Are we making the most of safe staffing research.

INTRODUCTION: The uptake of research evidence on staffing issues in nursing by nursing leadership, management and into organizational policies seems to vary across Europe. This study wants to assess this uptake of research evidence. DESIGN: Scoping survey. METHOD: The presidents of twelve country specific Sigma Chapters within the European Region answered written survey questions about work organisation, national staffing levels, national skill mix levels, staff characteristics, and education. RESULTS: Seven of the 12 chapters could not return complete data, reported that data was unavailable, there was no national policy or only guidance related to some settings. CONCLUSION: Enhancing the awareness of nursing research and of nursing leaders and managers regarding staffing level evidence is not enough. It seems necessary to encourage nurse leaders to lobby for staffing policies. CLINICAL RELEVANCE: Research evidence on staffing issues in nursing and how it benefits health care is available. In Europe this evidence should be used more to lobby for change in staffing policies.

The impact of electronic and self-rostering systems on healthcare organisations and healthcare workers: A mixed-method systematic review.

AIM: To synthesise evidence from studies that explored the impact of electronic and self-rostering systems to schedule staff on healthcare organisations and healthcare workers. DESIGN: Mixed-method systematic review. METHODS: Studies were screened by two independent reviewers and data were extracted using standardised data extraction tables. The quality of studies was assessed, and parallel-results convergent synthesis was conducted. DATA SOURCES: Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO and PsycARTICLES were searched on January 3, 2023. RESULTS: Eighteen studies were included (10 quantitative descriptive studies, seven non-randomised studies and one qualitative study). Studies examined two rostering interventions including self-rostering (n = 12) and electronic rostering (n = 6). It was found that the implementation of electronic and self-rostering systems for staff scheduling impacted positively on both, healthcare workers and healthcare organisations. Benefits included enhanced roster efficiency, staff satisfaction, greater control and empowerment, improved work-life balance, higher staff retention and reduced turnover, decreased absence rates and enhanced healthcare efficiency. However, self-rostering was found to be less equitable than fixed rostering, was associated with increased overtime, and correlated with a higher frequency of staff requests for shift changes. CONCLUSION: The impact of electronic and self-rostering systems to schedule staff on healthcare organisations and healthcare workers' outcomes was predominantly positive. Further randomised controlled trials and longitudinal studies are warranted to evaluate the long-term impact of various rostering systems, including electronic and self-rostering systems. IMPLICATIONS FOR HEALTHCARE: Rostering is a multifaceted responsibility for healthcare administrators, impacting patient care quality, workforce planning and healthcare expenditure. IMPACT: Given that healthcare staffing costs constitute a substantial portion of global healthcare expenditure, efficient and strategic resource management, inclusive of healthcare staff rostering, is imperative. REPORTING METHOD: The 27-item Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

The impact of the mySupport advance care planning intervention on family caregivers' perceptions of decision-making and care for nursing home residents with dementia: pretest-posttest study in six countries.

BACKGROUND: the mySupport advance care planning intervention was originally developed and evaluated in Northern Ireland (UK). Family caregivers of nursing home residents with dementia received an educational booklet and a family care conference with a trained facilitator to discuss their relative's future care. OBJECTIVES: to investigate whether upscaling the intervention adapted to local context and complemented by a question prompt list impacts family caregivers' uncertainty in decision-making and their satisfaction with care across six countries. Second, to investigate whether mySupport affects residents' hospitalisations and documented advance decisions. DESIGN: a pretest-posttest design. SETTING: in Canada, the Czech Republic, Ireland, Italy, the Netherlands and the UK, two nursing homes participated. PARTICIPANTS: in total, 88 family caregivers completed baseline, intervention and follow-up assessments. METHODS: family caregivers' scores on the Decisional Conflict Scale and Family Perceptions of Care Scale before and after the intervention were compared with linear mixed models. The number of documented advance decisions and residents' hospitalisations was obtained via chart review or reported by nursing home staff and compared between baseline and follow-up with McNemar tests. RESULTS: family caregivers reported less decision-making uncertainty (-9.6, 95% confidence interval: -13.3, -6.0, P < 0.001) and more positive perceptions of care (+11.4, 95% confidence interval: 7.8, 15.0; P < 0.001) after the intervention. The number of advance decisions to refuse treatment was significantly higher after the intervention (21 vs 16); the number of other advance decisions or hospitalisations was unchanged. CONCLUSIONS: the mySupport intervention may be impactful in countries beyond the original setting.

