The Involvement of Caregivers in the End-of-life Care of an Older Adult Living in a Long-term Care Home: A Qualitative Case Study with Nurses and Relatives

BACKGROUND

A key role of nurses working in long-term care homes (LTCHs) is to promote the involvement of care partners in end-of-life (EOL) care. However, studies on the involvement of care partners in EOL care in LTCHs have focused on care planning and decision-making. While care partners can participate in other ways, it's unclear how they are currently involved in EOL care by staff.

PURPOSE

We aimed to explore the involvement of care partners in the EOL care of an older adult living in a LTCH.

METHODS

A qualitative case study was conducted. Data was collected from a sample of four nurses and three care partners, using sociodemographic questionnaires, individual semi-structured interviews, documents pertaining to the LTCH's philosophy for EOL care, and a field diary.

RESULTS

The results of a thematic analysis showed the broad scope of care partners' possible involvement, including contributing to care, obtaining information, and being present. As there was some variation in care partners' desire to be involved, nurses seemed to rely on them to convey their wishes. To promote this involvement, some strategies aimed at health professionals and managers were suggested.

CONCLUSIONS

These results can guide improvement in clinical practices and raise awareness on the EOL care experiences of care partners.

Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study

BACKGROUND

Widespread inappropriate use of antimicrobial substances drives resistance development worldwide. In long-term care facilities (LTCF), antibiotics are among the most frequently prescribed medications. More than one third of antimicrobial agents prescribed in LTCFs are for urinary tract infections (UTI). We aimed to increase the number of appropriate antimicrobial treatments for UTIs in LTCFs using a multi-faceted antimicrobial stewardship intervention.

METHODS

We performed a non-randomized cluster-controlled intervention study. Four LTCFs of the Geriatric Health Centers Graz were the intervention group, four LTCFs served as control group. The main components of the intervention were: voluntary continuing medical education for primary care physicians, distribution of a written guideline, implementation of the project homepage to distribute guidelines and videos and onsite training for nursing staff. Local nursing staff recorded data on UTI episodes in an online case report platform. Two blinded reviewers assessed whether treatments were adequate.

RESULTS

326 UTI episodes were recorded, 161 in the intervention group and 165 in the control group. During the intervention period, risk ratio for inadequate indication for treatment was 0.41 (95% CI 0.19-0.90), p = 0.025. In theintervention group, the proportion of adequate antibiotic choices increased from 42.1% in the pre-intervention period, to 45.9% during the intervention and to 51% in the post-intervention period (absolute increase of 8.9%). In the control group, the proportion was 36.4%, 33.3% and 33.3%, respectively. The numerical difference between intervention group and control group in the post-intervention period was 17.7% (difference did not reach statistical significance). There were no significant differences between the control group and intervention group in the safety outcomes (proportion of clinical failure, number of hospital admissions due to UTI and adverse events due to antimicrobial treatment).

CONCLUSIONS

An antimicrobial stewardship program consisting of practice guidelines, local and web-based education for nursing staff and general practitioners resulted in a significant increase in adequate treatments (in terms of decision to treat the UTI) during the intervention period. However, this difference was not maintained in the post-intervention phase. Continued efforts to improve the quality of prescriptions further are necessary.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT04798365.

Support in acute situations when a community health nurse is called: experiences of older patients, their significant others, and involved healthcare professionals- a qualitative interview study

BACKGROUND

Care decisions for older patients in acute situations are challenging to make, and there is limited knowledge of support in home healthcare settings, where older patients receive ongoing health care from, for example, community health nurses. Therefore, this study aimed to describe the support for all involved in acute situations when a community health nurse was called, as experienced by older patients, their significant others and healthcare professionals involved.

METHODS

The study was conducted using a phenomenological reflective lifeworld research approach, in which meanings of the study phenomenon were analyzed. The included participants were those who had been involved in acute situations. Twelve participants from four acute situations were interviewed. The participant included three older patients, one significant other, four community health nurses, one registered nurse student, one specialist in general practice, and two ambulance personnel, with one being a registered nurse and the other a specialist ambulance nurse.

RESULTS

Support in decision-making was received from the knowledge of temporality, which provided a comprehensive understanding based on past and present knowledge of the older patient. The knowledge of temporality allowed for the early detection of new symptoms and facilitated care decisions tailored to the older patient. There was a dependency on pre-existing mutual interpersonal support, and confidence developed through relational, caring, and medical competence.

CONCLUSIONS

The advantages of temporality, confidence and mutual interpersonal support in acute situations highlight the importance of enhancing relational continuity in home healthcare settings and establishing a structural collaboration among community health nurses, specialists in general practice, and ambulance personnel. This collaboration aims to provide support for making decisions regarding tailored care.

