The implementation of telemedicine in wound care: a qualitative study of nurses' and patients' experiences.

BACKGROUND: The increasing use of telemedicine (TM) represents a major shift for health workers and patients alike. Thus, there is a need for more knowledge on how these interventions work and are implemented. We conducted a qualitative process-evaluation alongside a larger randomized controlled trial designed to evaluate a telemedicine follow-up intervention for patients with a leg- or foot-ulcer, who either have or do not have diabetes. Accordingly, the aim of this study was to explore how both health care professionals and patients experienced the implementation of TM follow-up in primary care. METHODS: The intervention comprised an interactive TM platform facilitating guidance and counselling regarding wound care between nurses in primary care and nurses in specialist health care in Norway. Nurses and patients from seven clusters in the intervention arm were included in the study. We conducted 26 individual interviews (14 patients and 12 nurses) in primary care between December 2021 and March 2022. Thematic analyses were conducted. RESULTS: The analyses revealed the following themes: (1) enhancing professional self-efficacy for wound care, (2) a need to redesign the approach to implementing TM technology and (3) challenging to facilitate behavioral changes in relation to preventive care. As to patients' experiences with taking part in the intervention, we found the following three themes: (1) experience with TM promotes a feeling of security over time, (2) patients' preferences and individual needs on user participation in TM are not met, and (3) experiencing limited focus on prevention of re-ulceration. CONCLUSIONS: TM presents both opportunities and challenges. Future implementation should focus on providing nurses with improved technological equipment and work on how to facilitate the use of TM in regular practice in order to fully capitalize on this new technology. Future TM interventions need to tailor the level of information and integrate a more systematic approach for working with preventive strategies. CLINICAL TRIAL REGISTRATION: NCT01710774. Registration Date 2012-10-17.

The association between shift work disorder and turnover intention among nurses.

BACKGROUND: Shift work disorder (SWD) is highly prevalent among shift-working nurses and has multiple negative health-related effects. There is a dearth of insight into career-related decisions made by nurses suffering from SWD, for instance in terms of their intention to quit work (turnover intention). In this study, we aimed to investigate the association between SWD and turnover intention among nurses, and the individual and work-related correlates of turnover intention. METHOD: Data were derived from the ongoing longitudinal cohort study "SUrvey of Shift work, Sleep and Health (SUSSH)" among Norwegian nurses. An annual survey was initiated in 2008/2009 (N = 2965). The present study used data collected in year 2015 (wave 7) and 2016 (wave 8). Nurses were included if: 1) they were working as nurses in both 2015 and 2016, and 2) had completed a three-item scale adapted from the Michigan Organizational Assessment Questionnaire assessing turnover intention (in wave 8), and 3) did not only work day-shifts. SWD was measured in wave 7 with three questions based on the minimal criteria from the third edition of the International Classification of Sleep Disorders. Job demands, decision latitude, and social support at the workplace were measured with subscales of the Swedish Demand-Control-Support Questionnaire. RESULTS: Eight Hundred eighty-nine nurses were included. The results from the hierarchical linear regression showed that SWD predicted turnover intention one year later, i.e. from 2015 to 2016 (F1,835 = 6.00, p < 0.05; ß = 0.084, p = 0.015). The findings remained significant when controlling for age, sex, organizational tenure, number of nights worked, shift work schedule and workplace social support, job demands and decision latitude. CONCLUSION: This study showed that SWD is associated with turnover intention, even when controlling for individual and work-related variables.

Sleep patterns among Norwegian nurses between the first and second wave of the COVID-19 pandemic.

BACKGROUND: Nurses are in the frontline and play an important role in the battle against the COrona VIrus Disease-2019 (COVID-19) pandemic. Sleep problems among health care workers are likely to increase due to the pandemic. However, it is conceivable that negative health outcomes related to the pandemic fluctuate with the infection rate waves of the pandemic. The present study aimed to investigate sleep patterns among Norwegian nurses, after the first wave, during a period with very low rates of COVID-19. METHODS: Data stemmed from the cohort study "SUrvey of Shift work, Sleep and Health (SUSSH)" among Norwegian nurses. A total of 1532 nurses responded one time to a questionnaire between June and September in 2020 including items about demographics and work, information about COVID-19 and quarantine, sleep patterns and changes in sleep patterns due to the pandemic. Descriptive statistics for all relevant variables were calculated and McNemar tests were used to compare categorical variables. RESULTS: The majority of nurses (84.2%) reported no change in sleep duration after the first wave of the COVID-19 pandemic compared to before, 11.9% reported less sleep, and 3.9% reported more sleep. Similarly, 82.4% of the nurses reported no change in their sleep quality, whereas 16.2% of the nurses reported poorer sleep quality after the first wave of the pandemic compared to before. The majority of nurses reported no change in their sleep schedule due to the pandemic, although 9.6% of the nurses reported to go to bed later and 9.0% woke up earlier than before the pandemic. CONCLUSIONS: Most existing literature exploring sleep among health care workers during the COVID-19 pandemic has been carried out during periods with high infection rates. In this study we aimed to investigate sleep patterns among Norwegian nurses following the first wave, during a period of low COVID-19 rates in Norway. Most of the nurses reported no change in neither sleep duration, sleep quality, bedtime, nor wake-up times compared to before the pandemic. Still, nearly 12% reported shorter sleep duration, and about 16% reported poorer sleep quality indicating that some nurses experienced worsening of their sleep following the pandemic.

