Healthcare professionals' experience with nutritional care beyond formal quality systems - A qualitative study.

BACKGROUND: Numerous formal strategies, screening tools, and interventions have been used to prevent malnutrition in long-term care patients. Despite these efforts, the proportion of screened patients is low, and a large proportion are malnourished. Previous research has revealed that healthcare professionals use a broad approach in their nutritional care but has also emphasised the need for further investigation into these approaches. OBJECTIVE: To explore how healthcare professionals working in long-term care experience and apply nutritional care. DESIGN: A descriptive, exploratory, qualitative design containing 240 h of participant observation, 12 focus groups and 2 individual interviews. SETTING(S): Twelve nursing homes and home care units in three Norwegian municipalities. PARTICIPANTS: Participant observation of interactions between healthcare professionals and patients. Forty-three registered nurses participated in focus group or individual interviews. METHODS: The data were analysed using inductive thematic analysis. RESULTS: The analysis identified three themes: The first theme, limited significance of nutritional screening, showed that healthcare professionals experienced the limited value of nutritional screening, as it often did not capture patients' nutritional challenges. They also perceived nutritional screening as unsuitable for patients at the end of their lives, those with overweight-related complications, or undergoing rehabilitation. In addition, nutritional screening was perceived as something healthcare professionals did for their managers or administrators, not because it was crucial to providing good nutritional care. The second theme, provision of individualised food, captures the healthcare professionals' efforts in adapting and preparing food according to the patient's preferences. Facilitation to enable patients to make individual food choices and the use of food cards or lists were two approaches to individualising nutrition care. The third theme, making meals more than about food, elucidated how healthcare professionals used meals to help patients cope with their situations and experience social belonging. Conversations about or around meals were used to provide patients with a sense of belonging to their past or present situation. The meals were also used as a diversion strategy for patients with unrest, as arenas for daily activity training, and for meaningful social interactions between patients around the tables. CONCLUSIONS: Nutritional screening and prevention of malnutrition are only one part of healthcare professionals' nutritional care. Individualised food and meals that create coping, a sense of belonging, and social experiences are equally important parts of their care. Emphasising healthcare professional's person-centred approach to nutritional care would be beneficial, as it could strengthen and further develop long-term nutritional care services.

The impact of elder abuse training on subacute health providers and older adults: study protocol for a randomized control trial.

BACKGROUND: Elder abuse often goes unreported and undetected. Older people may be ashamed, fearful, or otherwise reticent to disclose abuse, and many health providers are not confident in asking about it. In the No More Shame study, we will evaluate a co-designed, multi-component intervention that aims to improve health providers' recognition, response, and referral of elder abuse. METHODS: This is a single-blinded, pragmatic, cluster randomised controlled trial. Ten subacute hospital sites (i.e. clusters) across Australia will be allocated 1:1, stratified by state to a multi-component intervention comprising a training programme for health providers, implementation of a screening tool and use of site champions, or no additional training or support. Outcomes will be collected at baseline, 4 and 9 months. Our co-primary outcomes are change in health providers' knowledge of responding to elder abuse and older people's sense of safety and quality of life. We will include all inpatients at participating sites, aged 65 + (or aged 50 + if Aboriginal or Torres Strait Islander), who are able to provide informed consent and all unit staff who provide direct care to older people; a sample size of at least 92 health providers and 612 older people will provide sufficient power for primary analyses. DISCUSSION: This will be one of the first trials in the world to evaluate a multi-component elder abuse intervention. If successful, it will provide the most robust evidence base to date for health providers to draw on to create a safe environment for reporting, response, and referral. TRIAL REGISTRATION: ANZCTR, ACTRN12623000676617p . Registered 22 June 2023.

Health-promoting behaviors in older adulthood and intrinsic capacity 10 years later: the HUNT study.