Physicians' experiences and actions in making complex level-of-care decisions during acute situations within older patients' homes: a critical incident study

BACKGROUND

Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians' decision-making during acute situations in older patients' homes is limited. Therefore, this study aimed to describe physicians' experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes.

METHODS

Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included.

RESULTS

In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients' and their significant others' needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians' actions involved searching for an understanding of older patients' and their significant others' wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved.

CONCLUSION

Physicians strive to individualize complex level-of-care decisions based on older patients' and their significant others' wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 - 7 collaboration between organizations and health care professionals.

Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study

Background

Residents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process.

Objectives

The aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs.

Methods

This study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada.

Findings

There were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs.

Discussion

The findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care.

Conclusion

The findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01014-2.

Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial

BACKGROUND

When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI.

METHODS

This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062.

FINDINGS

Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33).

INTERPRETATION

The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality.

FUNDING

Danish Ministry of Health and the Velux Foundation.

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes

Aim:

The aim was to determine the association between healthcare workers’ (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention.

Background:

Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important.

Methods:

This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ² test and a linear mixed regression model were applied.

Findings:

Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (−7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (−5.64, P < 0.01). Native HCWs’ mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs’ mean change in knowledge-of-antibiotic score.

Conclusion:

Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Symbiosis Evolution Model and Behavior of Multiple Resource Agents in the Smart Elderly Care Service Ecosystem

Population aging has become an important factor restricting China′s social and economic development. The smart health and elderly care industry has developed rapidly in the past five years. However, the service resources among various elderly service providers are relatively isolated and scattered. In other words, the core management problem in the components of the smart elderly care service ecosystem is how to deal with the relationships of interest among multiple resource agents. Thus, the main contribution of this study is to employ symbiosis theory and the logistic growth model to construct a model of the evolution of the symbiosis of multiple resource agents in the smart elderly care service ecosystem. Then, we carry out a stability analysis, and analyze the evolutionary model of two resource agents′ symbiosis under different values of interdependence coefficients. Finally, we use computer simulations to dynamically simulate the model and comparatively analyze the population density of the hospital–nursing home symbiotic relationship using real cases in China. According to the study, we find that the enterprise goal in the smart elderly care service ecosystem should be to maximize the overall value of the multiple resource agents, and the result of the symbiotic evolution between different resource agents depends on the symbiotic interdependence coefficient, while the resource agent uses different strategies under different symbiosis models. Therefore, regulation is needed to ensure the relative fairness of the distribution of value co-creation in the smart elderly care service ecosystem when the resource agent takes actions that benefit itself. Of course, when the ecosystem is in a reciprocal symbiosis model, each resource agent benefits from the activities of the other resource agents, which is ideal in reality; in other words, the best symbiosis model between the two resource agents should be the similar reciprocal symbiosis model.

Healthcare professionals' perceptions of advance care planning in palliative care unit: a qualitative descriptive study

AIMS AND OBJECTIVES

To describe healthcare professionals' perceptions of advance care planning (ACP) in palliative care unit in hospital ward or outpatient clinic.

BACKGROUND

Clinical guidelines recommend timely ACP as a central component of patient-centred palliative care. However, the ACP concept and terminology have been judged to be confusing, and practices are not established. Professionals' views are needed for ACP adoption and usage.

DESIGN

Qualitative descriptive design.

METHODS

The study used purposive sampling. The data were collected through focus group interviews with registered nurses and practical nurses and individual or couple interviews with physicians and social workers. The data (n = 33) were analysed by inductive content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

Three main categories emerged: Information content of ACP, coordination of care activities through ACP, and support for patients' and family members' coping. The information content of ACP included assessment of need for patient care, preparing for changes in patient's state of health and proactive medication. Coordination of care activities through ACP contained ACP care planning, cooperation and work practices between healthcare professionals. Support for patients' and family members' coping included communication between patient, family members and professionals and promoting patient self-care.

CONCLUSIONS

ACP is a useful and proactive tool for integrating patient-centred information, care and services as well as support for patients' and family members' coping. Palliative care activities can be coordinated through ACP in a multidisciplinary manner. ACP is significant and relevant for both professionals' work and patient care throughout the service system.

RELEVANCE TO CLINICAL PRACTICE

Results highlight the importance of proactive, concrete and holistic ACP. ACP should be up to date to reflect patient's current wishes. Raising professional awareness and implementing ACP into work processes are essential. Results can be utilised in planning and implementing interprofessional in-service training.

Family members' experiences of care of the dying in residential care homes where the Liverpool Care Pathway was used

BACKGROUND

Residential care homes (RCHs) are increasingly becoming a common place of death for older people.

