Nursing care left undone in psychiatric hospitals and its association with nurse staffing: A cross-sectional multi-centre study in Switzerland

INTRODUCTION

Nursing care left undone occurs when nurses omit activities because of resource shortfalls. Higher levels of nursing care left undone are associated with worse nurse staffing and organizational factors. Plentiful evidence from acute, long-term and community care supports such associations; however, mental healthcare settings are under-studied.

AIM

The aim of the study was to describe nursing care left undone's frequency in mental health inpatient settings and explore its association with nurse staffing levels.

METHOD

As part of the multi-centre cross-sectional MatchRN Psychiatry study, data were collected by questionnaire from 114 units in 13 Swiss psychiatric hospitals. Nursing care left undone was analysed describing frequencies descriptively and used linear mixed models to assess its association with staffing.

RESULTS

Data from 994 nurses were analysed. The most commonly omitted activities were evaluating nursing processes (30.5%), formulating nursing diagnoses (27.4%) and defining care objectives (22.7%). Nursing care left undone was higher in units with low staffing levels.

DISCUSSION

As in somatic care settings, in psychiatric hospitals, 'indirect' care activities are most commonly omitted.

IMPLICATIONS FOR PRACTICE

This study highlights factors affecting the frequency of nursing care left undone, including staffing levels and perceived leadership. The findings emphasize the importance of nurse managers taking action to improve work environment factors.

How external and agency characteristics are related to coordination in homecare - findings of the national multicenter, cross-sectional SPOTnat study

BACKGROUND

Homecare client services are often distributed across several interdependent healthcare providers, making proper care coordination essential. However, as studies exploring care coordination in the homecare setting are scarce, serious knowledge gaps exist regarding how various factors influence coordination in this care sector. To fill such gaps, this study's central aim was to explore how external factors (i.e., financial and regulatory mechanisms) and homecare agency characteristics (i.e., work environment, workforce, and client characteristics) are related to care coordination in homecare.

METHODS

This analysis was part of a national multicentre, cross-sectional study in the Swiss homecare setting that included a stratified random sample of 88 Swiss homecare agencies. Data were collected between January and September 2021 through agency and employee questionnaires. Using our newly developed care coordination framework, COORA, we modelled our variables to assess the relevant components of care coordination on the structural, process, and outcome levels. We conducted both descriptive and multilevel regression analyses-with the latter adjusting for dependencies within agencies-to explore which key factors are associated with coordination.

RESULTS

The final sample size consisted of 1450 employees of 71 homecare agencies. We found that one explicit coordination mechanism ("communication and information exchange" (beta = 0.10, p <.001)) and four implicit coordination mechanisms-"knowledge of the health system" (beta = -0.07, p <.01), "role clarity" (beta = 0.07, p <.001), "mutual respect and trust" (beta = 0.07, p <.001), and "accountability, predictability, common perspective" (beta = 0.19, p <.001)-were significantly positively associated with employee-perceived coordination. We also found that the effects of agency characteristics and external factors were mediated through coordination processes.

CONCLUSION

Implicit coordination mechanisms, which enable and enhance team communication, require closer examination. While developing strategies to strengthen implicit mechanisms, the involvement of the entire care team is vital to create structures (i.e., explicit mechanisms) that enable communication and information exchange. Appropriate coordination processes seem to mitigate the association between staffing and coordination. This suggests that they support coordination even when workload and overtime are higher.

How regulatory frameworks drive differences in home-care agencies: Results from a national multicenter cross-sectional study in Switzerland

INTRODUCTION

The sustainability and rising costs of the health-care system are of concern. Although health-care reforms impact various areas of care, there is only limited evidence on how regulations affect home-care agencies and health-care delivery.

OBJECTIVES

The primary aim was to explore different financial and regulatory mechanisms and how they drive differences in the organizational structures, processes, and work environment of home-care agencies.

DESIGN AND METHODS

We used data from a national multicenter cross-sectional study of Swiss home care that included a random sample of 88 home-care agencies with a total of 3223 employees. Data was collected in 2021 through agency and personnel questionnaires including geographic characteristics, financial and regulatory mechanisms, service provision, financing, work environment, resources and time allocation, and personnel recruitment. We first conducted a cluster analysis to build agency groups with similar financial and regulatory mechanisms. We then performed Fisher's exact, ANOVA, and Kruskal-Wallis tests to determine group differences in organizational structures, processes, and work environments. Finally, we performed a lasso regression to determine which variables were predictive for the groups.

RESULTS

Four agency groups were built, differing in view of financial and regulatory mechanisms and we found differences in the range and amount of services provided, with regard to employment conditions and cost structures.

DISCUSSION

The most prominent differences were found between agency groups with versus agency groups without a service obligation. Financial incentives must be well aligned with the goal of achieving and maintaining financially sustainable, accessible, and high-quality home care.

The relationship between nursing home staffing and resident safety outcomes: A systematic review of reviews

BACKGROUND

Resident safety is an important topic for nursing home practice with up to 33 % of residents subjected to an adverse event. In spite of a large evidence base examining the relationship between nursing home staffing and resident outcomes, the findings of several systematic reviews remain inconclusive and contradicting, possibly due to methodological shortcomings.

OBJECTIVE

The main aim of this review was to provide a comprehensive overview of the literature on nursing home staffing and its relationship with resident safety outcomes.

DESIGN

We undertook a systematic review of reviews. We searched Medline, CINAHL and Embase by the end of November 2022. Reviews were included if they assessed the relationship between nursing home staffing and resident safety outcomes using objective measures and data at resident level. Quality appraisal was conducted using the SIGN-checklist, but we did not exclude any reviews based on quality assessment. We used a narrative approach, tables and figures to summarize the findings.

RESULTS

We included 13 systematic reviews published between 2006 and 2022 building on primary evidence from 1977 to 2022. Twelve reviews investigated the relationship between nurse staffing and resident safety outcomes (187 unique primary studies), and one review focused on allied health professionals (28 primary studies). Five reviews originated as work to inform governmental recommendations on staffing. We found diverse approaches used to investigate the staffing-outcome relationship with regard to design, timeframe, operationalization, data-source and theoretical rationales guiding the studies. The most prominently reported resident safety outcomes were pressure ulcers and urinary tract infections. Commonly reported staffing measures included number and level of education of nursing home staff. Based on narrative summaries, staffing seems to have a favorable relationship with resident safety outcomes, but logic models explaining the mechanisms of this relationship were sparsely reported.

CONCLUSIONS

The existing literature shows methodological limitations that demand a change in research on the staffing-outcome relationship in the nursing home setting. Our work highlights the need for carefully designed primary studies that address the pertinent shortcomings by design, timeframe, operationalization, data-source and theoretical rationales. These future studies will allow to carefully examine the causal relationship between selected staffing measures and resident safety outcomes in further detail and serve as legitimate evidence bases to inform action plans for clinical practice and to evaluate staffing policies.

Improving patient activation with a tailored nursing discharge teaching intervention for multimorbid inpatients: A quasi-experimental study

OBJECTIVE

Preliminary effectiveness test of a novel structured personalized discharge teaching intervention for multimorbid inpatients.

METHODS

Using a 2-group sequential pre/post-intervention design, the sample comprised 68 pre-intervention control group and 70 post- intervention group participants. The discharge teaching intervention by trained clinical nurses used structured tools to engage patients and individualize discharge teaching. Outcomes measures included Patient Activation Measure, Readiness for Hospital Discharge Scale, Discharge Care Experiences Survey, and readmission with 10 days post-discharge.

RESULTS

The intervention had a statistically significant positive effect on improving patient activation (M=4.8; p = 0.05) from admission to post-discharge. The participation subscale of the Discharge Care Experiences Survey was higher in the intervention (M=4.1, SD=0.7) than the control group (M=3.8, SD=0.7; t (127)= -2.79, p = .01, effect size= .34). There were no significant between-group differences in Readiness for Hospital Discharge Scale and readmission.

CONCLUSIONS

Our results suggest that a structured personalized discharge teaching intervention can improve patient activation and participation in discharge care. Further refinement of the intervention is needed to evaluate and improve specific components of the intervention.

PRACTICE IMPLICATIONS

Structured personalized discharge teaching should include patient engagement strategies in the teaching-learning process.

