The implementation of integrated emotion-oriented care: did it actually change the attitude, skills and time spent of trained caregivers?

BACKGROUND: Successful implementation is a vital precondition for investigating the outcome of care innovation. This study concerned the evaluation of the implementation of integrated emotion-oriented care (IEOC) in psychogeriatric nursing home wards. The main question was whether the trained caregivers actually applied the knowledge and techniques of IEOC during their daily work. METHODS: The study was conducted within the framework of a randomized clinical trial into the effectiveness of IEOC in 16 wards. Preceding the experimental period, staff from 16 wards were educated and trained to work with a standardized care plan, resulting in a similar level of quality of care at the start of the trial. On the experimental wards IEOC was then implemented by training on the job in addition to training courses for personnel. To examine the implementation effectiveness, a self-report questionnaire, 'Emotion-oriented Skills in the Interaction with Elderly People with Dementia', was administered at baseline and after 7 months to a sample of caregivers from the experimental and the control wards. In addition, participant observation was conducted on four experimental and four control wards, and time spent by care personnel on different type of care tasks was registered. RESULTS: The implementation of IEOC resulted in increased emotion-oriented skills and more knowledge of the residents among the caregivers. Providing IEOC was not more time consuming for the caregivers than providing usual care. CONCLUSION: This study shows that the implementation of IEOC was effective. It is recommended that in intervention studies the correct application of a new intervention or care approach is examined before jumping to conclusions about the effectiveness of the intervention or care approach itself.

[Long-term goals for oral health]. / Lang leve de duurzame mondzorg.

The current, optimistic prognosis is that newborns will reach an average age of 100 years. This increased life-expectancy requires a renewed vision of long-term goals for oral health. The starting-point could be a prospective end-point with minimal oral function which should be reached, for example, in the last years of one's life. The consequence is that adequate oral healthcare for the elderly starts in childhood. Choices such as the extraction of premolars for orthodontic reasons and the dental re-restoration cycle have a great negative impact on reaching this goal. The average sustainability of dental restorations or prosthetic constructions is commonly much shorter than the life-expectancy of a patient. If oral treatment is necessary, it is recommended to give priority to maintaining a minimally functional dentition up to an advanced age, instead offocusing on short- or medium-term goals.

[Proxy consent and responsibility: professional autonomy and adamant family members]. / Vertegenwoordiging en verantwoordelijkheid. Over medische verantwoordelijkheid en mondige familieleden.

Research into the role of family members in the decision making process concerning medical treatment of incompetent patients in nursing home care, shows that the involvement of a proxy decision maker implies a greater responsibility of the physician. It is the duty of the proxy decision-maker (mostly a family member) to look after the incompetent patient's interests. But it is the physician's duty to decide whether the proxy decision maker indeed fulfills this task. Even so, the physician has the professional responsibility to decide on the medical course of action. Involvement of others (relations and other health care professionals) is of great importance to the answer to the question 'What is good for this patient?' but does not absolve the physician from the obligation to decide professionally what is the right thing to do.

[Death due to or despite the doctor]. / Overlijden dankzij of ondanks de arts.

In the last week of life, the extent and kind of medical practice differ both in intention and in the degree of orientation on the outcome. Patients tend to put long-term prescriptions aside or ask for symptom-relieving medication and sometimes for palliative sedation, euthanasia or physician-assisted suicide. Competent physicians are able to offer or withhold treatment. In case of unconsciousness or severe cognitive impairment, proxies may ask for medical relief of disturbing symptoms. Medical practice is subject to the Dutch Medical Treatment Act (1995). At the start of the specific Dutch law specifying judicial review of euthanasia and physician-assisted suicide (1993, implemented in 2002) 1.8% of deaths concerned euthanasia. In 2005, standard drugs (choice, dose and route of administration) were highly effective in all cases of euthanasia in which they were used (76%): death within a median of 3-4 min, maximum 90 min. In the absence of medical indications for drug overdose, morphine and other choices are now considered obsolete for euthanasia and physician-assisted suicide. The definition of euthanasia must be based exclusively on a standard method and outcome: death on request by a standard medical method with a standard judicial review.

[There is no natural death without suffering, even in a nursing home]. / Geen natuurlijk overlijden zonder lijden, ook in het verpleeghuis.