Staff knowledge, attitudes and confidence levels for fall preventions in older person long-term care facilities: a cross-sectional study.

BACKGROUND: Falls are the most common health problem affecting older people in long-term care facilities (LTCFs), with well-recognised adverse psychological and physical resident outcomes, and high staff burden and financial cost. LTCF staff knowledge and skills can play a vital role in providing and promoting fall prevention care. METHODS: A descriptive cross-sectional survey study was conducted across 13 LTCF sites in the Southwest of Ireland; a sampling frame facilitated inclusion of a range of provider types and facility sizes. An existing questionnaire, based on fall prevention guidance, and examining staff knowledge, skills and attitudes, was distributed in physical and online formats. RESULT: The response rate was 15% (n = 155), predominantly healthcare assistants, staff nurses and senior nurses. Almost 90% expressed high confidence levels for delivering fall prevention interventions and being aware of how falls affect LTCFs. However, over half underestimated the fall rate in LTCFs, and only 60% had adequate knowledge. Longer experience in working with older people in healthcare services was associated with greater knowledge (p = .001) and confidence in fall prevention interventions (p = .01), while senior nurses had more knowledge than others (p = .01). LTCF staff had lowest knowledge about "identification systems for residents at high risk of falling", "keeping confused residents near nursing stations", "the effect of using antipsychotic medicine on falls", "using a toileting regimen" and "staff responsibility regarding fall prevention efforts". Despite their knowledge gaps, nearly 50% thought they had enough fall prevention training; their main preference for any further fall education training was face-to-face education. CONCLUSION: The results, with the caveat of a low response rate, show the need for interdisciplinary fall prevention training that is tailored to both the perceived learning needs and actual knowledge gap of LTCF staff and their preferences for learning delivery, as part of an overall approach to reducing fall-related adverse outcomes.

Staff's insights into fall prevention solutions in long-term care facilities: a cross-sectional study.

BACKGROUND: Falls are one of the most common and serious health issues in long-term care facilities (LTCFs), impacting not just residents, but staff and the healthcare system. This study aimed to explore LTCF staff's current practices around falls prevention, and their suggested solutions for better falls prevention. METHODS: In the southwest of Ireland, a descriptive cross-sectional study was conducted in 13 LTCF sites, across a range of provider types and facility sizes. A survey, measuring staff knowledge, skills and attitudes, was distributed in physical and online formats. Staff suggestions for prioritising fall and fall-related injury prevention activities, and current staff practices regarding fall incidents were also sought. Content analysis was used to analyse responses, mapping categories and subcategories to the refined theoretical domains framework (TDF) and to an existing fall prevention guideline. RESULTS: There were 155 respondents (15% response rate), from staff of the LTCFs. Environmental reviews and modifications (aligned to the TDF environmental context and resource domain) were the most common suggestions for preventing both falls and fall-related injuries. Other common suggestions for preventing falls were staff education, monitoring of residents, and using alarm/calling systems, while few staff members, across all roles, reported assessing residents, exercises, reviewing medications, and vitamin D supplements. For preventing fall-related injuries, suggestions included protective equipment, hip protectors and alarm/calling systems. Staff used a standardised approach when responding to a fall incident, with intensive and holistic post-fall control measures. HCAs focussed on transferring residents safely, while nurses of all grades focused more on post-fall assessment. Respondents believed that staff education, communication, increasing staffing levels and enhancing specialist care could support their practice. CONCLUSION: Noting the low response rate, the results suggest an awareness gap regarding some evidence-based, resident-focussed falls prevention solutions, such as pro-active fall-risk assessment, exercise, medication review, and Vitamin D supplements. These aspects should be included in future fall prevention education programmes in LTCFs.

Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review.

BACKGROUND: Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies. METHODS: A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001-2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results. RESULTS: Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3-17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders' interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8). CONCLUSION: This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined. TRIAL REGISTRATION: This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.

Family caregivers' experience of communication with nursing home staff from admission to end of life during the COVID-19 pandemic: A qualitative study employing a transitional perspective.

