Building a culture of safety in Australian residential aged care facilities: protocol for a longitudinal mixed methods research programme.

INTRODUCTION: The quality and safety of care within residential aged care facilities (RACFs) have been linked to their organisational culture. However, evidence for understanding and improving culture in this setting is limited. This research programme aims to validate a survey to measure organisational culture and determine the relationship of culture with safety and quality of care, then to evaluate an organisational culture change programme in Australian RACFs. METHODS AND ANALYSIS: This is a longitudinal mixed methods programme of research conducted across four studies in collaboration with a national aged care provider that cares for more than 5000 residents:Study 1: Cross-sectional staff survey of organisational culture in >50 RACFs with concurrent collection of data on quality and safety of care, and staff outcomes, to explore their associations with culture.Study 2: Ethnographic fieldwork in eight RACFs sampled to achieve maximum variation. Data from interviews, observations and documents will be analysed to identify the underlying assumptions and how cultural assumptions influence the enactment of safety and quality.Study 3: Evaluation of the implementation of the Speak Up for Safety culture change programme, focusing on its contextualisation for RACFs, implementation determinants and outcomes. Data will be collected through semistructured interviews, complimented with secondary data from program training and feedback system usage.Study 4: Evaluation of the effectiveness of the culture change programme using baseline data from study 1 and a follow-up survey of organisational culture postimplementation to assess changes in organisational culture and staff behaviour. ETHICS AND DISSEMINATION: The study has received approval from the Macquarie University Human Research Ethics Committee. Informed consent will be sought from all participants. Findings will be disseminated through journal articles, conference presentations and reports to the collaborating provider and RACFs. Survey data will be deposited into a data repository for use by others working on related research.

Incidence of Pressure Injuries in Patients at Risk Using a Powered Alternating Pressure Air Mattress: A Noninterventional Study in a Real-World Setting.

PURPOSE: The aim of the study was to determine the clinical value of using a powered alternating pressure air mattress (P-APAM) in the prevention of pressure injury (PI) in patients at medium to high risk. DESIGN: Noncomparative, observational study. SUBJECTS AND SETTING: The sample comprised 86 patients who were >18 years old, were classified as having medium to high risk of PI, had no PI at baseline, and were lying more than 15 hours a day on a specific P-APAM. Data were collected between September 2018 and July 2019, in 4 nursing homes, and 1 long-term care geriatrics hospital department in France. METHODS: In addition to guideline-based care for PI prevention, patients were followed up for 35 days following placement on the P-APAM. The main outcome was the percentage of patients who developed between day 0 and day 35 at least 1 PI of at least stage 2 on the sacrum, spine, or heel. Secondary outcomes were patient assessments of comfort, caregiver satisfaction, mattress noise level, and mattress safety. RESULTS: No patients experienced a PI (incidence = 0%; 95% confidence interval, 0.00%-4.28%). Patients were satisfied or very satisfied with the mattress in most cases in terms of comfort (77.9%) and stability (73.0%). Patients also rated the noise level of the mattress as satisfactory or very satisfactory in all cases (100%). CONCLUSION: When combined with guideline-based PI prevention measures, use of the P-APAM was associated with a low incidence of PI.

Perceptions of Older People in Nursing Facilities About Advance Care Planning: A Systematic Review.

BACKGROUND: With the ageing of the population intensifying, the implementation of advance care planning (ACP) in nursing facilities is especially crucial. OBJECTIVE: This study aimed to search and synthesise qualitative studies exploring the perspectives of older people in nursing facilities about ACP discussions. METHODS: The researchers conducted searches of PubMed, Web of Science, Cochrane Library, CNKI, Wanfang, VIP and CBM between the time of inception and October 2023. The PICo model was used to build the inclusion and exclusion criteria. Following the inclusion and exclusion criteria, two researchers screened the literature, extracted data and then integrated the literature using the integrative synthesis. RESULTS: A total of 12 articles were included, 47 themes were extracted, and three research integrations were summarised: (1) understanding of ACP; (2) attitude towards ACP; and (3) influencing factors of participation in ACP. CONCLUSION: This study offers guidance for the future development of ACP on the participation of older people in nursing facilities. IMPLICATIONS FOR PRACTICE: It is necessary to strengthen the education of ACP-related knowledge in conjunction with the cultural characteristics of different countries, to provide interdisciplinary support for older people through professional teamwork and to promote the development and improvement of ACP-related practices.