BACKGROUND: With the global population growing older, there is a need for more knowledge of how to improve and/or maintain functional capacities to promote healthy ageing. In this study we aimed to assess the effect of several known health-promoting behaviors in old age with intrinsic capacity ten years later. METHODS: This was a prospective cohort study looking at participants that were ≥ 65 years at the time of the third wave of the Trøndelag Health Study (HUNT3, 2006-2008) who also took part in the 70 + sub-study of the fourth wave (HUNT4 70+, 2017-2019). Self-reported behavior data from short questionnaires, including diet and physical activity, were collected in HUNT3, and data on the five domains of intrinsic capacity defined by the World Health Organization were collected in HUNT4 70+. A composite index was created for both healthy life and intrinsic capacity, awarding points for how well participants adhered to guidelines for healthy living and their level of functional impairment, respectively. Ordinal logistic regression was used to assess the relationship between health-promoting behaviors and intrinsic capacity. RESULTS: Of 12,361 participants in HUNT3 ≥ 65 years, 4699 (56.5% women) also participated in HUNT4 70+. On the health-promoting behaviors, lowest adherence to healthy living guidelines were seen for fruit and vegetables intake (47.2%), milk intake (46.7%) and physical activity (31.1%). On intrinsic capacity domains, highest impairment was seen in the domains of locomotion (29.7%), hearing (11.1%) and vitality (8.3%). A higher adherence to guidelines for healthy living was associated with higher intrinsic capacity 10 years later. A one-point increase in the healthy life index was associated with a 1.15 (95% confidence interval 1.10-1.21) times increased odds of being in a higher intrinsic capacity category. CONCLUSION: Health-promoting behaviors in old age are associated with better intrinsic capacity ten years later. In clinical settings assessment of health-promoting behaviors could potentially be done using short questionnaires.

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study.

BACKGROUND: Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs. METHODS: A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience. RESULTS: The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids. CONCLUSIONS: Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

How Is Quality of Care in Home Healthcare Created? A Qualitative Study of Health Professionals' Perspectives.

The demographic challenges with an increase in older adults in need of nursing care has put home healthcare services under pressure. However, research on what constitutes quality of home healthcare services and what factors influence good nursing care and patient safety is scarce. The aim of this study was to gain insight into health professionals' perceptions of how quality of care in home healthcare is created and what factors put patient safety at risk. The present study was a qualitative study with semi-structured interviews of eight health professionals working in home healthcare services. Qualitative content analysis was used. Four categories of factors the staff thought had to be present to provide good quality services were identified: (1) A workplace with adequate competence; (2) Communication, information flow and collaboration; (3) Continuity and organisation of care; and (4) Resources. Conclusions: The healthcare professionals perceived that the quality of the services overall was good, and if important factors were present, quality of care was achieved. However, they pointed out some factors that were important to prevent inadequate care and improve services, as quality of care was at risk when deficiencies in these areas occurred.

The short-term effect of a modified comprehensive geriatric assessment and regularly case conferencing on neuropsychiatric symptoms in nursing homes: a cluster randomized trial.

AIMS: To investigate the short-term effect of implementing a modified comprehensive geriatric assessment and regularly case conferencing in nursing homes on neuropsychiatric symptoms. BACKGROUND: Neuropsychiatric symptoms are common and may persist over time in nursing home residents. Evidence of effective interventions is scarce. DESIGN: A parallel cluster-randomised controlled trial. METHODS: The intervention was monthly standardised case conferencing in combination with a modified comprehensive geriatric assessment. The control group received care as usual. MAIN OUTCOME MEASURE: The total score on the short version of the Neuropsychiatric Inventory (NPI-Q, 12-items). RESULTS: A total of 309 residents at 34 long-term care wards in 17 nursing homes (unit of randomisation) were included. The intervention care units conducted on average two case conference-meetings (range 1-3), discussing a mean of 4.8 (range 1-8) residents. After 3 months, there were no difference of NPI-Q total score between the intervention (-0.4) and the control group (0.5) (estimated mean difference = -1.0, 95% CI -2.4 to 0.5, p = 0.19). There was a difference in favour of the intervention group on one of the secondary outcome measures, the apathy symptoms (-0.5 95% CI: -0.9 to -0.1, p = 0.03). CONCLUSION: In this study there were no short-term effect of case conferencing and modified comprehensive geriatric assessments after three months on the total score on neuropsychiatric symptoms. The intervention group had less apathy at 3 months follow-up compared to those receiving care as usual. The findings suggest that a more comprehensive intervention is needed to improve the total Neuropsychiatric symptoms burden and complex symptoms. TRIAL REGISTRATION: Due to delays in the organisation, the study was registered after study start, i.e. retrospectively in Clinicaltrials.gov # NCT02790372 at  https://clinicaltrials.gov/ ; Date of clinical trial registration: 03/06/2016.