OBJECTIVES: Family caregivers' (FCs) caregiving in nursing home (NH) moves across 3 main phases: transitioning relatives to long-term care, worsening of a relative's conditions, and end of life; each phase brings specific challenges that FCs must confront. Moreover, during the COVID-19 pandemic, strict mandatory visitor restrictions affected communication modalities. This study explored FCs' experience of communication with NH staff during the COVID-19 pandemic from admission to end of life. METHODS: A descriptive qualitative study with inductive content analysis was performed in 7 Italian NHs from May to June 2021. NH managers purposively identified 25 FCs at different phases of their caregiving trajectory: transitional (i.e., admission in the previous 8 weeks, n = 8), deterioration-in-condition (i.e., acknowledged changes in care needs of their relative after trigger events, n = 10), and end-of-life phase (i.e., death expected in the next weeks or a few months, n = 7), who were interviewed. RESULTS: Regardless the phase of caregiving trajectory, what mattered most to FCs was the opportunity to have regular and sensitive discussions with health-care professionals. The need of in-person communication increased nearing death. The COVID-19 pandemic enhanced FCs' need to interact with health-care professionals they trusted. Knowledge of residents' preferences mitigated FCs' turbulent emotions throughout the overall caregiving trajectory. SIGNIFICANCE OF RESULTS: Findings suggest that in-person contacts should be prioritized and facilitated when possible, particularly at the end of life; nonetheless, meaningful communication can occur also through remote modalities. Investments in training health-care professionals about effective long-distance communication and supportive skills can help trusting relationships to be established. Open discussions about residents' care preferences should be encouraged.

Interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes: A mixed-methods systematic review.

BACKGROUND: Most people with dementia transition into nursing homes as their disease progresses. Their family caregivers often continue to be involved in their relative's care and experience high level of strain at the end of life. AIM: To gather and synthesize information on interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes and provide a set of recommendations for practice. DESIGN: Mixed-Methods Systematic Review (PROSPERO no. CRD42020217854) with convergent integrated approach. DATA SOURCES: Five electronic databases were searched from inception in November 2020. Published qualitative, quantitative, and mixed-method studies of interventions to support family caregivers of people with advanced dementia at the end of life in nursing home were included. No language or temporal limits were applied. RESULTS: In all, 11 studies met the inclusion criteria. Data synthesis resulted in three integrated findings: (i) healthcare professionals should engage family caregivers in ongoing dialog and provide adequate time and space for sensitive discussions; (ii) end-of-life discussions should be face-to-face and supported by written information whose timing of supply may vary according to family caregivers' preferences and the organizational policies and cultural context; and (iii) family caregivers should be provided structured psychoeducational programs tailored to their specific needs and/or regular family meetings about dementia care at the end of life. CONCLUSION: The findings provide useful information on which interventions may benefit family caregivers of people with advanced dementia at the end of life and where, when, and how they should be provided.

A family carer decision support intervention for people with advanced dementia residing in a nursing home: a study protocol for an international advance care planning intervention (mySupport study).

BACKGROUND: Where it has been determined that a resident in a nursing home living with dementia loses decisional capacity, nursing home staff must deliver care that is in the person's best interests. Ideally, decisions should be made involving those close to the person, typically a family carer and health and social care providers. The aim of the Family Carer Decisional Support intervention is to inform family carers on end-of-life care options for a person living with advanced dementia and enable them to contribute to advance care planning. This implementation study proposes to; 1) adopt and apply the intervention internationally; and, 2) train nursing home staff to deliver the family carer decision support intervention. METHODS: This study will employ a multiple case study design to allow an understanding of the implementation process and to identify the factors which determine how well the intervention will work as intended. We will enrol nursing homes from each country (Canada n = 2 Republic of Ireland = 2, three regions in the UK n = 2 each, The Netherlands n = 2, Italy n = 2 and the Czech Republic n = 2) to reflect the range of characteristics in each national and local context. The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework will guide the evaluation of implementation of the training and information resources. Our mixed methods study design has three phases to (1) establish knowledge about the context of implementation, (2) participant baseline information and measures and (3) follow up evaluation. DISCUSSION: The use of a multiple case study design will enable evaluation of the intervention in different national, regional, cultural, clinical, social and organisational contexts, and we anticipate collecting rich and in-depth data. While it is hoped that the intervention resources will impact on policy and practice in the nursing homes that are recruited to the study, the development of implementation guidelines will ensure impact on wider national policy and practice. It is our aim that the resources will be sustainable beyond the duration of the study and this will enable the resources to have a longstanding relevance for future advance care planning practice for staff, family carers and residents with advanced dementia.

Guidance for family about comfort care in dementia: a comparison of an educational booklet adopted in six jurisdictions over a 15 year timespan.