Nursing Home Certificate of Need Moratoria During the COVID-19 Pandemic Had Little Impact on Access.

In over half of US states, health planning boards monitor and control the supply of health care through certificate of need (CON) laws. The COVID-19 pandemic led several states to impose moratoria on CON regulations, hoping to bolster hospital and skilled nursing facility (SNF) beds. Using a difference-in-difference research design, we leverage 2015 to 2021 cost report data from SNFs to study the association between COVID-related CON moratoria and health care supply. Counties that imposed moratoria experienced a slight decline in per-capita SNF bed count. However, once adjusted for potential differential shocks in pre-pandemic high utilization counties, we find little evidence that moratoria led to increased nursing home capacity, overall or by urbanicity. In the context of nursing homes, we conclude that CON deregulation was relatively ineffective at mitigating pandemic-era supply concerns.

The effectiveness of a knowledge translation intervention on the implementation of NEWS2 in nursing homes, a pragmatic cluster RCT.

BACKGROUND: Improving the uptake of relevant and reliable research is an important priority in long-term care to achieve sustainable and high-quality services for the increasingly older population. AIM: The purpose was to assess the effectiveness of a tailored, adaptive and a multifaceted KT capacity program, relative to usual practice, on the implementation of National Early Warning Score 2 (NEWS2). METHODS: This study was carried out as a pragmatic cluster-randomized controlled trial. The capacity program consisted of an educational part to address implementation capacity gaps and a facilitation-upon-implementation part to address a relevant knowledge gap in nursing homes. A collective decision was made to address the challenge of early detection of clinical deterioration among nursing home residents, by implementing the (NEWS2) as clinical innovation. Public nursing homes in a Norwegian municipality (n = 21) with a total of 1 466 beds were eligible for inclusion. The study-period spanned over a 22-month period, including a 12-month follow-up. Data was extracted from the Electronic Patient Journal system and analyzed using multilevel growth model analysis. RESULTS: The intervention had a large effect on the use of NEWS2 among care staff in intervention nursing homes, compared to the control group (standardized mean difference, d = 2.42). During the final month of the implementation period, residents in the intervention group was assessed with NEWS2 1.44 times (95% CI: 1.23, 1.64) per month, which is almost four times more often than in the control group (mean = 0.38, 95% CI: 0.19, 0.57). During the follow-up period, the effect of the intervention was not only sustained in the intervention group but there was a substantial increase in the use of NEWS2 in both the intervention (mean = 1.75, 95% CI: 1.55, 1.96) and control groups (mean = 1.45, 95% CI: 1.27, 1.65). CONCLUSIONS: This tailored implementation strategy had a large effect on the use of NEWS2 among care staff, demonstrating that integrated knowledge translation strategies can be a promising strategy to achieve evidence-based care in the nursing home sector. TRIAL REGISTRATION: ISRCTN12437773 . Registered 19/3 2020, retrospectively.

The influence of care home registration type and size on senior care leader's confidence to provide palliative and end-of-life care: an explanatory sequential mixed methods study.

