork at one long-term care home in western Canada; semi-structured interviews (70 h) with 31 care aides; and observation (170 h). Data were analysed using Reflexive Thematic Analysis.

RESULTS

Two themes were identified: (i) the emotional toll that delivering this care takes on the care aids and; (ii) the need for healing and support among this workforce. Findings show that the vast majority of care aides reported feeling unprepared for the delivery of the complex care work required for good EoL care. Findings indicate that there are no adequate resources available for care aides' to support the mental and emotional aspects of their role in the delivery of EoL care in LTC. Participants shared unique stories of their own self-care traditions to support their grief, processing and emotional healing.

CONCLUSIONS

To facilitate the health and well-being of this essential workforce internationally, care aides need to have appropriate training and preparation for the complex care work required for good EoL care. It is essential that mechanisms in LTC become mandatory to support care aides' mental health and emotional well-being in this role. Implications for practice highlight the need for greater care and attention played on the part of the educational settings during their selection and acceptance process to train care aides to ensure they have previous experience and societal awareness of what care in LTC settings entails, especially regarding EoL experiences.

Exploring COVID-19 education to support vaccine confidence amongst the general adult population with special considerations for healthcare and long-term care staff: A scoping review

Background

Despite the demonstrated efficacy of approved COVID-19 vaccines, high levels of hesitancy were observed in the first few months of the COVID-19 vaccines' rollout. Factors contributing to vaccine hesitancy are well-described in the literature. Among the various strategies for promoting vaccine confidence, educational interventions provide a foundationally and widely implemented set of approaches for supporting individuals in their vaccine decisions. However, the evidence around the measurable impact of various educational strategies to improve vaccine confidence is limited. We conducted a scoping review with the aim of exploring and characterizing educational interventions delivered during the pandemic to support COVID-19 vaccine confidence in adults.

Methods

We developed a search strategy with a medical information scientist and searched five databases, including Ovid MEDLINE and Web of Science, as well as grey literature. We considered all study designs and reports. Interventions delivered to children or adolescents, interventions on non-COVID-19 vaccines, as well as national or mass vaccination campaigns without documented interaction(s) between facilitator(s) and a specific audience were excluded. Articles were independently screened by three reviewers. After screening 4602 titles and abstracts and 174 full-text articles across two rounds of searches, 22 articles met our inclusion criteria. Ten additional studies were identified through hand searching. Data from included studies were charted and results were described narratively.

Results

We included 32 studies and synthesized their educational delivery structure, participants (i.e., facilitators and priority audience), and content. Formal, group-based presentations were the most common type of educational intervention in the included studies (75%). A third of studies (34%) used multiple strategies, with many formal group-based presentations being coupled with additional individual-based interventions (29%). Given the novelty of the COVID-19 vaccines and the unique current context, studies reported personalized conversations, question periods, and addressing misinformation as important components of the educational approaches reviewed.

Conclusions

Various educational interventions were delivered during the COVID-19 pandemic, with many initiatives involving multifaceted interventions utilizing both formal and informal approaches that leveraged community (cultural, religious) partnerships when developing and facilitating COVID-19 vaccine education. Train-the-trainer approaches with recognized community members could be of value as trust and personal connections were identified as strong enablers throughout the review.

Chart based data as a resource for tracking and improving a person-centred palliative approach in long-term care

AIMS AND OBJECTIVES

To enhance the practice of a person-centred palliative approach in long-term care.

BACKGROUND

Implementing a person-centred palliative approach in long-term care entails placing residents at the centre of care planning that attends to the 'whole' person, rather than prioritising biomedical needs.

DESIGN

We conducted a four-stage directed content analysis of long-term care progress notes to meet our study aims and applied the EQUATOR guidelines for qualitative research publication (COREQ).

METHODS

We qualitatively analysed 78 resident charts across three long-term care homes in southern Ontario to capture the extent to which person-centred care was absent, initiated or implemented in different types of documented care interactions.

RESULTS

Most residents had interactions related to daily care activities (65/78, 83%), social concerns (65/78, 83%) and treatment decisions (53/78, 68%). By contrast, interactions around pain and discomfort (34/78, 44%) and spirituality (27/78, 35%) were documented for less than half of the residents. Almost all (92%) residents had at least one progress note where staff initiated person-centred care by documenting their preference for a certain type of care, but only a third had at least one progress note that suggested their preference was implemented (35%).