During the past 30 years, the legal and moral framework for terminal care and hospice provision has changed, both nationally and internationally, but the situation is still not completely clear. The nursing homes in the Netherlands have also developed, described and implemented palliative care. In most regional systems for palliative care, a supportive and sometimes an active therapeutic role is played by medical, nursing, paramedical and pastoral nursing home professionals. In view of the strong relationship between a poor or worsening nutritional state and fluid balance and death, particularly of psychogeriatric nursing-home patients, a multiprofessional guideline has been drawn up for the responsible provision of food and fluids in nursing homes. It is likely, although not certain, that this guideline will contribute to the limitation of the suffering of the dying patient. The guideline will in any case make the compassion of the family and the sympathy of care-givers discussible and almost always manageable. In many nursing homes, meanwhile, it has become accepted practice, soon after admission, to discuss the future suffering of the patient during the process of dying and to record this conversation.

[Stroke services are increasingly effective]. / Stroke-services toenemend effectief.

Since the first Consensus Statement on the treatment of stroke (UK, 1988) and the European Helsingborg Declaration on the treatment of stroke (1995), 69 stroke services have been geographically spread in the Netherlands; these consist of an integrated hospital stroke unit, a nursing home rehabilitation unit, and home care. The Dutch stroke services have improved their outcomes in a cost-effective way in comparison with the usual care. Consensus on patient-oriented outcomes--arranged in order of the International Classification of Functioning, Disability and Health--is recommended.

[Practice guideline 'Influenza prevention in nursing homes and care homes', issued by the Dutch Society of Nursing Home Specialists; division of tasks between nursing home specialist, general practitioner and company doctor]. / De richtlijn 'Influenzapreventie in verpleeghuizen en verzorgingshuizen' van de Nederlandse Vereniging van Verpleeghuisartsen; taakverdeling tussen verpleeghuisarts, huisarts en bedrijfsarts.

The Dutch Society of Nursing Home Specialists has formulated a guideline for the prevention of influenza in nursing homes and care homes in The Netherlands. The guideline recommends the realisation of the highest possible degree of vaccination of both patients and health care workers. At the start of the flu season, the manager of the chronic care institute should organize a scheme for vaccination against influenza and a plan in case of an outbreak of influenza. The division of tasks between the nursing home specialist, the general practitioner and the company doctor should be recorded in both the vaccination scheme and the outbreak plan. In order to decrease the incidence of non-response to the vaccine a double dose of influenza vaccine for nursing home patients should be considered. The outbreak plan should raise the state of alertness for influenza and ensure that virological confirmation of clinical influenza is obtained quickly. Immediately after virological confirmation of clinical influenza, patients with influenza should be treated with oseltamivir and both patients and health care workers in the unit should receive prophylaxis with oseltamivir. Non-vaccinated patients should also be offered vaccination to restrict re-introduction of the virus. During an influenza outbreak, only patients with influenza or those who have had prophylactic treatment may be admitted to the facility. In the case of an influenza pandemic, national guidelines should be followed.

Classifying the probability of urinary incontinence in psychogeriatric nursing home patients.

Urinary incontinence (UI) frequently occurs in psychogeriatric nursing home patients. In general the personnel involved in the care for these patients act on incontinence noted. Patients are not monitored or classified according to likelihood or severity of incontinence. This study was conducted to develop and validate a model for the classification of the likelihood of UI in demented nursing home patients. A multi-center cross-sectional study was conducted using data on clinical and functional status of 692 subjects. Subjects were subdivided in a Derivation set of 532 patients and a Validation set of 160 patients. The data were ascertained with questionnaires completed by physicians and nursing staff. All psychogeriatric wards (25) of four Dutch nursing homes were included. Using univariate logistic regression analysis on the derivation set we identified correlates of UI among 22 clinical and functional patient characteristics. Subsequently, we developed a classification model for prevalent UI, including independent patient characteristics by means of multivariable logistic regression. Next, we stratified patients into groups with varying likelihood's of UI based on the model developed. Subsequently, we transformed the model to an easy applicable classification rule for the identification of patient subgroups with high or low likelihood on UI. Finally, the rule was validated on the validation set. The independent multivariate factors associated with urinary incontinence were impaired ADL and mobility, diminished alertness and fecal impaction. After transforming the regression model to an easy classification rule, the scores ranged from 0 to 7. The area under the curve was 0.88 (95% Confidence Interval (CI): 0.85-0.91) in the derivation set. In the validation set a similar area under the curve was obtained (0.90 (95% CI: 0.85-0.95)). Among subjects with none of the associated factors the rule classified 0.5% as incontinent patients. In case all associated factors were present the proportion classified as incontinent increased to 91%. In conclusion, the developed classification rule provides means to stratifying nursing home patients according to their likelihood of being incontinent of urine.