BACKGROUND: Care home staff are key providers of palliative and end-of-life care. Yet, little is known about how care home characteristics can influence care leader's confidence in their ability to provide optimal palliative and end-of-life care. AIM: To understand the influence of care home registration type (nursing, residential or dual registered) and size on senior care leader's confidence to provide palliative and end-of-life care. DESIGN: An explanatory sequential mixed methods study comprising an online cross-sectional survey (including the Palliative Care Self-Efficacy Scale) and qualitative individual interviews. Analysis of survey data used a multivariate logistic regression and qualitative interview data used Framework Analysis. A 'Following the Thread' method was undertaken for data integration. SETTING/PARTICIPANTS: UK care home senior care leaders, purposively sampled by registration type, size and geographical location. RESULTS: The online survey (N = 107) results indicated that nursing home senior care leaders had higher confidence scores on the Palliative Care Self-Efficacy Scale than residential care home leaders (aOR: 3.85, 95% CI 1.20-12.31, p = 0.02). Care home size did not show effect when adjusting for registration type (medium - aOR 1.71, 95% CI 0.59-4.97, p = 0.33; large - aOR 0.65, 95% CI 0.18-2.30, p = 0.5). Interviews (n = 27) identified three themes that promote confidence, (1) 'feelings of preparedness' stemming from staff expertise and experience and care home infrastructure, (2) 'partnership working' with external services as a valued member of the multidisciplinary team, and (3) a shared language developed from end-of-life care guidance. CONCLUSION: Care home senior care leader's confidence is influenced by care home characteristics, particularly availability of on-site registered nurses and the infrastructure of large care homes. All care home leaders benefit from training, working with external, multidisciplinary teams and use of guidance. However, mechanisms to achieve this differed by care home type and size. Further exploration is needed on successful integration of palliative care services and interventions to enhance confidence in residential care homes.

Navigating artificial intelligence in care homes: Competing stakeholder views of trust and logics of care.

The COVID-19 pandemic shed light on systemic issues plaguing care (nursing) homes, from staff shortages to substandard healthcare. Artificial Intelligence (AI) technologies, including robots and chatbots, have been proposed as solutions to such issues. Yet, socio-ethical concerns about the implications of AI for health and care practices have also been growing among researchers and practitioners. At a time of AI promise and concern, it is critical to understand how those who develop and implement these technologies perceive their use and impact in care homes. Combining a sociological approach to trust with Annemarie Mol's logic of care and Jeanette Pol's concept of fitting, we draw on 18 semi-structured interviews with care staff, advocates, and AI developers to explore notions of human-AI care. Our findings show positive perceptions and experiences of AI in care homes, but also ambivalence. While integrative care incorporating humans and technology was salient across interviewees, we also identified experiential, contextual, and knowledge divides between AI developers and care staff. For example, developers lacked experiential knowledge of care homes' daily functioning and constraints, influencing how they designed AI. Care staff demonstrated limited experiential knowledge of AI or more critical views about contexts of use, affecting their trust in these technologies. Different understandings of 'good care' were evident, too: 'warm' care was sometimes linked to human care and 'cold' care to technology. In conclusion, understandings and experiences of AI are marked by different logics of sociotechnical care and related levels of trust in these sensitive settings.

The Experiences of Migrant Care Workers in Long-term Care Facilities: A Scoping Review.

The employment of migrant care workers provides a remedy to face the challenges of increased demand for care of older adults. A scoping review aimed to identify, categorize, and summarize the existing knowledge about migrant care workers' working experiences in long-term care facilities. Identifying gaps in the literature can inform future research. Five electronic databases were searched in April 2024 in addition to a manual search for articles published in English. Forty-five articles were reviewed. A few studies described migrant care assistants' main tasks as assisting physical care and care assistants' characteristics grouped into personal and acquired qualities to provide good quality care. Migrant care workers experienced work satisfaction, achievement, adaptability and adjustment, organizational support, work burden, sense of loneliness, low wages, low social status, and loss of profession. They faced challenges involving inadequate knowledge of palliative care, communication and language barriers, cultural and religious differences, and health concerns. Friendly and discriminatory relationships were found between migrant care workers and stakeholders. Existing evidence regarding the experiences of migrant care workers in delivering palliative care to dying residents or facilitating death preparation is limited. Additionally, there is a notable absence of data from the perspectives of employers and residents on discrimination issues. Further research is necessary to investigate these areas.

Leadership Perspectives on Nursing Home Operations From Crisis to Control: A Mixed Methods Study.