BACKGROUND: To support family caregivers of people with dementia in end-of-life decision making, a family booklet on comfort care has been adapted and adopted by several European jurisdictions since the original publication in Canada in 2005. METHODS: We analyzed and compared the adaptations to the family booklets used in Canada, the Czech Republic, Italy, the Netherlands, the UK and Ireland that were made up to 2021. Qualitative content analysis was used to create a typology of changes to the original booklet. Interviews with the teams that adapted the booklets contributed to methodological triangulation. Further, using an established framework, we assessed whether the contents of the booklets addressed all domains relevant to optimal palliative dementia care. RESULTS: The booklets differed in the types of treatment addressed, in particular tube feeding, euthanasia, and spiritual care. There was also variability in the extent to which medical details were provided, an emphasis on previously expressed wishes in medical decision making, addressing of treatment dilemmas at the end of life, the tone of the messages (indirect or explicit) and the discussion of prognosis (as more or less positive), and the involvement of various healthcare professionals and family caregivers in care. All booklets addressed all domains of palliative dementia care. CONCLUSIONS: We identified core elements in providing information on end-of-life care to family caregivers of people with dementia as related to optimal palliative care in dementia. Additionally, local adaptations and updates are required to account for socio-cultural, clinical, and legal differences which may also change over time. These results may inform development of educational and advance care planning materials for different contexts.

Visitor restrictions during the COVID-19 pandemic: An ethical case study.

To prevent and reduce the transmission of the coronavirus to vulnerable populations, the World Health Organization recommended the restriction of visitors to nursing homes. It was recognised that such restrictions could have profound impact on residents and their families. Nonetheless, these measures were strictly imposed over a prolonged period in many countries; impeding families from remaining involved in their relatives' care and diluting the meaningful connections for residents with society. It is timely to explore the impact of public health measures on people living in nursing homes from an ethical perspective. In order to foreground the ethical dimensions of the implications of visitor restrictions in nursing homes, we compiled an ethical case that reflects some recent experiences of nursing homes residents and their families, in the Irish Republic. We describe a series of events encountered by a woman and her family during the first wave of the pandemic in 2020 and we deploy an ethical decision-making tool to guide and structure our analysis. Our case analysis draws attention to ethical principles that are relevant to explicating the ethical duties and obligations that arise in relation to the interests, well-being, and safety of residents and their families, as well as nursing home staff and the wider community during a pandemic. These include the right of autonomy, trust, minimising harm, and proportionality. We conclude that a number of different strategies should be adopted by nursing homes and relevant regulatory bodies. This includes honest, regular communication between the nursing home staff, the resident and their family. Central to communications is the resident's wishes, their current clinical status and the all-important wider public health obligations. National strategies include mass vaccination, the timely provision of guidance documents and interventions from regulatory bodies that are patient-centred, adaptable, and cost effective.

Challenges of living with and managing inflammatory bowel disease: A meta-synthesis of patients' experiences.

AIMS AND OBJECTIVES: To examine qualitative studies which reported on patients' challenges of living with and managing inflammatory bowel disease (IBD). BACKGROUND: There is a growing body of qualitative research focusing on the subjective experiences of patients with IBD. This research points to the daily challenges that patients experience which can relate to their physical and psychological health, as well as their social well-being, and may impact negatively on their lives. To date, there has been little attempt to synthesise these studies, and little is known about how patients manage the challenges they experience. DESIGN: A meta-synthesis was conducted, based on guidelines developed by Sandelowski and Barroso (Handbook for synthesizing qualitative research, Springer, New York, NY, 2007) and PRISMA (Int J Surg, 8, 2009, 336). METHODS: Searches were conducted within the CINAHL, MEDLINE, PsycINFO, Psychology and Behavioural Sciences Collection and SocINDEX databases to locate qualitative and mixed methodology studies. The retrieved articles were screened against predetermined inclusion criteria. Quality appraisal was assessed using the Joanna Briggs Institute critical appraisal tool for qualitative research (Int J Evid Based Healthc, 13, 2015, 179). RESULTS: Thematic analysis resulted in three themes: the unpredictability of living with IBD, the emotional turmoil of living with IBD and striving to maintain a normal life in managing IBD. CONCLUSION: The greatest challenges for patients identified in this meta-synthesis were the physical symptoms associated with IBD. These impacted negatively on their psychological and social well-being and reduced their quality of life. There is a notable gap in research on patient experiences of managing the challenges identified in everyday life and to what extent they receive support from healthcare professionals. RELEVANCE TO CLINICAL PRACTICE: The results of this meta-synthesis offer insights into how the physical challenges of living with IBD, particularly in relation to symptoms, impact adversely on patients' psychological and social well-being. These insights are clinically relevant to healthcare professionals as a basis for supporting patients to manage their challenges.