Short sleep duration and high exposure to quick returns are associated with impaired everyday memory in shift workers.

PURPOSE: To investigate the relationship between self-reported everyday memory problems the last month, and: (a) shift work schedule, (b) night shifts and quick returns worked the last year, and (c) sleep duration the last month. METHODS: In all, 1,275 nurses completed the Everyday Memory Questionnaire - revised, and answered questions about shift work exposure and sleep duration. We performed multiple linear regression analyses with memory score as dependent variable, and the shift work exposure variables as well as sleep duration as predictors, while adjusting for potential confounders. FINDINGS: High exposure to quick returns (ß = .10, p < .05) and short sleep duration (ß = .10, p < .05) were both positively associated with memory problems, whereas shift work schedule, long sleep duration, night shift exposure, and low and moderate exposure to quick returns were not. DISCUSSION: Frequent insufficient time for rest between shifts as well as short sleep was associated with poorer everyday memory.

Effects of pain treatment on sleep in nursing home patients with dementia and depression: A multicenter placebo-controlled randomized clinical trial.

OBJECTIVE: To investigate the effects of pain treatment on sleep in nursing home (NH) patients with dementia and depression. METHODS: A multicenter, 2-armed, double-blinded, placebo-controlled, randomized clinical trial conducted between August 2014 and September 2016. One hundred six long-term patients from 47 NHs in Norway with dementia and depression according to the Mini-Mental State Examination and the Cornell Scale for Depression in Dementia were included. Patients received stepwise pain treatment in which those who did not use analgesics were randomized to receive either paracetamol (3 g/day) or placebo tablets; those who already used pain treatment were allocated to buprenorphine transdermal system (max. 10 µg/h/7 days) or placebo transdermal patches. Sleep was assessed continuously for 14 days by actigraphy, 1 week of baseline measurement, and 1 week of ongoing treatment. The following sleep parameters were evaluated: total sleep time, sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset, early morning awakening (EMA), and number of wake bouts. RESULTS: In the intervention group (paracetamol/buprenorphine), SE (70%-72%), SOL (32-24 min), and EMA (50-40 min) improved compared with the control group (SE, 70%-67%; SOL, 47-60 min; EMA, 31-35 min). Treatment effects were significant (P < .01, P < .05, and P < .05, respectively). CONCLUSION: Compared with placebo, pain treatment improved sleep as measured with actigraphy. This implies that sleep, pain, and depression in NH patients should be critically evaluated and that pain treatment should be considered to be a potentially beneficial treatment.

Clinically significant discrepancies between sleep problems assessed by standard clinical tools and actigraphy.

BACKGROUND: Sleep disturbances are widespread among nursing home (NH) patients and associated with numerous negative consequences. Identifying and treating them should therefore be of high clinical priority. No prior studies have investigated the degree to which sleep disturbances as detected by actigraphy and by the sleep-related items in the Cornell Scale for Depression in Dementia (CSDD) and the Neuropsychiatric Inventory - Nursing Home version (NPI-NH) provide comparable results. Such knowledge is highly needed, since both questionnaires are used in clinical settings and studies use the NPI-NH sleep item to measure sleep disturbances. For this reason, insight into their relative (dis)advantages is valuable. METHOD: Cross-sectional study of 83 NH patients. Sleep was objectively measured with actigraphy for 7 days, and rated by NH staff with the sleep items in the CSDD and the NPI-NH, and results were compared. McNemar's tests were conducted to investigate whether there were significant differences between the pairs of relevant measures. Cohen's Kappa tests were used to investigate the degree of agreement between the pairs of relevant actigraphy, NPI-NH and CSDD measures. Sensitivity and specificity analyses were conducted for each of the pairs, and receiver operating characteristics (ROC) curves were designed as a plot of the true positive rate against the false positive rate for the diagnostic test. RESULTS: Proxy-raters reported sleep disturbances in 20.5% of patients assessed with NPI-NH and 18.1% (difficulty falling asleep), 43.4% (multiple awakenings) and 3.6% (early morning awakenings) of patients had sleep disturbances assessed with CSDD. Our results showed significant differences (p<0.001) between actigraphy measures and proxy-rated sleep by the NPI-NH and CSDD. Sensitivity and specificity analyses supported these results. CONCLUSIONS: Compared to actigraphy, proxy-raters clearly underreported NH patients' sleep disturbances as assessed by sleep items in NPI-NH and CSDD. The results suggest that the usefulness of proxy-rater measures of sleep may be questionable and further research is needed into their clinical value. The results highlight the need for NH staff to acquire and act on knowledge about sleep and sleep challenges among NH patients. TRIAL REGISTRATION: Registered at www.clinicaltrials.gov (registration number NCT02238652 ) on July 7th 2014 (6 months after study initiation).