AIM

The aim of this study was to describe family members' experiences of care of the dying in RCHs where the Liverpool care pathway for the dying patient was used.

METHODS

This study had a descriptive qualitative study design. Fifteen (n=15) individual interviews were analysed using qualitative content analysis.

RESULTS

The analysis resulted in three themes: being confident in a familiar and warm atmosphere, being involved vs not being involved in end-of-life (EoL) care, and being consoled by witnessing the health professional's endeavour to relieve suffering.

SIGNIFICANCE OF RESULTS

The results indicated that taking part in a care plan seems to increase family members' feelings of involvement in EoL care. This study also highlights the family members' needs for increased possibilities for EoL discussions with the GP.

The willingness of patients to make the first visit to primary care institutions and its influencing factors in Beijing medical alliances: a comparative study of Beijing's medical resource-rich and scarce regions

BACKGROUND

To improve the efficiency of the use of medical resources, China has implemented medical alliances (MAs) to implement a hierarchical diagnosis and treatment system. The willingness to undertake a first visit to primary care institutions (PCIs) is an important indicator of the effect of this system. Beijing has also built MAs since 2013, but to date, there have been few studies on the first visit to PCIs in Beijing. The purpose of this study is to analyze patients' willingness to make their first visit to PCIs and its influencing factors to provide references for the realization of a hierarchical diagnosis and treatment system.

METHODS

Two relatively different districts with large differences in resources in Beijing, D and F, were selected, and a self-reported questionnaire and convenience sampling method were applied. A cross-sectional survey was administered to 1221 patients of MAs. The chi-square test and binary logistic regression were used to analyze the influencing factors of patients' willingness to undertake a first visit to a PCI.

RESULTS

Fewer patients in District D received medical alliance services (44.42%) than those in District F (59.25%), but patients in District D had a higher degree of satisfaction with the services they received (72.04%) than those in District F (28.96%). Patients in District D had a higher willingness to undertake a first visit (64.00%) than those in District F (58.18%). Patients of an older age, low medical expenses, participation in urban employees' basic medical insurance, a high understanding of MAs and high satisfaction with medical services were indicators of being more willing to choose primary care institutions for their first visit.

CONCLUSIONS

The different medical resources and MA constructions in the two districts have resulted in a difference between the two districts in terms of the willingness of individuals to make their first visit to PCIs. Strengthening the service capabilities of PCIs remains a priority. The government should propose solutions to solve the problems encountered in practice and actively promote the realization of MAs and hierarchical diagnosis and treatment.

Australian general practitioner attitudes to residential aged care facility visiting

Demographic trends suggest that the sustainability of the general practitioner (GP) Residential Aged Care Facility (RACF) workforce, worldwide and in Australia, is under threat, compromising the ongoing care of chronically ill RACF residents. It is therefore important to ascertain current GP attitudes towards this work, to better understand and hypothesise means of reversing this trend. To this end, during 2014 the views of 26 GPs and GP Registrars working in rural and regional New South Wales, Australia, were captured during focus group discussions and one-on-one interviews. Analysis of the qualitative date revealed that GP attitudes towards RACF visiting fell into five key themes: pleasure, duty, remuneration and logistics, hesitation, and frustration. The data also revealed that the overriding emotion GPs felt about RACF visitation was frustration with the avoidable delays and inefficiencies associated with the work. Despite the pleasure GPs derived from their work in RACFs and their sense of obligation to be involved, their hesitation and frustration was compounded by the work's perceived poor remuneration. This research suggests that the barriers to GP participation in RACF visiting were managerial rather than attitudinal, and that a strategic focus upon improving administrative and logistical support is needed.

Transfer of nursing home residents to emergency departments: organizational differences between nursing homes with high vs. low transfer rates

AIM

To explore possible factors in the organization of nursing homes that could be related to differences in the rate of transfer of residents from nursing homes to emergency department.

DESIGN

Explorative.

METHOD

In a single municipality, qualitative and quantitative data were collected from documents and through semi-structured interviews with 11 RNs from five nursing homes identified as having the highest vs. six identified as having the lowest transfer rates to emergency department. Data were analysed by non-parametric tests and basic content analysis.

RESULTS

All nursing homes in the highest transfer rate group and one in the lowest transfer rate group were run by private for-profit providers. Compared with the low group, the high group had fewer updated advance care plans and the RNs interviewed had less work experience in care of older people and less training in care of persons with dementia. There was no difference in nursing home size or staff/resident ratio. The RNs described similar possibilities to provide palliative care, medical equipment and perceived medical support from GPs.