CONCLUSIONS

While person-centred care is often initiated by nurses and other allied health professionals, changes to care plans to address resident preferences are implemented less often. Nurses and other allied health professionals should be encouraged to elicit care preferences crucial for holistic care planning and equipped with the skills and support to enact collaborative care planning.

RELEVANCE TO CLINICAL PRACTICE

Collaborative care planning appears relatively absent in charted progress notes, constraining the full implementation of a person-centred palliative approach to care.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group consisting of long-term care resident and staff representatives informed the overall study design and dissemination of the results.

Gift of time: learning together to embed a palliative approach to care in long-term care

BACKGROUND

Embedding a Palliative Approach to Care (EPAC) is a model that helps shift the culture in long-term care (LTC) so that residents who could benefit from palliative care are identified early. Healthcare Excellence Canada supported the implementation of EPAC in seven teams from across Canada between August 2018 and September 2019.

OBJECTIVE

To identify effective strategies for supporting the early identification of palliative care needs to improve the quality of life of residents in LTC.

INTERVENTION

Training methods on the EPAC model included a combination of face-to-face education (national and regional workshops), online learning (webinars and access to an online platform) and expert coaching. Each team adapted EPAC based on their organisational context and jurisdictional requirements for advance care planning.

MEASURES

Teams tracked their progress by collecting monthly data on the number of residents who died, date of their most recent goals of care (GOCs) conversation, location of death and number of emergency department (ED) transfers in the last 3 months of life. Teams also shared their implementation strategies including successes, barriers and lessons.

RESULTS

Implementation of EPAC required leadership support and dedicated time for changing how palliative care is perceived in LTC. Based on 409 resident deaths, 89% (365) had documented GOC conversations; 78% (318) had no transfers to the ED within the last 3 months of life; and 81% (333) died at home. A monthly review of the results showed that teams were having earlier GOC conversations with residents. Teams also reported improvements in the quality of care provided to residents and their families.

CONCLUSION

EPAC was successfully adapted and adopted to the organisational contexts of homes participating in the collaborative.

Effects of a person-centred and thriving-promoting intervention on nursing home residents' experiences of thriving and person-centredness of the environment

AIM

To evaluate the effects of a person-centred and thriving-promoting intervention on nursing home residents´ experiences of thriving and person-centredness of the environment, and to evaluate if the effects varied between female and male residents.

DESIGN

A multi-centre, non-equivalent controlled group before-after intervention design.

METHODS

Six nursing homes in Australia, Norway and Sweden were allocated to either intervention or control group. The intervention comprised a staff educational programme. A survey using proxy-ratings by staff was administered before (T0), immediately after (T1) and six months after (T2) the intervention. The sample varied between 205 and 292 residents. Linear regression models were used to explore effects.

RESULTS

Statistically significant effects were found on experiences of thriving and person-centredness of the environment. These effects were significant for male residents but not for female residents. The results emphasize the importance of individually tailored social and recreational activities.

Experience and Appreciation of Health Care Teams Regarding a New Model of Pharmaceutical Care in Long-Term Care Settings

In long-term care (LTC) homes, the management of frail older residents’ pharmacotherapy may be challenging for health care teams. A new pharmaceutical care model highlighting the recently expanded scope of pharmacists’ practice in Quebec, Canada, was implemented in two LTC homes. This study aimed to evaluate health care providers’ experience and satisfaction with this new practice model. Twenty-three semi-structured interviews were performed and analyzed thematically. Positive results of the model have been identified, such as increased timeliness of interventions. Barriers were encountered, such as lack of clarity regarding roles, and suboptimal communication. The increased involvement of pharmacists was perceived as useful in the context of scarce medical resources. Although requiring time and adjustments from health care teams, the new model seems to contribute to the health care providers’ work satisfaction and to positively influence the timeliness and quality of care offered to LTC residents.

Quality improvement studies in nursing homes: a scoping review

BACKGROUND

Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

METHODS

This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

RESULTS

Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

CONCLUSIONS

This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

A learning process towards person-centred care: A second-year follow-up of guideline implementation

BACKGROUND

Research claims that 'learning by doing' creates new thinking, often leading to new practice.

OBJECTIVES

The aim was to explore and describe the staff learning process from the first to the second year when adopting person-centred care into clinical practice in a nursing home for persons with dementia.

METHOD

The data consisted of poster texts from staff and written notes by researchers obtained from the group discussions. The study involved 24 care units (200 staff). Content analysis was chosen as method to explore the learning process.