Exploring medication safety structures and processes in nursing homes: a cross-sectional study

BACKGROUND

Medication safety is important to limit adverse events for nursing home residents. Several factors, such as interprofessional collaboration with pharmacists and medication reviews, have been shown in the literature to influence medication safety processes.

AIM

This study had three main objectives: (1) To assess how facility- and unit-level organization and infrastructure are related to medication use processes; (2) To determine the extent of medication safety-relevant processes; and (3) To explore pharmacies' and pharmacists' involvement in nursing homes' medication-related processes.

METHOD

Cross-sectional multicenter survey data (2018-2019) from a convenience sample of 118 Swiss nursing homes were used. Data were collected on facility and unit characteristics, pharmacy services, as well as medication safety-related structures and processes. Descriptive statistics were used.

RESULTS

Most of the participating nursing homes (93.2%) had electronic resident health record systems that supported medication safety in various ways (e.g., medication lists, interaction checks). Electronic data exchanges with outside partners such as pharmacies or physicians were available for fewer than half (10.2-46.3%, depending on the partner). Pharmacists collaborating with nursing homes were mainly involved in logistical support. Medication reviews were reportedly conducted regularly in two-thirds of facilities.

CONCLUSION

A high proportion of Swiss nursing homes have implemented diverse processes and structures that support medication use and safety for residents; however, their collaboration with pharmacists remains relatively limited.

Identifying work-related factors associated with work-family conflict of care workers in nursing homes: A cross-sectional study

AIMS

To investigate which work-related factors are associated with work-family conflict of care workers in nursing homes, this study aimed to: (a) describe the prevalence of work-family conflict of care workers in nursing homes and (b) assess the association of work-related factors with work-family conflict.

DESIGN

Cross-sectional multicentre sub-study based on data from the Swiss Nursing Homes Human Resources Project 2018.

METHODS

Data were collected between September 2018 and October 2019. Work-family conflict of care workers was assessed with the Work-Family Conflict Scale (range 1-5). Prevalence was described in percentages. We used multilevel linear regression to assess the association of time-based factors (working overtime or during one's free time, employment percentage, presenteeism, shift working) and strain-based factors (staffing adequacy, leadership support) with work-family conflict.

RESULTS

Our study sample consisted of 4324 care workers working in a total of 114 nursing homes. Overall, 31.2% of respondents stated to have experienced work-family conflict (>3.0 on the Work-Family Conflict Scale). The overall mean score of the study sample for work-family conflict was 2.5. Care workers experiencing presenteeism 10 or more days per year showed the highest scores for work-family conflict (mean: 3.1). All included predictor variables were significant (p < .05).

CONCLUSION

Work-family conflict is multifactorial. Possible intervention points to tackle work-family conflict could be strengthening care workers' influence in planning work schedules, enabling flexible planning to ensure adequate staffing, lowering presenteeism and implementing a supportive leadership style.

IMPACT

Care workers' jobs become less desirable when workplace demands interfere with family life. This study highlights the multifaceted nature of work-family conflict and suggests intervention options to prevent care workers from experiencing work-family conflict. Action is needed at nursing home and policy level.

Care coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study

INTRODUCTION

As health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare.

OBJECTIVES

Therefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations.

DESIGN AND METHODS

This study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses.

RESULTS

Employee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = -0.55, p < .001). Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings.

DISCUSSION

While results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination.

Factors associated with avoidable hospital transfers among residents in Swiss nursing homes

Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.

Institutional Factors Associated with Residents' Malnutrition in Nursing Homes: A Cross-Sectional Study

OBJECTIVES

Malnutrition is frequent in older adults, associated with increased morbidity, mortality, and higher costs. Nursing home residents are especially affected, and evidence on institutional factors associated with malnutrition is limited. We calculated the prevalence of malnutrition in Swiss nursing home residents and investigated which structure and process indicators of nursing homes are associated with residents' malnutrition.

DESIGN

Subanalysis of the Swiss Nursing Homes Human Resources Project 2018, a multicenter, cross-sectional study conducted from 2018 to 2019 in Switzerland.

SETTING AND PARTICIPANTS

This study included 76 nursing homes with a total of 5047 residents.

METHODS

Malnutrition was defined as a loss of bodyweight of ≥5% in the last 30 days or ≥10% in the last 180 days. Binomial generalized estimating equations (GEE) were applied to examine the association between malnutrition and structural (staffing ratio, grade mix, presence of a dietician, malnutrition guideline, support during mealtimes) and process indicators (awareness of malnutrition, food administration process). GEE models were adjusted for institutional (profit status, facility size) and specific resident characteristics.

RESULTS

The prevalence of residents with malnutrition was 5%. A higher percentage of units per nursing home having a guideline on prevention and treatment of malnutrition was significantly associated with more residents with weight loss (OR 2.47, 95% CI 1.31-4.66, P = .005). Not having a dietician in a nursing home was significantly associated with a higher rate of residents with weight loss (OR 1.60, 95% CI 1.09-2.35, P = .016).

CONCLUSIONS AND IMPLICATIONS

Having a dietician as part of a multidisciplinary team in a nursing home is an important step to address the problem of residents' malnutrition. Further research is needed to clarify the role of a guideline on prevention and treatment of malnutrition to improve the quality of care in nursing homes.

[Toward a safe home: Experiencing the transition to an outpatient setting with home mechanical ventilation. A thematic analysis]

Toward a safe home: Experiencing the transition to an outpatient setting with home mechanical ventilation. A thematic analysis Abstract. Background: With the progress in medical options, the need for home mechanical ventilation increases. The transition from long-term ventilation in an institution to home mechanical ventilation in an outpatient setting is a difficult phase in terms of setting up the network of care, coordination of care for those with the ventilatory insufficiency and the financing. Aim: The study describes how patients with ventilatory insufficiency and family caregivers experience the transition from an institution to an ambulatory setting with invasive or non-invasive home mechanical ventilation. Methods: A qualitative research design with a social-constructivist approach was adopted using thematic analysis according to Braun and Clarke. We included seven German-speaking patients (≥ 18 years old) with ventilatory insufficiency and home mechanical ventilation (> 6 h/day) from the German part of Switzerland, with discharge from an institution to home, and five family caregivers who care for patients with the described criteria. Results: The institution was seen as a safe place. Affected persons and their family caregivers had to create a safe environment at home. Three themes were formed inductively: To gradually build trust with each other, to become experts as family caregivers, to align their own network with the new care needs.Conclusions: The transition home succeeds in the interplay of gaining trust, building expertise, and creating sustainable networks. Professionals can use this knowledge to provide targeted support to patients with home mechanical ventilation and their family caregivers.

Administrative burden in Swiss nursing homes and its association with care workers' outcomes-a multicenter cross-sectional study

BACKGROUND

Care workers in nursing homes often perform tasks that are rather related to organizational or management activities than 'direct patient care'. 'Indirect care activities', such as documentation or other administrative tasks are often considered by care workers as a burden, as they increase overall workload and keep them away from caring for residents. So far, there is little investigation into what kind of administrative tasks are being performed in nursing homes, by which type of care workers, and to which extent, nor how administrative burden is associated with care workers' outcomes.

PURPOSE

The objective of this study was to describe care workers' administrative burden in Swiss nursing homes and to explore the association with four care worker outcomes (i.e., job dissatisfaction, emotional exhaustion, intention to leave the current job and the profession).

METHODS

This multicenter cross-sectional study used survey data from the Swiss Nursing Homes Human Resources Project 2018. It included a convenience sample of 118 nursing homes and 2'207 care workers (i.e., registered nurses, licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the administrative tasks and burden, staffing and resource adequacy, leadership ability, implicit rationing of nursing care and care worker characteristics and outcomes. For the analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, 73.9% (n = 1'561) of care workers felt strongly or rather strongly burdened, with one third (36.6%, n = 787) reporting to spend 2 h or more during a "normal" day performing administrative tasks. Ratings for administrative burden ranged from 42.6% (n = 884; ordering supplies and managing stocks) to 75.3% (n = 1'621; filling out the resident's health record). One out of four care workers (25.5%, n = 561) intended to leave the profession, whereby care workers reporting higher administrative task burden (OR = 1.24; 95%CI: 1.02-1.50) were more likely to intend to leave the profession.