Sleep and its Association With Pain and Depression in Nursing Home Patients With Advanced Dementia - a Cross-Sectional Study.

Objective: Previous research suggests a positive association between pain, depression and sleep. In this study, we investigate how sleep correlates with varying levels of pain and depression in nursing home (NH) patients with dementia. Materials and methods: Cross-sectional study (n = 141) with sleep-related data, derived from two multicenter studies conducted in Norway. We included NH patients with dementia according to the Mini-Mental State Examination (MMSE ≤ 20) from the COSMOS trial (n = 46) and the DEP.PAIN.DEM trial (n = 95) whose sleep was objectively measured with actigraphy. In the COSMOS trial, NH patients were included if they were ≥65 years of age and with life expectancy >6 months. In the DEP.PAIN.DEM trial, patients were included if they were ≥60 years and if they had depression according to the Cornell Scale for Depression in Dementia (CSDD ≥ 8). In both studies, pain was assessed with the Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale (MOBID-2), and depression with CSDD. Sleep parameters were total sleep time (TST), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), early morning awakening (EMA), daytime total sleep time (DTS) and time in bed (TiB). We registered use of sedatives, analgesics, opioids and antidepressants from patient health records and adjusted for these medications in the analyses. Results: Mean age was 86.2 years and 76.3% were female. Hierarchical regressions showed that pain was associated with higher TST and SE (p < 0.05), less WASO (p < 0.01) and more DTS (p < 0.01). More severe dementia was associated with more WASO (p < 0.05) and TiB (p < 0.01). More severe depression was associated with less TST (p < 0.05), less DTS (p < 0.01) and less TiB (p < 0.01). Use of sedative medications was associated with less TiB (p < 0.05). Conclusion: When sleep was measured with actigraphy, NH patients with dementia and pain slept more than patients without pain, in terms of higher total sleep time. Furthermore, their sleep efficiency was higher, indicating that the patients had more sleep within the time they spent in bed. Patients with more severe dementia spent more time awake during the time spent in bed. Furthermore, people with more severe depression slept less at daytime and had less total sleep time Controlling for concomitant medication use did not affect the obtained results.

Changes in work schedule affect the prevalence of shift work disorder among Norwegian nurses - a two year follow-up study.

This study aimed to explore how changes in the work schedule would affect the prevalence of Shift Work Disorder (SWD) over time. Two-year follow-up data from 1076 nurses participating in the longitudinal SUrvey of Shift work, Sleep and Health among Norwegian nurses (SUSSH) were included in the study. The questionnaires included measures of work-related factors, i.e., work schedule and numbers of night shifts and quick returns (QRs) worked the last year, as well as questions related to SWD according to the ICSD-3 diagnostic criteria at both baseline and at 2-year follow-up. Data were analyzed with paired samples t-tests, chi-square tests, and logistic regression analyses adjusting for sex and age. Terminating night work was the strongest predictor for recovering from SWD from baseline to follow-up (OR 10.91, 95% CI 6.11-19.46). Additionally, changing the work schedule from day work to night work from baseline to follow-up was the strongest predictor for developing SWD in the same period (OR 4.75, 95% CI 2.39-9.47). Reductions in number of nights (more than 10) and QRs (more than 10) worked the last year were associated with recovering from SWD between baseline and follow-up. Nurses who recovered from SWD had significantly reduced the mean number of night shifts worked the last year from 32.3 at baseline to 20.4 at follow-up (p = .001). Furthermore, an increase of more than 10 nights or more than 10 QRs worked the last year between baseline and follow-up predicted developing SWD. Nurses developing SWD between baseline and follow-up had significantly increased the mean number of nights worked the last year from 25.8 at baseline to 31.0 at follow-up (p =-.043). Changes in night work exposure were the strongest predictors for both recovering from or developing SWD from baseline to follow-up. Reducing exposure to night work and QRs were associated with recovering from SWD and increasing exposure to night work and QRs were associated with developing SWD. The results imply that unfavorable work schedules play a role in the development of sleep problems among nurses. These results may be useful when designing healthy working schedules.