The Role, Education, and Experience of Health Care Assistants in End-of-Life Care in Long-Term Care: A Scoping Review.

The changing age profile of the human population globally means that the requirement for residential long-term care (LTC) for older adults is escalating, with an associated increase in deaths in these facilities. Health care assistants (HCAs), whose main role is provision of direct care to residents, comprise the largest staff cohort in residential care for older adults. The purpose of this scoping review was to explore three key areas related to HCAs: their role and responsibilities, end-of-life (EOL) education, and their views and experiences of caring for residents at EOL. The literature search included five databases and 32 studies were ultimately reviewed. Key issues were as follows: HCAs feel marginalized and undervalued, they need and desire EOL education, and resident deaths impact negatively on them. The changing care needs for older adults with complex comorbidities at EOL in LTC will place an increased onus on HCAs' skills, knowledge, and personal and professional development. [Journal of Gerontological Nursing, 46(1), 21-29.].

The impact of compassionate care education on nurses: A mixed-method systematic review.

AIMS: To identify, describe, and summarize evidence from quantitative, qualitative, and mixed-method studies conducted to prepare nurses and nursing students to lead on and/or deliver compassionate care. DESIGN: Mixed-method systematic review. DATA SOURCES: CINAHL, Medline, PsychINFO, and SocINDEX (January 2007-February 2018). REVIEW METHODS: Papers were screened by two independent reviewers using an online screening tool and data were extracted using a standardized data extraction table. Parallel-results convergent synthesis was used to synthesize evidence from included qualitative, quantitative, and mixed-method studies. Quality appraisal and risk of bias assessment were conducted. RESULTS: Fifteen studies were included with three main themes and six sub-themes: (a) programme impact (impact on ward-level and senior nurses and impact on nursing students and educators); (b) programme characteristics (characteristics leading to positive outcomes and characteristics leading to negative outcomes); and (c) programme implementation (implementation barriers and implementation facilitators). Compassionate care education programmes helped enhance nurses' ability to engage in reflective practice, deal with clinical challenges, and gain confidence. The importance of nurturing compassionate care delivery in nursing education was highlighted in the literature. Various nursing-level, patient-level, and organizational barriers to compassionate care delivery were identified. CONCLUSION: The impact of compassionate care educational programmes on nurses was predominantly positive. Further evaluation of the long-term impact of these programmes on nurses, patients, and organizations is warranted. IMPACT: Optimal delivery of compassionate care can be achieved by building organizational infrastructures that support nurses from all levels to attend education programmes and lead on compassionate care delivery.

Impact of a compassionate care leadership programme.

Compassionate care delivery enhances patient satisfaction and quality of life and reduces nurse burnout. This study measured the perceptions of nursing and midwifery leaders regarding the impact of the 'Leaders for Compassionate Care Programme' on their personal development, learning experience, service and care delivery, programme quality, and satisfaction with the programme. Seventy-nine leaders were surveyed using the Leaders for Compassionate Care Outcomes Evaluation Questionnaire and the Leaders for Compassionate Care Evaluation Questionnaire. Participants' perceived ability to support peer learning, manage conflict, and build trust with patients increased significantly following the programme (P≤0.001). Over 80% of participants reported that they were able to apply to practice what they had learnt from the programme and reported an increase in their motivation to lead in compassionate care delivery. Various strategies are needed to improve compassionate care leadership and further research is needed to explore the long-term impact of the programme.

Men's perspectives on cancer prevention behaviors associated with HPV.

BACKGROUND: The human papillomavirus (HPV) is associated with the diagnosis of anal, penile, and oropharyngeal cancers in men. Evidence indicates that correct condom use in addition to obtaining the HPV vaccine provides the greatest protection from HPV infections. OBJECTIVE: To explore young men's beliefs and behavioral intention in relation to receiving the HPV vaccine and using a condom correctly and consistently for sexual contact. METHODS: A cross-sectional study underpinned by the theory of planned behavior (TPB) was conducted with male participants (n = 359, 18-28 years) who completed an online survey. Descriptive, correlational, and hierarchical regression analyses were performed on both status variables and variables of the TPB. RESULTS: Subjective norms (ß = 0.519, P < .001) was identified as the most influential predictor in relation to men's intention to receive the HPV vaccine, while relationship status (ß = -0.215, P < .001) and attitudes (ß = 0.394, P < .001) presented as the most significant predictors of intention to use a condom. Summarily, 51% of the variance in intention to receive the HPV vaccine and 44% in intention to use a condom were explained by the TPB model. CONCLUSION: Results from this study will impact on future sexual health research, education programs, and interventions for both HPV preventative behaviors towards the elimination of HPV-related cancers in men.