OBJECTIVES: Nursing home (NH) leaders remain challenged to deliver quality care, despite the COVID-19 transition to an endemic phase. This study describes NH leadership perspectives on preparing and maintaining quality care during times of diminishing resources as experienced through the COVID-19 pandemic to gain insight on how best to support NHs moving forward. DESIGN: This was a cross-sectional, parallel convergent mixed methods study. SETTING AND PARTICIPANTS: This study reports quantitative data from N = 5001 NHs across 12 states along with qualitative data from a subsample of NH leaders (N = 15). METHODS: Publicly reported survey data were analyzed using descriptive statistics. Individual in-depth interviews with NH leaders conducted at 12-month follow-up were analyzed using inductive thematic coding organized by a guiding framework. Data were integrated using convergent analysis and a joint display. RESULTS: NH leaders (licensed administrators, clinical directors, and managers) reported resident and staff infection rates, and access to resources (such as personal protective equipment and testing supplies) that aligned with national trends. Leaders described their NHs (n = 14; 43% rural; 71% not for profit) to be in varied states of operational readiness (standard, contingency, crisis) to support quality infection prevention and control (IPC) at the transition to the endemic COVID-19 phase. Leadership reported continued challenges in addressing resident and staff vaccinations, securing testing supplies, obtaining financial resources to maintain acceptable levels of personal protective equipment, continued staffing shortages, and issues in implementing isolation practices in current facilities. CONCLUSION AND IMPLICATIONS: NH leaders continue to struggle delivering quality IPC care post-pandemic and require focused support in several areas. Clinical practice guidelines should include IPC practices to prevent the infection and spread of any COVID-19 variant in this endemic phase. Policies should support continued reporting of IPC-related metrics and adequate funding to account for the long-term financial burden NHs face.

Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study.

Background: Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this. Objective: To co-design and implement a scalable UK model of Needs Rounds. Design: A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework. Setting: Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each. Participants: Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings). Interventions: (1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings. Main outcome measures: A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement. Data sources: Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members. Results: The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality. Limitations: COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care. Conclusions: Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff. Future work: Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care. Study registration: This study is registered as ISRCTN15863801. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.

Care home residents often lack access to end-of-life care from hospice teams and so may experience distressing symptoms at end of life if care home staff cannot fully meet their needs. We examined how an approach which worked well in Australia called 'Palliative Care Needs Rounds' (or 'Needs Rounds') could be used in the United Kingdom. We interviewed 28 people (care home staff, hospice staff and other National Health Service/social care professionals in the community) about their understanding of the United Kingdom setting, what might help trigger change and what results they would want. We discussed these interviews at online workshops with 43 people, where we started to develop a theory of 'what would work, for whom, under what circumstances' and determine what United Kingdom Needs Rounds would look like. Six specialist palliative care services, each partnered with three to six local care homes, used Needs Rounds for a year. We collected information on care home residents, staff experiences of using Needs Rounds, relatives' perceptions of care quality, staff views of residents' quality of death, and on their ability to provide a palliative approach to residents. We found that Needs Rounds can provide care home staff and specialist palliative care staff the opportunity to work together during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while using each services' expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication between care home staff, families, specialist palliative care staff and primary care. This improves the quality of resident care, enabling residents to be cared for and die in their preferred place, and also benefits relatives by increasing their confidence in care quality.

[Towards "homelike" in nursing home: feedback from a co-design workshop with residents]. / Vers un « comme chez-soi ¼ en Ehpad: retour d'expérience d'un atelier de co-design avec des habitants.

While it is necessary to provide « homelike ¼ in nursing homes, the risk is to reduce it to decoration. As the aim is to reconcile care and home, we propose co-design, an approach involving users in the design of living spaces, as a solution. We propose tools and a protocol, then provide feedback from a workshop on co-designing a collective space with three residents in a nursing home in Île-de-France. We thoroughly analyse the contributions of the residents during the workshop, and then compare their proposals with the opinions of the nurses. We found that the workshop enabled participants to express concret needs that tended towards « homelike ¼ proposals. The convergence of day-to-day expertise, through co-design, encourages design solutions that are suitable for everyone, while its role in mediation supports organisational change in the nursing home.

Nursing Process for institutionalized older adults: contributions from knowledge awareness workshop.