CONCLUSION

This study provides first insights on care workers' administrative burden in nursing homes. By limiting care workers' burdensome administrative tasks and/or shifting such tasks from higher to lower educated care workers or administrative personnel when appropriate, nursing home managers could reduce care workers' workload and improve their job satisfaction and retention in the profession.

Developing a reflection and analysis tool (We-ReAlyse) for readmissions to the intensive care unit: A quality improvement project

BACKGROUND

Readmissions to the intensive care unit are associated with poorer patient outcomes and health prognoses, alongside increased lengths of stay and mortality risk. To improve quality of care and patients' safety, it is essential to understand influencing factors relevant to specific patient populations and settings. A standardized tool for systematic retrospective analysis of readmissions would help healthcare professionals understand risks and reasons affecting readmissions; however, no such tool exists.

PURPOSE

This study's purpose was to develop a tool (We-ReAlyse) to analyze readmissions to the intensive care unit from general units by reflecting on affected patients' pathways from intensive care discharge to readmission. The results will highlight case-specific causes of readmission and potential areas for departmental- and institutional-level improvements.

METHOD

A root cause analysis approach guided this quality improvement project. The tool's iterative development process included a literature search, a clinical expert panel, and a testing in January and February 2021.

RESULTS

The We-ReAlyse tool guides healthcare professionals to identify areas for quality improvement by reflecting the patient's pathway from the initial intensive care stay to readmission. Ten readmissions were analyzed by using the We-ReAlyse tool, resulting in key insights about possible root causes like the handover process, patient's care needs, the resources on the general unit and the use of different electronic healthcare record systems.

CONCLUSIONS

The We-ReAlyse tool provides a visualization/objectification of issues related to intensive care readmissions, gathering data upon which to base quality improvement interventions. Based on the information on how multi-level risk profiles and knowledge deficits contribute to readmission rates, nurses can target specific quality improvements to reduce those rates.

IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH

With the We-ReAlyse tool, we have the opportunity to collect detailed information about ICU readmissions for an in-depth analysis. This will allow health professionals in all involved departments to discuss and either correct or cope with the identified issues. In the long term, this will allow continuous, concerted efforts to reduce and prevent ICU readmissions. To obtain more data for analysis and to further refine and simplify the tool, it may be applied to larger samples of ICU readmissions. Furthermore, to test its generalizability, the tool should be applied to patients from other departments and other hospitals. Adapting it to an electronic version would facilitate the timely and comprehensive collection of necessary information. Finally, the tool's emphasis comprises reflecting on and analyzing ICU readmissions, allowing clinicians to develop interventions targeting the identified problems. Therefore, future research in this area will require the development and evaluation of potential interventions.

Expanded role of nurses in Swiss nursing homes and their engagement in quality improvement: A cross-sectional study

AIMS

To report on the engagement of Swiss nursing homes and of nurses in expanded roles in quality improvement.

DESIGN

A cross-sectional study (2018-2019).

METHODS

Survey data from a sample of 115 Swiss nursing homes and 104 nurses in expanded roles. Descriptive statistics were used.

RESULTS

Most participating nursing homes reported carrying several quality improvement activities (median of eight out of 10 activities surveyed) but some were only engaged in five activities or less. Nursing homes working with nurses in expanded roles (n = 83) showed greater engagement in quality improvement than those working with none. Nurses with more advanced qualifications (Bachelor's or Master's degree) engaged more in quality improvement than nurses with standard training. Specifically, higher educated nurses were more involved in data-focused activities. Using nurses in expanded roles can be a way forward for nursing homes seeking to actively carry out quality improvement in their facilities.

CONCLUSION

Although a large proportion of nurses in expanded roles surveyed were implementing quality activities, their level of engagement depended on their educational level. Our findings support the principle that higher level competencies are a key aspect of data-based quality improvement in nursing homes. However, as Advance Practice Registered Nurses will remain difficult to recruit in nursing homes, using nurses in expanded roles might contribute to quality improvement.

Clarifying the muddy concept of home healthcare coordination: A comprehensive theoretical framework

Effective healthcare coordination is vital when such care is provided as a collaborative effort by many individuals and their task activities are interdependent. Coordination is necessary to ensure that care not only meets the needs of patients, but also avoids negative consequences for them due to omitted, inefficient, unnecessary, or even incorrect treatments. It also helps conserve resources. This has contributed to a rapid increase in articles on this subject. Still, while care coordination topics are gaining the attention of researchers, there are a number of issues experienced, including the delineation of limitations, inconsistent definitions, and problems with measurement. Therefore, the aim of this article is to refine the concept of homecare coordination and provide a comprehensive theoretical framework, illustrated with examples from practice. Focusing on this goal, we have reviewed the extant literature on the subject to develop a theoretical homecare coordination framework. The first intermediary goal was to integrate relevant concepts across multiple theories and frameworks into a unified synthesis. We do so in two parts: (1) analysis of extant coordination frameworks and theories; and (2) the presentation of our newly developed theoretical framework for homecare coordination. The new framework differentiates clearly between coordination as a process-i.e., what people do to coordinate and coordination as an outcome-i.e., the state of coordination. Applying this distinction to both, measurement and interpretation of results helps avoid misleading conclusions. As a research outcome, our framework builds upon the extant coordination literature, considers the complex relationships among the various coordination-related factors and, while focusing on homecare, is applicable to various healthcare settings in general. A nuanced differentiation and explanation of the elements involved enable a more consistent operationalization of the coordination concept. Additionally, as they explicitly address the healthcare system's micro, meso, and macro levels, they can be applied across diverse healthcare settings to investigate homecare coordination.

How Long-Term Care Quality Measures Address Alzheimer's Disease and Related Dementias in European Countries

OBJECTIVES

Alzheimer's disease and related dementias (ADRD) are prevalent conditions in long-term care homes (LTCHs) with most LTCH residents living with ADRD in many countries. Despite the prevalence of ADRD in LTCHs, a recent examination of LTCH quality measurement programs in 4 countries revealed few LTCH quality measures addressed ADRD, most commonly as a risk adjuster. We sought to better understand how quality measurement programs address ADRD internationally.

DESIGN

International comparative analysis.

SETTING AND PARTICIPANTS

We examined LTCH quality measures in 4 European countries-Germany, Switzerland, Belgium, and the Netherlands.

METHODS

The specifications to calculate each measure were assessed to determine whether the measure was calculated without assessing for ADRD, included only residents with ADRD, excluded residents with ADRD, or was risk adjusted for the presence of ADRD among the LTCH residents.

RESULTS

A total of 143 measures were examined across 4 quality measurement programs. Thirty-seven percent of the measures explicitly address ADRD. The programs addressed ADRD in starkly different ways. In Germany, most (13 of 15) measures addressed ADRD, and did so as an exclusion or inclusion criterion, and in Switzerland all the measures addressed ADRD through risk adjustment. In Flanders, Belgium, all measures were calculated without assessing for ADRD. In the Netherlands, one-third of the measures explicitly addressed ADRD by restricting the measure to psychogeriatric units.

CONCLUSIONS AND IMPLICATIONS

Although limited to examining measures from LTCH quality measurement programs in 4 European countries, this study adds evidence that ADRD tends not to be addressed by LTCH quality measures, but when ADRD is addressed, it tends to be through inclusion or exclusion criteria. LTCH regulators, policymakers, and providers can use this information to assess options for addressing ADRD in quality measurement programs. Future research is needed to assess how standard indicators of ADRD care quality differ across quality measurement programs.

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations

BACKGROUND

Implementation fidelity assesses the degree to which an intervention is delivered as it should be. Fidelity helps to determine if the outcome(s) of an intervention are attributed to the intervention itself or to a failure of its implementation. Little is known about how fidelity impacts the intended outcome(s) and what elements or moderators can affect the fidelity trajectory over time. We exemplify the meaning of implementation fidelity with INTERCARE, a nurse-led care model that was implemented in eleven Swiss nursing homes (NHs) and showed effectiveness in reducing unplanned hospital transfers. INTERCARE comprises six core elements, including advance care planning and tools to support inter- and interprofessional communication, which were introduced with carefully developed implementation strategies.