Stability and Change of the Personality Traits Languidity and Flexibility in a Sample of Nurses: A 7-8 Years Follow-Up Study.

The traits languidity (tendency to become tired/sleepy upon losing sleep) and flexibility (ability to sleep and work at odd times) have been implicated in shift work tolerance. However, there is a dearth of knowledge about their temporal stability. The aim of the present study was to explore these traits during a long follow-up (FU) period and identify factors related to potential changes in trait scores over time. In all, 1,652 nurses completed the Circadian Type Inventory-revised (CTI-r), which measures languidity and flexibility, at both 2008/2009 (baseline, BL) and again in 2016 (FU). The latent scores of these two constructs at BL, in addition to age, sex, childcare responsibility, marital status, night work status, and insomnia status, were regressed on the corresponding latent scores at follow-up using a structural equation modeling (SEM) approach. Stability was found for both languidity (rho = 0.59) and flexibility (rho = 0.58). Both composite scores declined significantly from baseline (20.62 and 12.48) to follow-up (19.96 and 11.77). Languidity at baseline was positively associated with languidity at follow-up (ß = 0.89, p < 0.009). Undertaking childcare responsibility between baseline and follow-up was inversely related to languidity at follow-up (ß = -0.09, p < 0.05). Starting night work was positively related to languidity at follow-up (ß = 0.06, p < 0.05). Developing insomnia between baseline and follow-up (ß = 0.15, p < 0.05) was positively, whereas remitting from insomnia during the same period was negatively (ß = -0.11, p < 0.01) associated with languidity at follow-up. Flexibility at baseline was positively associated with flexibility at follow-up (ß = 0.64, p < 0.05). Having childcare responsibility at baseline, but not at follow-up was inversely related to flexibility at follow-up (ß = -0.05 p < 0.05). Becoming cohabitant with a partner between baseline and follow-up (ß = -0.07, p < 0.05) was negatively associated with flexibility at follow-up. Starting night work between baseline and follow-up (ß = 0.17, p < 0.01) and reporting night work at both baseline and follow-up (ß = 0.18, p < 0.01) were both positively associated with flexibility at follow-up, whereas stopping working nights was negatively (ß = -0.09, p < 0.05), associated with flexibility at follow-up. The personality traits languidity and flexibility show fairly high stability, albeit the mean scores were significantly reduced during the 7-8 years follow-up period. The results suggest that these personality traits are partly modifiable.

Comorbid Dementia and Cancer in Residents of Nursing Homes: Secondary Analyses of a Cross-Sectional Study.

BACKGROUND: Life expectancy is increasing continuously, which increases the likelihood of developing dementia or cancer. Both dementia and cancer are serious conditions that give manifold symptoms. The interaction of these conditions is however complex and less explored. OBJECTIVES: The aim of this study was to identify the prevalence of cancer and differences regarding neuropsychiatric symptoms (NPS) and medication among nursing home (NH) patients with and without dementia and cancer. METHODS: This is a cross-sectional study of Norwegian NH patients (N = 1825). Participants were categorized according to degree of dementia (Clinical Dementia Rating > 1) and cancer diagnoses. Differences in NPS and other symptoms, as well as the use of medication, were explored. RESULTS: Eighty-four percent of NH patients had dementia, and 5.5% had comorbid dementia and cancer. Patients with comorbid dementia and cancer received significantly more analgesics compared with patients without cancer but with dementia (P < .05). Compared with patients without dementia but with cancer, patients with comorbid dementia and cancer had significantly more NPS, including sleep disturbances and agitation. CONCLUSIONS: Patients with comorbid dementia and cancer receive more analgesics than patients with dementia but still display more agitation and sleep disturbances than patients with cancer and patients with neither dementia nor cancer, suggesting that symptoms may not be treated adequately. IMPLICATIONS FOR PRACTICE: The results indicate a considerable strain for patients with comorbid dementia and cancer and highlight essential challenges for the clinician who is responsible for treatment and care. Nurses should pay attention to agitation and sleep disturbances among patients with comorbid dementia and cancer.