OBJECTIVE: To analyze the knowledge of professionals working in a Nursing Home about the Nursing Process before and after the awareness workshop. METHODS: This is strategic action research, developed with nursing professionals and managers of a Nursing Home in Rio Grande do Sul, Brazil. Data were collected between January and June 2023, through semi-structured interviews before and after an awareness workshop. Discursive textual analysis of the data was carried out. RESULTS: The central category "Understanding about the Nursing Process in Nursing Homes" emerged, which was unitized into two units of meaning and three categories of analysis. CONCLUSION: Data revealed non-use and lack of knowledge of the Nursing Process before awareness raising. Afterwards, a deeper understanding of the topic and its importance was identified. Awareness-raising workshops contribute to transformation of knowledge.

Introducing virtual reality to older adults: A qualitative analysis of a co-design innovation with care staff.

Previous studies of Virtual Reality (VR) in aged care settings have demonstrated that the benefits can be multiple, including improved social connection and engagement and reduced social isolation in later life. However, there remains a lack of widespread uptake of VR in aged care facilities. This prompts an important question: Given the potential benefits, why is there such poor engagement in VR by aged care facilities? The aim of this qualitative study is to investigate the experience of introducing VR into an aged care facility. Our innovative approach supported care staff to introduce VR into aged care facilities. Fieldwork diaries and focus group discussions were used to document experiences of introducing VR, including the obstacles, challenges and benefits and the adaptations to aged care environments that were required to accommodate new VR activities. Thematic analysis of the data revealed that VR can be an important medium to support the wellbeing of older residents. However, our findings also indicate that there are significant challenges associated with introducing VR, including substantial costs in time, money and institutional resources and attention. This study concludes that, to be successful, VR requires substantive care and relational resources from both staff and residents that are only visible when paying attention to the contextual adjustments required to introduce the technology to a new setting. This suggests that other research on gerontechnologies would likely also benefit from further attention to the role of the broader social context - including care and relational resources - in ensuring their successful design and implementation.

Pain Prevalence and Pain Management in Nursing Home Residents With Cognitive Impairment. Results From Five Multicenter Cross-Sectional Surveys in Germany Between 2014 and 2018.

BACKGROUND: Pain management depends on continuous pain assessment and a pain concept. In particular, pain assessment and treatment are major challenges for nursing home residents (NHR) with cognitive impairment (CI). Many caregivers often lack the knowledge to recognize and appropriately treat pain in this vulnerable group. Little is known about the proportion of NHR who are fundamentally dependent on external assessment for pain due to CI. OBJECTIVE: The aim of the study was to determine pain prevalence and management among NHR with and without CI. A second objective was to determine the proportion of NHR who are dependent on external assessment for pain. METHODS: Information on pain was collected from 3,437 NHR in multicenter cross-sectional surveys in 51 German nursing homes between 2014 and 2018. The presence of current pain in one-to-one interviews was determined as well as dependencies on third-party information, number of daily pain recordings, and administration of medication for pain. The analysis included a contingency table and log regression analyses. RESULTS: Pain prevalence was 24.9% among NHR with severe CI and 40.4% among NHR without CI. Overall, 19.8% of all NHRs relied on a third-party assessment of pain. Significantly, NHR with severe CI were less likely to be classified as having pain (OR 0.51), to be assessed for pain several times a day (OR 0.53) or to receive pain medication (OR 0.55) compared with NHR without CI. No influence on pain management was shown for the type of pain assessment. CONCLUSIONS: The study provides evidence of significant deficits in pain management among NHR with moderate and severe CI in nursing homes in Germany. NHR with moderate and severe CI are significantly less likely to be observed for pain or classified as pain sufferers and receive significantly less pain medication than NHR without CI. Intensive training of staff on pain management of NHR with severe CI is recommended.

Long-Term Adoption of Televisits in Nursing Homes During the COVID-19 Crisis and Following Up Into the Postpandemic Setting: Mixed Methods Study.