METHODS

A mixed-methods convergent/triangulation design was used to investigate the influence of implementation fidelity on unplanned transfers. A fidelity questionnaire measuring the degree of fidelity to INTERCARE's core components was fielded at four time points in the participating NHs. Two-monthly meetings were conducted with NHs (September 2018-January 2020) and structured notes were used to determine moderators affecting fidelity (e.g., participant responsiveness). We used the fidelity scores and generalized linear mixed models to analyze the quantitative data. The Framework method was used for the qualitative analysis. The quantitative and qualitative findings were integrated using triangulation.

RESULTS

A higher overall fidelity score showed a decreasing rate of unplanned hospital transfers post-intervention (OR: 0.65 (CI = 0.43-0.99), p = 0.047). A higher fidelity score to advance care planning was associated with lower unplanned transfers (OR = 0.24 (CI 0.13-0.44), p = < 0.001) and a lower fidelity score for communication tools (e.g., ISBAR) to higher rates in unplanned transfers (OR = 1.69 (CI 1.30-2.19), p = < 0.003). In-house physicians with a collaborative approach and staff's perceived need for nurses working in extended roles, were important moderators to achieve and sustain high fidelity.

CONCLUSION

Implementation fidelity is challenging to measure and report, especially in complex interventions, yet is crucial to better understand how such interventions may be tailored for scale-up. This study provides both a detailed description of how fidelity can be measured and which ingredients highly contributed to reducing unplanned NH transfers.

TRIAL REGISTRATION

The INTERCARE study was registered at clinicaltrials.gov Protocol Record NCT03590470.

Daily practices of advanced practice nurses within a multi-professional primary care practice in Switzerland: a qualitative analysis

BACKGROUND

The rising global population of older persons with chronic conditions demands new primary care models. Advanced practice nurses (APNs) can help meet that need. In Switzerland, APNs have only recently been introduced in primary care and little is known about their daily practice. This study aims to describe APNs' activities and general roles at four sites with multi-professional primary care practices in the Swiss cantons of Bern and Solothurn.

METHODS

To study the practices of APNs at the study sites, we adopted a social constructivist perspective, lending methods from ethnographic field research. We interviewed, observed and accompanied participants over five months, generating rich data on their daily practices. The analysis followed Braun and Clarke's six-step thematic analysis process.

RESULTS

The APNs' daily practices cover three main themes. Their core activities are working with expanded clinical skills and being on-site specialists for patients and their relatives. These practices are surrounded by net activities, i.e., taking care of patients in tandem with the physicians and regular visits in residential long-term care facilities. The outer activity layer consists of cohesive activities, with which APNs anchor and facilitate their role and catalyze further development of the care model. APNs tailor their expanded medical knowledge and nursing practice to maximize the value they provide in patient care.

CONCLUSIONS

This study extends our knowledge of APNs' daily practice within a Swiss multi-professional primary care practice. Our results indicate competencies that need to be integrated in APN education and point out the high potential of APN integration in such primary care practices.

The Interaction Between Leadership, the Patient-to-Nurse Ratio and Nurses' Work-Life Balance in the Psychiatric Inpatient Setting in Switzerland: A Secondary Data Analysis of Cross-Sectional Data

Psychiatric nurses' work environment factors, including long hours, heavy workloads and leadership issues, can serve as barriers to achieving a healthy work-life balance. However, for both individuals and organizations, that balance is crucial as it is a key determinant of job satisfaction and leaving intentions. To address the limiting evidence to that topic, this study had two objectives: (1) to describe the work-life balance of nurses working in psychiatric inpatient settings; and (2) to examine those nurses' work-life balance and its associations with individual (i.e., age, gender), psychosocial (i.e., leadership) and structural factors (i.e., employment percentage). To analyze these factors and their impacts, we conducted a cross-sectional study in a sample of 1209 nurses from 116 units in 13 psychiatric hospitals of the German-speaking part of Switzerland and analyzed the resulting data via multilevel analysis. This led to three main results. First, nurses reported a high mean value regarding their work-life balance. Second, multivariable regression results indicated that their work-life balance ratings correlated directly with certain psychosocial work environment factors (leadership and support of nurses, perceived staffing resources) and inversely with structural factors (employment percentage, overtime). And third, we found an interaction between leadership and support of nurses and the patient-to-nurse ratio: the lower the leadership level, the stronger the inverse association between patient load and work-life balance. No individual factors were significantly associated with work-life balance. Overall, though, we found that organizational factors are vital to nurses' work-life balance. Therefore, interventions to improve nurses' work-life balance should be institution-level, and should focus on improving either leadership or structural factors, e.g., employment percentage, overtime, and patient-to-nurse ratios.

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project

BACKGROUND

Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs.

METHODS

For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months.

DISCUSSION

This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention.

TRIAL REGISTRATION

Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.

Factors associated with health-related quality of life among home-dwelling older adults aged 75 or older in Switzerland: a cross-sectional study

BACKGROUND

HRQoL is an indicator of individuals' perception of their overall health, including social and environmental aspects. As a multidimensional concept, HRQoL can be influenced by a multitude of factors. Studies of HRQoL and factors associated with it among home-dwelling older adults have often been limited to inpatient settings or to a sub-population with a chronic disease. Studying HRQoL and its correlating factors among this population, by providing an ecological lens on factors beyond the individual level, can provide a better understanding of the construct and the role of the environment on how they perceive their HRQoL. Thus, we aimed to assess the HRQoL and investigate the correlates of HRQOL among home-dwelling older adults, guided by the levels of the ecological model.

METHODS

This is a cross-sectional population survey conducted in 2019 in Canton Basel-Landschaft, in northwestern Switzerland, and includes a sample of 8786 home-dwelling older adults aged 75 and above. We assessed HRQoL by using the EQ-index and the EQ-VAS. The influence of independent variables at the macro, meso and micro level on HRQoL was tested using Tobit multiple linear regression modelling.

RESULTS

We found that having a better socio-economic status as denoted by higher income, having supplementary insurance and a higher level of education were all associated with a better HRQoL among home-dwelling older adults. Furthermore, being engaged in social activities was also related to an improved HRQoL. On the other hand, older age, female gender, presence of multimorbidity and polypharmacy as well as social isolation and loneliness were found to all have a negative impact on HRQoL.

CONCLUSIONS

Understanding factors related to HRQoL by using an ecological lens can help identify factors beyond the individual level that impact the HRQoL of home-dwelling older adults. Our study emphasises the importance of social determinants of health and potential disparities that exists, encouraging policymakers to focus on policies to reduce socio-economic disparities using a life-course approach, which consequently could also impact HRQoL in later stages of life.

CARE WORKERS’ ADMINISTRATIVE BURDEN IN SWISS NURSING HOMES: A MULTICENTER CROSS-SECTIONAL STUDY

Apart from ‘direct’ resident care, care workers in nursing homes also perform tasks that are related to organizational or management activities. ‘Indirect’ care activities, such as administrative tasks, are often considered as burdensome, as they increase overall workload and keep care workers away from caring for their residents. So far, there is little investigation on care workers’ administrative burden. The multicenter cross-sectional Swiss Nursing Homes Human Resources Project (2018) study included a convenience sample of 118 Swiss nursing homes and 2207 care workers (i.e., registered nurses and licensed practical nurses). Care workers completed questionnaires assessing the administrative burden, staffing and resource adequacy, leadership ability, implicit rationing of nursing care and care worker characteristics and outcomes. For the analysis, we applied 2-level binomial generalized linear mixed models. Overall, 73.91% (n=1561) of care workers felt strongly or rather strongly burdened, with one third (36.6%, n=787) reporting to spend 2h or more during a "normal" day performing administrative tasks. Ratings ranged from 42.6% (n=884; ordering supplies and managing stocks) to 75.3% (n=1621; filling out the patient’s medical record). One out of four care workers (25.5%, n=561) intended to leave the profession, whereby care workers reporting higher administrative burden (OR=1.24; 95%CI: 1.02-1.50) were more likely to leave the profession. This study provides first insights on care workers’ administrative burden in nursing homes, which can inform the development of interventions to reduce the workload related to ‘indirect care activities’ and to improve care workers’ job satisfaction and retention in the profession.