RESULT

The staff described the actions that they took during year 1 and year 2, in which five categories emerged, activities, environment, information, priorities and staff routines. With researchers' analysis the categories together created the learning process and formed a sub-theme. They further formed an overarching theme from simplicity to complexity and consensus. Staff changes year 1 pertained more to planning and doing, while year 2 changes constituted a larger complexity of person-centred care with reflection, collaborative learning and a mind-set change.

CONCLUSION

Staff chose the development area, and the learning process was illuminated by the researchers. This underscores the value to visualise and verbalise the steps of change as well as include these steps in the design of an implementation process. The concept of person-centred care could be viewed on different levels. The findings may contribute to a more comprehensive understanding of staff learning process when implementation of person-centred care.

IMPLICATIONS FOR PRACTICE

Making staff's learning process visible can be a guide for improvement and change from a generic care towards person-centred care. The Regional Board of Research Ethics approved the study (Reg no. 2010/1234-31/5).

Strengthening International Research in Long-Term Care: Recommended Common Data Elements to Support Clinical Staff Training

The purpose of this study is to develop candidate common data element (CDE) items related to clinical staff training in long-term care (LTC) homes that can be used to enable international comparative research. This paper is part of the WE-THRIVE (Worldwide Elements to Harmonize Research in Long-Term Care Living Environments) group's initiative which aims to improve international academic collaboration. We followed best practices to develop CDEs by conducting a literature review of clinical staff (i.e., Regulated Nurses, Health Care Aides) training measures, and convening a subgroup of WE-THRIVE experts to review the literature review results to develop suitable CDEs. The international expert panel discussed and critically reflected on the current knowledge gaps from the literature review results. The panel proposed three candidate CDEs which focused on the presence of and the measurement of training. These three proposed CDEs seek to facilitate international research as well as assist in policy and decision-making regarding LTC homes worldwide. This study is a critical first step to develop candidate CDE items to measure staff training internationally. Further work is required to get feedback from other researchers about the proposed CDEs, and assess the feasibility of these CDEs in high and low resourced settings.

The impact of oral health education taken by personal support workers caring for a geriatric population in a long-term care facility: A mixed-methods study

OBJECTIVE

To evaluate the impact of an online oral health education module on personal support workers' (PSW) knowledge and beliefs in their care for long-term care (LTC) residents in one Canadian LTC residence.

BACKGROUND

LTC residents are dependent on PSWs for their oral health needs. However, PSWs receive minimal to no oral health education placing residents at risk for poor oral health.

METHODS

A mixed-methods convergent design comprising a before-and-after questionnaire (N = 88), focus groups (N = 23) and interviews (N = 4) exploring module learning. Analysis of each data set was followed by their amalgamation and comparison.

RESULTS

The online module had limited impact on the PSWs' knowledge and beliefs regarding resident oral health care. The quantitative results demonstrated knowledge improvements in two domains and changes in two belief domains. However, the qualitative results demonstrated new knowledge was not developed or sustained in practice. Themes that emerged include the following: lack of module recall, unmet learning needs and methods for oral care delivery, and timing of oral care in a busy clinical environment.

CONCLUSION

Online oral health education alone has limited impact on PSWs' knowledge and beliefs. Research evaluating multifaceted education interventions including hands-on training with a dental expert is warranted.

Towards an Integrated Care Organisation from a CEO Perspective

Many experimental projects towards Person-Centred Care (PCC) are successful in the early stages, but founder when the attempt is made to scale them up to encompass the whole organisation. This case study therefore focusses on one manager's attempts to extend the successes of a preliminary project 'Etxean Ondo' that aimed to provide adequate support for the elderly living at home or in nursing homes, as well as for their families and care professionals. Through in-depth interviews with stakeholders, this qualitative study, based on Grounded Theory, sets out to analyse which behaviours, attitudes and values on the part of management appeared to favour full-integration of PCC in this wider context. Analysis of the data gathered allowed the researcher to generate an experimental case model which suggests how the extrinsic, intrinsic and transcendent motivation of stakeholders can be aligned with the goals of upper management to promote full-integration of PCC in such a way as to generate trust, increase participant engagement and create a win-win situation for all. Whilst this is clearly an experimental project, it is hoped that the model provided may prove helpful to other researchers and managers interested in pioneering this type of comprehensive organisational strategic change towards integration.