Challenges in implementing an advance care planning programme in long-term care.

BACKGROUND: A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the 'Let Me Decide' advance care planning programme in long-term-care. RESEARCH DESIGN: This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval. FINDINGS: Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training. DISCUSSION: The challenges encountered were largely concerned with preserving resident's autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources. CONCLUSIONS: Although it may be too late for many long-term-care residents to complete their own advance care directive, the ' Let Me Decide' programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.

Measuring staff perception of end-of-life experience of older adults in long-term care.

BACKGROUND: Quality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards. METHODS: A questionnaire measuring staff perception of their patient's end of life experience (SPELE) was developed. Content validity (CVI) was assessed by a panel of experts, and piloting was conducted with dyads of healthcare assistants (n=15) and nurses (n=15). RESULTS: The SPELE captures facets of the quality of the death and dying experience from healthcare staff's perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain. CONCLUSION: Further testing of the questionnaire is required. However it is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL.

The inter-rater reliability of the Risk Instrument for Screening in the Community.

Predicting risk of adverse healthcare outcomes is important to enable targeted delivery of interventions. The Risk Instrument for Screening in the Community (RISC), designed for use by public health nurses (PHNs), measures the 1-year risk of hospitalisation, institutionalisation and death in community-dwelling older adults according to a five-point global risk score: from low (score 1,2) to medium (3) to high (4,5). We examined the inter-rater reliability (IRR) of the RISC between student PHNs (n=32) and expert raters using six cases (two low, medium and high-risk), scored before and after RISC training. Correlations increased for each adverse outcome, statistically significantly for institutionalisation (r=0.72 to 0.80, p=0.04) and hospitalisation (r=0.51 to 0.71, p<0.01) but not death. Training improved accuracy for low-risk but not all high-risk cases. Overall, the RISC showed good IRR, which increased after RISC training. That reliability fell for some high-risk cases suggests that the training programme requires adjustment to improve IRR further.

The Risk Instrument for Screening in the Community (RISC): a new instrument for predicting risk of adverse outcomes in community dwelling older adults.

BACKGROUND: Predicting risk of adverse healthcare outcomes, among community dwelling older adults, is difficult. The Risk Instrument for Screening in the Community (RISC) is a short (2-5 min), global subjective assessment of risk created to identify patients' 1-year risk of three outcomes:institutionalisation, hospitalisation and death. METHODS: We compared the accuracy and predictive ability of the RISC, scored by Public Health Nurses (PHN), to the Clinical Frailty Scale (CFS) in a prospective cohort study of community dwelling older adults (n = 803), in two Irish PHN sectors. The area under the curve (AUC), from receiver operating characteristic curves and binary logistic regression models, with odds ratios (OR), compared the discriminatory characteristics of the RISC and CFS. RESULTS: Follow-up data were available for 801 patients. The 1-year incidence of institutionalisation, hospitalisation and death were 10.2, 17.7 and 15.6 % respectively. Patients scored maximum-risk (RISC score 3,4 or 5/5) at baseline had a significantly greater rate of institutionalisation (31.3 and 7.1 %, p < 0.001), hospitalisation (25.4 and 13.2 %, p < 0.001) and death (33.5 and 10.8 %, p < 0.001), than those scored minimum-risk (score 1 or 2/5). The RISC had comparable accuracy for 1-year risk of institutionalisation (AUC of 0.70 versus 0.63), hospitalisation (AUC 0.61 versus 0.55), and death (AUC 0.70 versus 0.67), to the CFS. The RISC significantly added to the predictive accuracy of the regression model for institutionalisation (OR 1.43, p = 0.01), hospitalisation (OR 1.28, p = 0.01), and death (OR 1.58, p = 0.001). CONCLUSION: Follow-up outcomes matched well with baseline risk. The RISC, a short global subjective assessment, demonstrated satisfactory validity compared with the CFS.