SWISS NURSING HOMES’ ENGAGEMENT IN QUALITY IMPROVEMENT: A MULTICENTER CROSS-SECTIONAL STUDY

Many publications have focused on quality improvement interventions in nursing homes but the self-initiated daily involvement of nursing homes in quality improvement activities has rarely been investigated (e.g., conducting surveys, using data to set quality aims and track quality of care over time, conducting quality improvement projects). Such activities can be carried out by nurses in expanded roles with competences beyond those of regular registered nurses (e.g., advanced studies, Bachelor/Master’s degree), but evidence is lacking. We aimed to described the involvement of nursing homes and of nurses working in expanded roles in quality improvement activities in Swiss nursing homes. A cross-sectional multi-center study (2018-2019) using survey data from a convenience sample of 115 Swiss nursing homes and 104 nurses in expanded roles was used and descriptive statistics applied. Most nursing homes reported carrying several quality improvement activities (median = 8 activities out of 10 surveyed). The group of nursing homes working with a nurse in an expanded role (n = 83) were more engaged in quality improvement than the other group (median = 8 versus 6.5) Higher-educated nurses participated more in a majority of quality improvement activities than lower-educated nurses (Bachelor/Master-educated nurses: median of 13 out of 17 activities surveyed, versus diploma-educated nurses: 10), except for clinical teaching. This study provides insights into nursing homes’ involvement in daily quality improvement and suggests that, depending on the targeted quality improvement needs, nursing homes use different profiles and education levels of nurses in expanded roles.

INTERNATIONAL LONG-TERM CARE HOME QUALITY ASSURANCE: HOW DO EUROPEAN MEASURES ADDRESS DEMENTIA?

Alzheimer’s Disease and related dementias (ADRD) are prevalent conditions in long-term care homes (LTCHs) with about 50% of LTCH residents living with ADRD in many countries. Despite the prevalence of ADRD in LTCHs, a recent examination of LTCH quality assurance programs in four countries revealed a small percentage of LTCH quality measures across those countries addressed ADRD, most commonly as a risk adjuster, and once each as an inclusion or exclusion criterion. To better understand how quality assurance programs address ADRD internationally, we examined LTCH quality measures in four European countries—The Netherlands, Switzerland, Germany, and Belgium—following procedures previously used to examine international LTCH quality assurance measures. 73 measures were examined across 4 quality assurance programs. 26% of the measures addressed ADRD. The programs addressed ADRD in starkly different ways: in The Netherlands and Belgium no measures addressed ADRD; in Germany the majority (13/15) of measures addressed ADRD as an exclusion or inclusion criterion; and in Switzerland all the measures addressed ADRD through risk adjustment. Although limited to examining measures from LTCH quality assurance programs in four European countries, this study adds evidence that ADRD tends not to be addressed by LTCH quality measures, but when ADRD is addressed, it tends to be through risk adjustment. LTCH regulators, policymakers, and providers can use this information to assess options for addressing ADRD in quality assurance programs. Future research is needed to assess how standard indicators of quality differ across quality assurance regimes and how to address dementia beyond risk adjustment.

Methodological approaches to study context in intervention implementation studies: an evidence gap map

BACKGROUND

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.

METHODS

We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.

RESULTS

Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.

CONCLUSIONS

This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.

Exploring resident experiences of person-centred care at mealtimes in long-term residential care: a rapid ethnography

INTRODUCTION

Poor nutrition is a common ongoing problem in long-term residential care, often resulting in reduced quality of life. Previous research has concluded that the content of the meal, dining environment, service style and general atmosphere all add to the mealtime experience, suggesting that person-centred mealtimes are optimal. However, knowledge about which elements of person-centred care can be achieved in a mealtime setting in a given context is currently lacking. We aimed to understand the mealtime experience in long-term residential care by exploring (missed) opportunities for person-centred care in different settings.

METHODS

As part of the TRANS-SENIOR research network, rapid ethnographies, were conducted across multiple sites (including interviews, observations and informal conversations), in a long-term residential care home in the UK, Switzerland and the Netherlands between October 2020 and December 2021.  RESULTS: Following analysis and interpretation of observations, interviews and informal conversations, the following themes were developed where either successfully achieved or missed opportunities for person-centred moments were observed: 1) considering the setting, 2) listening to and implementing resident choice, 3) enabling residents to help/care for themselves and others, 4) providing individualised care in a communal setting, and 5) knowing the person in the past and present. Residents experienced moments of participatory choice, interaction, independence and dignity, but opportunities for these were often missed due to organisational or policy constraints.

CONCLUSIONS

There are opportunities for person-centred moments during the mealtime, some of which are taken and some missed. This largely depended on the setting observed, which includes the overall environment (size of dining area, seating arrangements etc.) and allocation of staff resources, and the level of resident involvement in mealtimes, from preparation to the actual activity.

Development of a medication literacy assessment instrument (MELIA) for older people receiving home care

AIM

To develop a consensus-based instrument [MELIA] to assess the medication literacy of older home care patients to ultimately optimize medication safety.

DESIGN

This study was part of the project 'Study of Medication Safety in Home Care' (doMESTIC), which took place from 2016 to 2020 in Switzerland. The development process for the medication literacy assessment instrument encompassed six steps.

METHOD

First, a scoping literature search was conducted in the Pubmed, CINAHL, EMBASE and Cochrane Library databases as 2) a basis for the development of assessment items. This was followed by 3) a cognitive interview with home care patients and 4) the first round of a Delphi process. Then, 5) a focus group interview with home care experts was conducted before 6) the second Delphi round. The project took place between August 2020 and June 2021. With these different steps, perspectives of both patients and various home care and medication safety experts were included in the development of the assessment instrument.

RESULTS

A detailed instrument consisting of 20 items as well as a 7-item short version were developed. The short version is intended for efficient preliminary screening to identify patients at high risk for medication management-related problems.

CONCLUSION

Medication literacy in patients 65 years and older receiving professional home care is a key issue in preventing medication errors. A targeted assessment, starting with an efficient short version of MELIA, allows for prioritization of patients for interventions to optimize medication safety while ensuring their independence as much as possible.

IMPACT

Systematic assessment of patients' medication literacy helps to provide them with targeted and individual support in their medication management to avoid medication errors and increase patient safety. The development of MELIA is a first step in providing an assessment instrument specifically for the home care setting.

PATIENT OR PUBLIC CONTRIBUTION

Patient participation was an integral part of the instrument development. The initial 23 items were optimized based on cognitive interviews with four home care patients. The next steps of the instrument development were based on feedback of health care professionals-encompassing advance practice nurses, regular nurses, pharmacists and general practitioners-during a two-step Delphi process as well as a focus group discussion.

Evidence for publicly reported quality indicators in residential long-term care: a systematic review

BACKGROUND

An increasing number of countries are using or planning to use quality indicators (QIs) in residential long-term care. Knowledge regarding the current state of evidence on usage and methodological soundness of publicly reported clinical indicators of quality in nursing homes is needed. The study aimed to answer the questions: 1) Which health-related QIs for residents in long-term care are currently publicly reported internationally? and 2) What is the methodological quality of these indicators?

METHODS

A systematic search was conducted in the electronic databases PubMed, CINAHL and Embase in October 2019 and last updated on August 31st, 2022. Grey literature was also searched. We used the Appraisal of Indicators through Research and Evaluation (AIRE) instrument for the methodological quality assessment of the identified QIs.

RESULTS

Of 23'344 identified records, 22 articles and one report describing 21 studies met the inclusion criteria. Additionally, we found 17 websites publishing information on QIs. We identified eight countries publicly reporting a total of 99 health-related QIs covering 31 themes. Each country used between six and 31 QIs. The most frequently reported indicators were pressure ulcers, falls, physical restraints, and weight loss. For most QI sets, we found basic information regarding e.g., purpose, definition of the indicators, risk-adjustment, and stakeholders' involvement in QIs' selection. Little up to date information was found regarding validity, reliability and discriminative power of the QIs. Only the Australian indicator set reached high methodological quality, defined as scores of 50% or higher in all four AIRE instrument domains.