Preventing Fractures in Long-Term Care: Translating Recommendations to Clinical Practice

The Ontario Osteoporosis Strategy for long-term care (LTC) aims to support fracture risk-reduction. LTC specific recommendations for fracture prevention were developed in 2015. This article describes the use of the Knowledge-to Action framework to guide the development and application of research evidence on fracture prevention in older adults. Knowledge translation activities highlighted fractures as a significant source of morbidity in LTC, significant gaps in fracture risk assessment and treatment, and barriers and facilitators to guideline implementation. Multifaceted knowledge translation strategies, targeting staff in LTC homes in Ontario, Canada to support fracture guideline implementation have included education, audit and feedback, team-based action planning, and engagement of LTC residents, their families, and health professionals. Provincial administrative databases were accessed to monitor fracture rates between 2005 and 2015. Our research has identified enablers and barriers to knowledge use such as limited knowledge of osteoporosis, fracture risk, and prevention. Province-wide over a 10-year period, hip fracture rates in LTC decreased from 2.3% to 1.9%, and any fracture rates decreased from 4% to 3.6%. This body of work suggests that multifaceted knowledge translation initiatives are feasible to implement in LTC and can improve the uptake of clinical recommendations for fracture prevention. A key aspect of our fracture prevention knowledge translation activities has been the full engagement of key stakeholders to assist in the co-development and design of knowledge translation products.

Effects of a person-centred and thriving-promoting intervention on nursing home staff job satisfaction: A multi-centre, non-equivalent controlled before-after study

Aim

To evaluate the effects of a person‐centred and thriving‐promoting intervention in nursing homes on staff job satisfaction, stress of conscience and the person‐centredness of care and of the environment.

Design

A multi‐centre, non‐equivalent control group, before–after trial design.

Methods

Staff (N = 341) from six nursing homes in Australia, Norway and Sweden were assigned to the intervention or the control group and both groups were evaluated before the intervention, immediately after and by 6 months follow‐up. Staff completed a questionnaire about job satisfaction (primary endpoint), stress of conscience and the person‐centredness of care and of the environment (secondary endpoints). Linear regression models were used to identify the mean scores and to analyse group differences to test the effects of the intervention.

Results

The intervention had no statistically significant effects on staff job satisfaction, level of stress of conscience or the perceived person‐centredness of care and of the environment.

Effectiveness of reminders to sustain practice change among direct care providers in residential care facilities: a cluster randomized controlled trial

BACKGROUND

The study purpose was to compare the effectiveness of monthly or quarterly peer reminder knowledge translation interventions, with monthly or quarterly paper-based reminders, to sustain a mobility innovation, the sit-to-stand activity.

METHOD

A cluster RCT using a stratified 2 × 2 factorial design was conducted in 24 Canadian residential care facilities with 416 residents and 54 peer reminder care aides. The 1-year intervention included two intensities of reminders (high: socially based peer reminders delivered by volunteer care aides to other care aides; low: paper-based reminders posted in residents' rooms), at two frequencies (monthly; every 3 months). Intervention fidelity was assessed using questionnaires and observations. Monthly sustainability rate of the sit-to-stand activity was calculated as the percentage of opportunities that residents successfully completed the activity in 30 days. Residents' sustainability rates were analyzed using a linear mixed model that mirrored the clustered repeated-measures factorial trial design. The model included a random intercept to account for clustering within sites. An unstructured covariance structure characterized the interdependence of repeated measures over time.

RESULTS

Twenty-four sites were randomized. One site was excluded because of falsifying data, leaving 23 sites and 349 residents for intention-to-treat analysis. Paper reminders were implemented with high fidelity across all arms (91.5% per protocol), while the peer reminders were implemented with moderate fidelity in the monthly group (81.0% per protocol) and poor fidelity in the quarterly group (51.7% per protocol). At month 1, mean sustainability ranged from 40.7 to 47.2 per 100 opportunities, across the four intervention arms (p = 0.43). Mean rate of sustainability in the high intensity, high frequency group diverged after randomization, yielding statistically significant differences among the groups at 4 months which persisted for the remainder of the trial. After 12 months, the mean sustainability in the high intensity, high frequency group was approximately twice that of the other three groups combined (64.1 versus 37.8 per 100 opportunities, p < 0.001).

CONCLUSIONS

A monthly peer reminder intervention was more effective than a quarterly peer reminder intervention, a monthly paper-based reminder intervention, and a quarterly paper-based reminder intervention, in supporting care aides to sustain a mobility innovation in residential care facilities over 1 year.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT01746459. Registered 11 December 2012: https://clinicaltrials.gov/ct2/show/NCT01746459 .