BACKGROUND: There is growing evidence that telemedicine can improve the access to and quality of health care for nursing home residents. However, it is still unclear how to best manage and guide the implementation process to ensure long-term adoption, especially in the context of a decline in telemedicine use after the COVID-19 crisis. OBJECTIVE: This study aims to identify and address major challenges for the implementation of televisits among residents in a nursing home, their caring nurses, and their treating general practitioners (GPs). It also evaluated the impact of televisits on the nurses' workload and their nursing practice. METHODS: A telemedical system with integrated medical devices was introduced in 2 nursing homes and their cooperating GP offices in rural Germany. The implementation process was closely monitored from the initial decision to introduce telemedicine in November 2019 to its long-term routine use until March 2023. Regular evaluation was based on a mixed methods approach combining rigorous qualitative approaches with quantitative measurements. RESULTS: In the first phase during the COVID-19 pandemic, both nursing homes achieved short-term adoption. In the postpandemic phase, an action-oriented approach made it possible to identify barriers and take control actions for long-term adoption. The implementation of asynchronous visits, strong leadership, and sustained training of the nurses were critical elements in achieving long-term implementation in 1 nursing home. The implementation led to enhanced clinical skills, higher professional recognition, and less psychological distress among the nursing staff. Televisits resulted in a modest increase in time demands for the nursing staff compared to organizing in-person home visits with the GPs. CONCLUSIONS: Focusing on health care workflow and change management aspects depending on the individual setting is of utmost importance to achieve successful long-term implementation of telemedicine.

Physicians' understandings and experience of advance care planning in Norwegian nursing homes: a qualitative study.

BACKGROUND: Advance care planning is a way of facilitating conversations with patients about future health care, values, and preferences at end of life. Nursing home physicians have the medical responsibility and the main obligation to facilitate planned meetings with patients. Although there has been a great deal of focus on establishing advance care planning in Norwegian nursing homes, it has yet to be widely implemented. Stated reasons are that the work routines in a nursing home do not include such meetings or that implementation seems complex due to frail patients. The aim of this study is thus to explore how physicians understand and experience advance care planning and follow-up of care plans in Norwegian nursing homes. METHODS: The study has a qualitative research design with a phenomenological-hermeneutic approach based on interviews of twelve nursing home physicians working in community care. Interviews were conducted in February 2023 to May 2023, using a semi-structured interview guide. All interviews were recorded on audio files, transcribed, and analyzed using structural text analysis. RESULTS: The findings are presented based on the following themes: (1) advance care planning is a dialog and a process, (2) advance care planning implies clarifying mutual expectations, and (3) advance care planning that brings relief and hope to patients is a medical art. CONCLUSIONS: Advance care planning is a complex and dynamic process that implies medical treatment, decisions on treatment level, pain relief, and formulation of care plans where the patient's self-determination and personal values are respected. It implies an ongoing dialogue between physicians, patients, and their relatives about values such as dignity, self-understanding, social relations, and existential questions at end of life. Advance care planning requires a holistic approach that meets patients' psychological and existential needs such as comfort, trust, hope, and respect as well as their preferences and concerns.

Evaluating Real-World Implementation of INFORM (Improving Nursing Home Care through Feedback on Performance Data): An Improvement Initiative in Canadian Nursing Homes.

BACKGROUND: INFORM (Improving Nursing Home Care through Feedback on Performance Data) was a research intervention that equipped nursing home managers with skills to conduct local improvement projects and supported them in improving performance through modifiable elements in their units. Prior reports have found positive and sustained outcomes from INFORM intervention. In this article, the authors report findings from a formative service evaluation of INFORM as modified for implementation in real-world settings. METHODS: INFORM was transformed for real-world implementation with an initial cohort of 26 nursing homes in British Columbia, Canada (INFORM BC). Three stakeholder groups were involved: nursing home teams, an academic team that modified INFORM for implementation, and a BC team that implemented INFORM and coached participating nursing home teams in applying it locally. Service evaluation was conducted drawing on participants from all three stakeholder groups, using convenience sampling, with numbers varying by data source. Using a mixed methods design, outcome data included qualitative and quantitative assessment of surveys, discussions, observations, and a review of documents and resources. RESULTS: The majority of nursing home teams reported positive outcomes relative to the usefulness and relevance of the initiative for local needs despite a number of operational challenges during implementation. A key factor in their success was combining targeted external support with the opportunity to set goals and measure success locally. Challenges included a lack of time at the nursing home level, COVID-19-related disruptions, and issues with role clarity and alignment of expectations among the academic and BC teams. CONCLUSION: INFORM BC advanced the processes of change planning and transferable learning among nursing home managers and their local teams. Success was facilitated externally but defined and achieved locally. Future iterations should probe outcome sustainability and how nursing home teams adapt the INFORM approach in practice.