CONCLUSIONS

Little information is available to the public and researchers for the evaluation of a large number of publicly reported QIs in the residential long-term care sector. Better reporting is needed on the methodological quality of QIs in this setting, whether they are meant for internal quality improvement or provider comparison.

Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study

Background

Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support.

Methods

Using an explanatory sequential mixed methods design, we first conducted a secondary analysis of a subset of cross-sectional data from the ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns (INSPIRE) population survey using descriptive analysis. Subsequently, we analyzed existing data from interviews in the parent study to help explain the survey results using applied thematic analysis. Results were organized according to adapted domains and concepts of the SELFIE framework and integrated via a joint display table.

Results

Of the parent population survey respondents, 2314 older adults indicating frailty were included in the quantitative arm of this study. Interview data was included from 7 older adults who indicated frailty. Support from health and social, formal and informal caregivers is diverse and anticipated to increase (e.g., for ‘care and assistance at home’ and ‘meal services’). Informal caregivers fulfilled various roles and while some older adults strongly relied on them for support, others feared burdening them. Most participants (93.5%) perceived their overall support to meet their needs; however, findings suggest areas (e.g., assessment of overall needs) which merit attention to optimize future care.

Conclusions

Given the anticipated demand for future care and support, we recommend efforts to prevent fragmentation between health and social as well as formal and informal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03552-z.

Unraveling implementation context: the Basel Approach for coNtextual ANAlysis (BANANA) in implementation science and its application in the SMILe project

BACKGROUND

Designing intervention and implementation strategies with careful consideration of context is essential for successful implementation science projects. Although the importance of context has been emphasized and methodology for its analysis is emerging, researchers have little guidance on how to plan, perform, and report contextual analysis. Therefore, our aim was to describe the Basel Approach for coNtextual ANAlysis (BANANA) and to demonstrate its application on an ongoing multi-site, multiphase implementation science project to develop/adapt, implement, and evaluate an integrated care model in allogeneic SteM cell transplantatIon facILitated by eHealth (the SMILe project).

METHODS

BANANA builds on guidance for assessing context by Stange and Glasgow (Contextual factors: the importance of considering and reporting on context in research on the patient-centered medical home, 2013). Based on a literature review, BANANA was developed in ten discussion sessions with implementation science experts and a medical anthropologist to guide the SMILe project's contextual analysis. BANANA's theoretical basis is the Context and Implementation of Complex Interventions (CICI) framework. Working from an ecological perspective, CICI acknowledges contextual dynamics and distinguishes between context and setting (the implementation's physical location).

RESULTS

BANANA entails six components: (1) choose a theory, model, or framework (TMF) to guide the contextual analysis; (2) use empirical evidence derived from primary and/or secondary data to identify relevant contextual factors; (3) involve stakeholders throughout contextual analysis; (4) choose a study design to assess context; (5) determine contextual factors' relevance to implementation strategies/outcomes and intervention co-design; and (6) report findings of contextual analysis following appropriate reporting guidelines. Partly run simultaneously, the first three components form a basis both for the identification of relevant contextual factors and for the next components of the BANANA approach.

DISCUSSION

Understanding of context is indispensable for a successful implementation science project. BANANA provides much-needed methodological guidance for contextual analysis. In subsequent phases, it helps researchers apply the results to intervention development/adaption and choices of contextually tailored implementation strategies. For future implementation science projects, BANANA's principles will guide researchers first to gather relevant information on their target context, then to inform all subsequent phases of their implementation science project to strengthen every part of their work and fulfill their implementation goals.

Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review

Background

Emergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital.

Methods

This is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits—measured as ambulatory-care sensitive conditions (ACSCs)—were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis.

Results

Six percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits.

Conclusions

We revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings’ public health implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03308-9.

Understanding dynamic complexity in context-Enriching contextual analysis in implementation science from a constructivist perspective

Context in implementation science includes not only characteristics of a setting in which an intervention will be delivered, but also social systems (e.g., interrelationships). Context is dynamic and interacts with both, the intervention and its implementation. Therefore, contextual analysis is recognized as an indispensable part of implementation science methodology: it provides the foundation for successful and sustainable implementation projects. Yet, driven by the prevailing post-positivist understanding of context, contextual analysis typically focuses on individual characteristics of context i.e., contextual dynamics and interactions go unnoticed. Conducting contextual analysis from a constructivist perspective promotes a multilayered approach, building a more comprehensive understanding of context, and thus facilitating successful implementation. In this article, we highlight the limitations of prevailing perspectives on context and approaches to contextual analysis. We then describe how contextual analysis can be enriched by working from a constructivist perspective. We finish with a discussion of the methodological and practical implications the proposed changes would entail. Emerging literature attempts to address both the concept of context and methods for contextual analysis. Various theories, models and frameworks consider context, however, many of these are reductionistic and do not acknowledge the dynamic nature of context or interactions within it. To complement recent conceptualizations of context, we suggest consider the following five constructivist concepts: 1) social space; 2) social place; 3) agency; 4) sensation; and 5) embodiment. We demonstrate the value of these concepts using COVID-19 vaccination uptake as an example and integrate the concepts in the Context and Implementation of Complex Interventions (CICI) framework-an implementation science framework that pays ample attention to context. To study context from a constructivist perspective, we also suggest additional considerations in view of methodologies for data collection and analysis, e.g., rapid ethnographic methods. A constructivist perspective contributes to a stronger conceptualization of contextual analysis. Considering the five constructivist concepts helps to overcome contextual analysis' current shortcomings, while revealing complex dynamics that usually go unnoticed. Thus, more comprehensive understanding of context can be developed to inform subsequent phases of an implementation project, thereby maximizing an intervention's uptake and sustainability.

Increasing implicit rationing of care in nursing homes: A time-series cross-sectional analysis

BACKGROUND

Implicit rationing of nursing care is a socio-ecological problem where care workers, due to lack of resources, have to leave necessary nursing care activities undone. Cross-sectional studies on implicit rationing of nursing home care revealed associations with organizational and work environment characteristics. However, little is known on how implicit rationing of nursing care varies over time in nursing homes.

OBJECTIVE

This study's purpose was to describe changes in levels and patterns of implicit rationing of nursing care in Swiss nursing homes over time, while accounting for key explanatory factors related to organizational, work environment, and individual characteristics.

DESIGN

Time-series cross-sectional analysis.

SETTING

Nursing homes in Switzerland.

PARTICIPANTS

A convenience sample of 47 nursing homes and 3269 care workers from all educational levels participating in two multicenter cross-sectional studies (the Swiss Nursing Home Human Resources Project) conducted in 2013 and 2018.

METHODS

To quantify implicit rationing of nursing care, care workers' data were collected via the nursing home version of the Basel Extent of Rationing of Nursing Care instrument. To control for leadership ability, staffing and resource adequacy, we used the Nursing Work Index-Practice Environment Scale. Objective measures including turnover, staffing and skill mix levels were aggregated at the nursing home level. Our analyses included multiple linear mixed models, using time as a fixed effect and nursing home as a random effect.

RESULTS

We found overall increases of rationing of care activities over the five-year period studied, with documentation and social activities most rationed at both measurement points (overall coefficients varied between 0.11 and 0.23, as well as the 95%-confidence intervals between 0.05 and 0.30). Moreover, a considerable increase in rationing of activities of daily living (coefficient of 0.47 in 2013 and 0.63 in 2018) was observed.

CONCLUSIONS

Alongside long-term deterioration of staff resources, increases in rationing of nursing care are a worrying development, particularly given their potential negative impacts both on residents and on care workers. To assess nursing home care quality and to determine adequate staffing levels and skill mixes, policy makers and nursing home managers should consider regular monitoring of rationing of nursing care.

TWEETABLE ABSTRACT

Time-series cross-sectional analysis reveals increasing rationing of nursing care activities in Swiss nursing homes from 2013 to 2018.