Core values and local guarantees of dignity in the care of older persons - Application, obstacles and further actions

BACKGROUND AND AIM

Due to reported shortcomings in elderly care in Sweden, the government has introduced national guidelines to establish core values and guarantees of dignity. With a bottom-up perspective, core values and local guarantees of dignity were developed using an participatory and appreciative action and reflection (PAAR) approach and implemented in municipal elderly care. The aim of this study was to evaluate the core values and local guarantees of dignity applied by the municipal healthcare staff caring for older persons.

METHOD AND RESULTS

A cross-sectional descriptive design study using a questionnaire was conducted one year after the implementation of core values and local guarantees of dignity in municipal elderly care. In total, 608 caregivers answered the questionnaire. The results show that the caregivers strived to apply the core values and local guarantees of dignity, but experienced obstacles from the organisation. Proposals were given to facilitate further application of the core values.

Stakeholder Engagement in Practice Change: Enabling Person-Centred Mealtime Experiences in Residential Care Homes

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence-Based Care in Long-Term Care Settings

BACKGROUND

Evidence-based improvements in long-term care (LTC) are challenging due to human resource constraints.

AIMS

To evaluate implementation of a multimodal, participatory intervention aimed at improving evidence-based care.

METHODS

Using a qualitative descriptive design, we conducted and inductively analyzed individual interviews with staff at midpoint and end-point to identify action plan implementation processes and challenges. The 9-month intervention engaged professional and unregulated staff in an on-site workshop and provided support for their development and implementation of site-specific action plans.

RESULTS

Ten of 12 enrolled sites participated for the full study period. Interviews were conducted with 44 and 69 participants at midpoint and end-point, respectively. Seven of 10 sites focused their action plan on team functioning and communication. Main achievements described at end-point were improved team communication, better staff engagement, and improved teamwork. Internal and external supports for action plan implementation were described as critical for success.

DISCUSSION

Three factors influenced change: vertically and horizontally linked teams, external facilitator support for action plan implementation, and coaching by Best Practice Coordinators that emphasized organizational change and normalization of evidence-based practice.

IMPLICATIONS

Team functioning and communication are forerunners of clinical practice changes in LTC. An off-site model of facilitation is promising and may provide a more efficient means to reach a wider array of LTC settings.

LINKING EVIDENCE TO ACTION

Practice changes need engagement of all staff.

Nonpharmacological Management of Behavioral and Psychological Symptoms of Dementia: What Works, in What Circumstances, and Why?

Objective

Behavioral and psychological symptoms of dementia (BPSD) refer to the often distressing, noncognitive symptoms of dementia. BPSD appear in up to 90% of persons with dementia and can cause serious complications. Reducing the use of antipsychotic medications to treat BPSD is an international priority. This review addresses the following questions: What nonpharmacological interventions work to manage BPSD? And, in what circumstances do they work and why?

Method

A realist review was conducted to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases for empirical studies that reported a formal evaluation of nonpharmacological interventions to decrease BPSD.

Results

Seventy-four articles met the inclusion criteria. Three mechanisms emerged as necessary for sustained effective outcomes: the caring environment, care skill development and maintenance, and individualization of care. We offer hypotheses about how different contexts account for the success, failure, or partial success of these mechanisms within the interventions.

Discussion

Nonpharmacological interventions for BPSD should include consideration of both the physical and the social environment, ongoing education/training and support for care providers, and individualized approaches that promote self-determination and continued opportunities for meaning and purpose for persons with dementia.

An Action Research to Optimize the Well-Being of Older People in Nursing Homes: Challenges and Strategies for Implementing a Complex Intervention

Few studies have been conducted on strategies to promote the implementation of complex interventions in nursing homes (NHs). This article presents a pilot study intended to assess the strategies that would enable the optimal implementation of a complex intervention approach in NHs based on the meanings of screams of older people living with Alzheimer’s disease. An action research approach was used with 19 formal and family caregivers from five NHs. Focus groups and individual interviews were held to assess different implementation strategies. A number of challenges were identified, as were strategies to overcome them. These latter included interactive training, intervention design, and external support. This study shows the feasibility of implementing a complex intervention to optimize older people’s well-being. The article shares strategies that may promote the implementation of these types of interventions in NHs.