Rethinking Infection Control: Nursing Home Administrator Experiences during the COVID-19 Pandemic.

OBJECTIVE: To examine nursing home administrator perspectives of infection control practices in nursing homes at the height of the COVID-19 pandemic and characterize lessons learned. DESIGN: Descriptive qualitative study. SETTING AND PARTICIPANTS: Administrators from 40 nursing homes across 8 diverse health care markets in the United States. METHODS: Semistructured interviews were conducted via telephone or Zoom with nursing home administrators. Interviews were repeated at 3-month intervals, for a total of 4 interviews per participant between July 2020 and December 2021 (n = 156). Qualitative analysis of interview transcripts used modified grounded theory and thematic analysis to identify overarching themes. RESULTS: Three major themes emerged reflecting administrator experiences managing infection control practices and nursing home operations at the height of the COVID-19 pandemic. First, administrators reported that the more stringent infection control protocols implemented to manage and mitigate COVID-19 at their facilities increased awareness and understanding of the importance of infection control; second, administrators reported incorporating higher standards of infection control practices into facility-level policies, emergency preparedness plans, and staff training; and third, administrators said they and their executive leadership were reevaluating and upgrading their facilities' physical structures and operational processes for better infection control infrastructure in preparation for future pandemics or other public health crises. CONCLUSIONS AND IMPLICATIONS: Insights from this study's findings suggest important next steps for restructuring and improving nursing home infection control protocols and practices in preparation for future pandemics and public health emergencies. Nursing homes need comprehensive, standardized infection control training and upgrading of physical structures to improve ventilation and facilitate isolation practices when needed. Furthermore, nursing home emergency preparedness plans need better integration with local, state, and federal agencies to ensure effective communication, proper resource tracking and allocation, and coordinated, rapid response during future public health crises.

Leadership Matters: Investigating the Association Between Nursing Home Administrator Turnover and Quality.

BACKGROUND AND OBJECTIVES: Existing research has associated nursing home (NH) staff turnover with poor performance, yet the impact of nursing home administrator (NHA) turnover remains relatively understudied. This study aimed to explore the relationship between NHA turnover and NH quality, and to determine if this relationship was mediated by registered nurse (RN) turnover. RESEARCH DESIGN AND METHODS: Utilizing data from multiple secondary sources, including the Care Compare: Skilled Nursing Facility Quality Reporting Program (SNF QRP) and LTCFocus.org, this study employed a longitudinal analysis covering the period 2021-2022 (n = 19,645). The dependent variable was quality star ratings from SNF QRP, whereas the independent variable was NHA turnover, reflecting the number of administrators who left each facility annually. We used Baron and Kenny's mediation testing method, incorporating 2-way fixed effects (state and year level) with appropriate organizational and market level control variables. RESULTS: The results affirmed that NHA turnover negatively affected quality, decreasing the likelihood of a higher star rating by 14% with one departure and 25% with multiple departures (p = .001). Additionally, NHA turnover correlated with an increase in RN turnover by 7% and 11%, respectively, for one and multiple departures (p = .001). RN turnover fully mediated the impact of NHA turnover on quality, nullifying the direct effect of NHA turnover. DISCUSSION AND IMPLICATIONS: The results of this study highlight the synergistic relationship between administrators and caregivers in NHs. To enhance NHA retention, NHs should improve compensation and benefits. Nonetheless, broader governmental support and interventions might be necessary to sustain these improvements.