Wie Pflegeexpert_innen in Deutschschweizer Pflegeheimen ihre Rollenentwicklung gestalten

Zusammenfassung. Hintergrund: Die Entwicklung und Aufrechterhaltung der Pflegequalität wird in Schweizer Pflegeheimen oft von Pflegeexpert_innen übernommen. Dabei handelt es sich um diplomierte Pflegefachpersonen mit heterogenem Bildungshintergrund und langjähriger Berufserfahrung. Wie diese ihre Rollenentwicklung in den Pflegeheimen gestalten, ist nicht bekannt. Fragestellung/Ziel: Ziel der Studie ist es darzulegen, wie Pflegeexpert_innen in Pflegeheimen ihre berufliche Rollenentwicklung gestalten. Methode: Wir führten eine qualitative, konstruktivistische Sekundärdatenanalyse von 14 semistrukturierten Interviews mit Pflegeexpert_innen aus Deutschschweizer Pflegeheimen durch. Die Daten wurden induktiv mit einer reflexiven thematischen Analyse ausgewertet. Ergebnisse: Aus den Berichten der 14 Pflegeexpert_innen konnten wir das konstituierende Thema „Vision als Motivation“ und drei Phasen der Rollenentwicklung ableiten. Die Vision, eine gute Pflegequalität für die Bewohner_innen sicherzustellen, motiviert Pflegeexpert_innen zum Rollenaufbau und zur Weiterentwicklung in drei Phasen: 1) „Rolle sukzessive gestalten“; 2) „Rolle kontinuierlich weiterentwickeln“; 3) „Rolle neu ausrichten“. Schlussfolgerungen: Pflegeexpert_innen passen ihre Rolle kontinuierlich an den sich verändernden Kontext an, um an der Pflegequalität arbeiten zu können. Zum Gelingen benötigen sie eine gemeinsame Vision mit ihren Vorgesetzten für die Pflegequalität.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations

BACKGROUND

Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care.

METHODS

The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective.

RESULTS

Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate.

CONCLUSIONS

As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03590470 ).

Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes

Background | objective

To evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents.

Design

Convergent mixed-method design within a hybrid type-2 effectiveness-implementation study.

Setting

Eleven nursing homes in the German-speaking region of Switzerland.

Participants

Quantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes.

Intervention

Three intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used.

Methods

The quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention’s acceptability, feasibility and uptake were assessed using validated and self-developed scales.

Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach.

Results

The ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users’ perceived ease of using the intervention and its adaptations, and the intervention’s usefulness, appeared to influence the implementation’s success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation.

Conclusions

Our findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly.

Trial registration

This study was registered at clinicaltrials.gov (NCT03590470) on the 18/06/2018.

Occurrence of No-Harm Incidents and Adverse Events in Hospitalized Patients with Ischemic Stroke or TIA: A Cohort Study Using Trigger Tool Methodology

Adverse events (AEs)—healthcare caused events leading to patient harm or even death—are common in healthcare. Although it is a frequently investigated topic, systematic knowledge on this phenomenon in stroke patients is limited. To determine cumulative incidence of no-harm incidents and AEs, including their severity and preventability, a cohort study using trigger tool methodology for retrospective record review was designed. The study was carried out in a stroke center at a university hospital in the German speaking part of Switzerland. Electronic records from 150 randomly selected patient admissions for transient ischemic attack (TIA) or ischemic stroke, with or without acute recanalization therapy, were used. In total, 170 events (108 AEs and 62 no-harm incidents) were identified, affecting 83 patients (55.3%; 95% CI 47 to 63.4), corresponding to an event rate of 113 events/100 admissions or 142 events/1000 patient days. The three most frequent AEs were ischemic strokes (n = 12, 7.1%), urinary tract infections (n = 11, 6.5%) and phlebitis (n = 10, 5.9%). The most frequent no-harm incidents were medication events (n = 37, 21.8%). Preventability ranged from 12.5% for allergic reactions to 100% for medication events and pressure ulcers. Most of the events found (142; 83.5%; 95% CI 76.9 to 88.6) occurred throughout the whole stroke care. The remaining 28 events (16.5%; 95% CI 11.4 to 23.1) were detected during stroke care but were related to care outside the stroke pathway. Trigger tool methodology allows detection of AEs and no-harm incidents, showing a frequent occurrence of both event types in stroke and TIA patients. Further investigations into events’ relationships with organizational systems and processes will be needed, first to achieve a better understanding of these events’ underlying mechanisms and risk factors, then to determine efforts needed to improve patient safety.

Exploring Interrelations Between Person-Centred Care and Quality of Life Following a Transition into Long-Term Residential Care: A Meta-Ethnography

BACKGROUND AND OBJECTIVES

Globally, a culture change in long-term residential care (LTRC) moving towards person-centred care (PCC) has occurred in an attempt to improve resident quality of life (QoL). However, a clear understanding of how different aspects contributing to a PCC approach are interrelated with resident QoL is still lacking. This review explores interrelating aspects between PCC and QoL in LTRC using qualitative synthesis.

RESEARCH DESIGN AND METHODS

Ten relevant primary studies were identified from a search of interdisciplinary research databases providing qualitative information. Studies were critically reviewed for key themes and concepts by the research team. We used a meta-ethnography approach to inductively interpret findings across multiple studies and reinterpreted the information using a constructivist approach.

RESULTS

We identified 5 second order constructs sharing commonalities suggesting interrelations between PCC and QoL: (1) Maintaining dignity, autonomy and independence. (2) Knowing the whole person. (3) Creating a 'homelike' environment. (4) Establishing a caring culture. (5) Integrating families and nurturing internal and external relationships. Synthesis translation led to the following third order constructs: (1) Personalising care within routines (2) Optimising resident environments (3) Giving residents a voice.

DISCUSSION AND IMPLICATIONS

There are many interrelating aspects of PCC and QoL following a permanent transition into LTRC, but successful implementation of PCC, which enhances QoL presents challenges due to organisational routines and constraints. However, by prioritising resident voices to include their needs and preferences in care, QoL can be supported following a transition into LTRC.

Detecting delirium in nursing home residents using the Informant Assessment of Geriatric Delirium (I-AGeD): a validation pilot study

Aim

The aims of this study were to record the prevalence of delirium in residents with the DSM-5, to investigate the feasibility of the I-AGeD in a Swiss nursing home and to compare the results of the I-AGeD with the DSM-5 criteria as the reference standard.

Findings

This study shows that the I-AGeD is suitable for detecting delirium in nursing home residents with a sensitivity of 60% and a specificity of 94%.

Message

The I-AGeD is a simple, brief and feasible assessment tool for the detection of delirium in nursing home residents.

Purpose

Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard.

Methods

This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult.

Results

85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer.

Conclusion

The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.

Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design

Background

Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse‐led models of care focusing on improving in‐house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse‐led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals.

Methods

A multicenter nonrandomized stepped‐wedge design within a hybrid type‐2 effectiveness‐implementation study was implemented in 11 NHs in German‐speaking Switzerland. The first NH enrolled in June 2018 and the last in November 2019. The study lasted 18 months, with a baseline period of 3 months for each NH. Inclusion criteria were 60 or more long‐term care beds and 0.8 or more hospitalizations per 1′000 resident care days. Nine hundred and forty two long‐term NH residents were included between June 2018 and January 2020 with informed consent. Short‐term residents were excluded. The primary outcome was unplanned hospitalizations. A fully anonymized dataset of overall transfers of all NH residents served as validation. Analysis was performed with segmented mixed regression modeling.

Results

Three hundred and three unplanned and 64 planned hospitalizations occurred. During the baseline period, unplanned transfers increased over time (β₁ = 0.52), after which the trend significantly changed by a similar but opposite amount (β₂ = −0.52; p = 0.0001), resulting in a flattening of the average transfer rate throughout the postimplementation period (β₁ + β₂ ≈ 0). Controlling for age, gender, and cognitive performance did not affect these trends. The validation set showed a similar flattening trend.

Conclusion

A complex intervention with six evidence‐based components demonstrated effectiveness in significantly reducing unplanned transfers of NH residents to hospitals. INTERCARE's success was driven by registered nurses in expanded roles and the use of tools for clinical decision‐making.

See related Editorial by Kaehr et al. in this issue.

Who’s in the House: Staffing in Long-Term Care Homes During the COVID-19 Pandemic

There is an absence of high-quality workforce data that could be used globally for comparative research on workforce planning in the residential long-term care (LTC) sector. We know that older adults residing in the LTC settings have multimorbidities resulting in complex care needs, yet the workforce is insufficiently able to meet their needs. A further reduction in LTC workforce was noted during the COVID-19 pandemic which increased the risk of adverse outcomes for residents. Survey results focused on the workforce in LTC homes collected from several countries during the current pandemic, highlighted that several members of the workforce were either absent or worked virtually (e.g., physicians, social workers). A better understanding of who is/or should be in the house to meet the needs of residents during or after future pandemics requires a workforce data system that routinely collects this information to ensure best quality outcomes for residents and their carers.

Transition Into LTRC During the COVID-19 Pandemic: An Ethnographic Case Study

COVID-19 has affected long-term residential care (LTRC) disproportionally due to the high-risk population, lack of resources and insufficient preventative measures. Protective measures, including quarantine and strict visitation restrictions have made transitions into LTRC more challenging. Further insight is needed to understand how residents, relatives and staff have experienced this during the COVID-19 pandemic. During four months of fieldwork in a LTRC facility in Switzerland, a rapid ethnography consisting of interviews, observations, informal conversations and document analysis was conducted. This study included a total of 14 residents, 21 healthcare staff from varying departments and 7 relatives of residents. First results indicate that protective measures interfere with a resident’s ability to find meaningful activities and interactions within LTRC as well as the possibility to maintain mobility. This and limited family contact following a move into LTRC prevents a smooth transition from home to LTRC and impacts overall resident quality of life.

Challenges in the Measurement of Staffing: A Review of Reviews

The question concerning the relationship of staffing and quality of care of residents in residential long-term care (LTC) has been explored extensively; however, no consistent evidence has been brought forth so far. Inconsistent measurement of staffing might hinder this research field to move forward. We assessed its measurement in a narrative review of reviews that explore the staff – quality of care relationship. We identified 12 systematic reviews, covering 1960 to May 2018. Most studies included had a cross-sectional design, were performed in the USA and worked with secondary, administrative data (e.g., OSCAR). Comparability of studies was limited by diverse definitions and measurement methods for staffing, including data about grade-mix, number of staff, and staff-resident ratios. We suggest performing international multi-case studies to compare and contrast LTC staffing and develop appropriate international common data elements. Logic models support the description of the expected relationship between staffing aspects and quality.

Laying Down the Groundwork for an International Measurement Infrastructure

The COVID-19 epidemic has brought to light the significant problems in the long-term care (LTC) sector, specifically the lack of an infrastructure to collect and aggregate data between LTC sectors in different countries. This talk will briefly describe goals of the WE-THRIVE initiative, and focus on exploring the development of “workforce and staffing” common data elements for LTC. We will describe how the subgroup is “laying down the groundwork” within this domain with various methodologies to develop CDEs related to workforce and staffing. The CDEs aim to measure staff retention and turnover, evaluating nursing supervisor effectiveness, and staff training in LTC. Anticipated challenges of this international work will also be highlighted. International research on LTC can valuably inform LTC policy and practice, and the proposed CDEs can facilitate data sharing and aggregation internationally, including low-, middle-, and high-income countries.

Defining Appropriate Resources for Nursing Homes to Reduce Potentially Avoidable Transfers After a Fall

Falls are common in nursing home (NH) residents and are the predominant reason for an emergency department (ED) transfer. Falls are responsible for 25% - 87% of ED transfers, a proportion of which are potentially avoidable. INTERCARE – an implementation science study reducing unplanned hospitalizations (2018 – 2020) – involved experts to identify potentially avoidable fall-related transfers. Focus group and stakeholder survey enabled identification of resources to safely manage some falls in NHs. 25.9% of fall-related transfers were potentially avoidable based on using root-cause analysis and discharge reports. Avoidability was associated to ED visit, compared to hospitalizations. Appropriate resources identified by stakeholders included timely access to outpatient services for diagnostic imaging (e.g., X-Ray) and clinical skills’ training in suturing and wound care for registered or specialist nurses. Although NHs are striving for a home-like environment, better access to basic diagnostic and treatment services within NHs should be possible.

Quality of care is what we make of it: a qualitative study of managers' perspectives on quality of care in high-performing nursing homes

Background

Leadership has a vital role regarding quality of care in nursing homes. However, few studies have explored upper-level managers’ views on how to assure that residents receive high quality of care. Therefore, this study’s aim was to examine how managers of top-quality nursing homes define, develop and maintain high-quality of care.

Method

We used interpretive description, an inductive, qualitative approach. Our research included 13 semi-structured interviews with 19 managers. We analyzed their input using reflexive thematic analysis, which is an iterative approach.

Results

Quality development and maintenance are cyclic processes. Managers in high-performing nursing homes lead with high commitment towards a person-centred quality of care, creating appropriate working conditions and continuously co-creating a vision and the realization of quality of care together with employees.

Conclusions

This study confirms that, in high-performing nursing homes, a person-centered approach—one where both residents and employees are at the center—is essential for quality development and maintenance. The most effective managers exemplify “person centeredness”: they lead by example and promote quality-focused working conditions. Such strategies motivate employees to provide person-centered care. As this means focusing on residents’ needs, it results in high care quality.

Residents' and Relatives' Experiences of Acute Situations: A Qualitative Study to Inform a Care Model

Background and Objectives

As new models of care aiming to reduce hospitalizations from nursing homes emerge, their implementers must consider residents’ and relatives’ needs and experiences with acute changes in the residents’ health situations. As part of the larger INTERCARE implementation study, we explored these persons’ experiences of acute situations in Swiss nursing homes.

Research Design and Methods

3 focus groups were conducted with residents and their relatives and analyzed via reflexive thematic analysis.

Results

The first theme, the orchestra plays its standards, describes experiences of structured everyday care in nursing homes, which functions well despite limited professional and competency resources. The second theme, the orchestra reaches its limits, illustrates accounts of acute situations in which resources were insufficient to meet residents’ needs. Interestingly, participants’ perceptions of acute situations went well beyond our own professional view, that is, changes in health situations, and included situations best summarized as “changes that might have negative consequences for residents if not handled adequately by care workers.” Within the third theme, the audience compensates for the orchestra’s limitations, participants’ strategies to cope with resource limitations in acute situations are summarized.

Discussion and Implications

Our findings suggest differences between care providers’ and participants’ perspectives regarding acute situations and care priority setting. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning and meeting individual residents’ and relatives’ needs. Implications for the development and implementation of a new nurse-led model of care are discussed.

Regional variation of potentially avoidable hospitalisations in Switzerland: an observational study

Background

Primary health care is subject to regional variation, which may be due to unequal and inefficient distribution of services. One key measure of such variation are potentially avoidable hospitalisations, i.e., hospitalisations for conditions that could have been dealt with in situ by sufficient primary health care provision. Particularly, potentially avoidable hospitalisations for ambulatory care-sensitive conditions (ACSCs) are a substantial and growing burden for health care systems that require targeting in health care policy.

Aims

Using data from the Swiss Federal Statistical Office (SFSO) from 2017, we applied small area analysis to visualize regional variation to comprehensively map potentially avoidable hospitalisations for five ACSCs from Swiss nursing homes, home care organisations and the general population.

Methods

This retrospective observational study used data on all Swiss hospitalisations in 2017 to assess regional variations of potentially avoidable hospitalisations for angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, diabetes complications and hypertension. We used small areas, utilisation-based hospital service areas (HSAs), and administrative districts (Cantons) as geographic zones. The outcomes of interest were age and sex standardised rates of potentially avoidable hospitalisations for ACSCs in adults (> 15 years). Our inferential analyses used linear mixed models with Gaussian distribution.

Results

We identified 46,479 hospitalisations for ACSC, or 4.3% of all hospitalisations. Most of these occurred in the elderly population for congestive heart failure and COPD. The median rate of potentially avoidable hospitalisation for ACSC was 527 (IQR 432–620) per 100.000 inhabitants. We found substantial regional variation for HSAs and administrative districts as well as disease-specific regional patterns.

Conclusions

Differences in continuity of care might be key drivers for regional variation of potentially avoidable hospitalisations for ACSCs. These results provide a new perspective on the functioning of primary care structures in Switzerland and call for novel approaches in effective primary care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06876-5.