Relatives' experiences with abuse and neglect in Norwegian nursing homes. A qualitative study.

BACKGROUND: Elder abuse in nursing homes (NH) is a widespread and complex problem. Residents' ability to share their experiences are impeded, due to a high degree of cognitive problems and frailty, and previous studies are thus mainly based on reports from staff. Therefore, we aimed to give voice to the residents by investigating their relatives' experiences with elder abuse in NH. METHODS: Qualitative individual interviews were conducted with 16 relatives of residents with experience of abuse and/or neglect in NH. Content analysis was used to analyse the data. RESULTS: Relatives perceived neglect as most pervasive and staff-to-resident psychological abuse as a key problem. Physical abuse was mostly related to resident-to-resident aggression. Relatives perceived elder abuse in NH to be related to low competence among staff, low staffing, poor NH leadership, working cultures characterized by fear and loyalty to employer or co-workers, and a lack of individualized care for the residents. Furthermore, relatives themselves experienced maltreatment from NH, which caused them to suffer stress, anxiety and distrust. Relatives also expressed a need to compensate for lack of care. CONCLUSIONS: Relatives of NH residents who had experienced abuse reported that neglect of basic care and individual rights was predominant and viewed organizational explanations as most important. Relatives perceive themselves as collaborators in care and are emotionally attached to their family member. Therefore, if relatives experience resident abuse or neglect, it inflicts a feeling of being mistreated themselves, particularly if they are not listened to or their notice of abuse on the part of the resident is ignored or trivialized. Including relatives in a committed partnership with NH in care practices is not only a valuable path to reduce the risk of abuse, but it also leads to a more sustainable healthcare with high standards of quality and safety.

Cornell's Depression for Dementia Scale: A psychometric study among Norwegian nursing home residents.

BACKGROUND: Depression is common among residents in long term-care facilities. Therefore, access to a valid and reliable measure of depressive symptoms among nursing home (NH) residents is highly warranted. AIM: The aim of this study was to test the psychometrical properties of the Norwegian version of the Cornell Scale for Depression in Dementia (CSDD). METHODS: A sample of 309 NH residents were assessed for depressive symptoms using the CSDD in 2015-2016. Data on CSDD were missing for 64 residents, giving an effective sample of 245 (79.3%). Principal component and confirmatory factor analysis were used. RESULTS: A five-dimensional solution yielded the best fit with the data (χ2=174.927, df=94, χ2/df=1.86, p=0.0001, RMSEA=0.058, p-value for test of close fit=0.152, CFI=0.94, TLI=0.92 and SRMR=0.056). As expected, higher depressive symptoms correlated positively with higher scores on the Minimum Data Set Depression Rating Scale (MDSDRS) and correlated negatively with Quality of life assessed with the Quality of Life in Late Stage-Dementia Scale. LIMITATIONS: The excluded residents (n=64, 20.7%) had lower cognitive function, which may limit the generalizability of the study results. CONCLUSION: This study suggests a five-dimensional solution of the CSDD scale. Sixteen of the 19 original items showed highly significant loadings, explaining a notable amount of the variation in the CSDD-construct. Further development and testing of a well-adapted scale assessing depression in the nursing home population with and without dementia is required.

React and act: a qualitative study of how nursing home leaders follow up on staff-to-resident abuse.

BACKGROUND: Elder abuse in nursing homes is a complex multifactorial problem and entails various associations across personal, social, and organisational factors. One way leaders can prevent abuse and promote quality and safety for residents is to follow up on any problems that may arise in clinical practice in a way that facilitates learning. How nursing home leaders follow up and what they follow up on might reflect their perceptions of abuse, its causal factors, and the prevention strategies used in the nursing home. The aim of this study was to explore how nursing home leaders follow up on reports and information regarding staff-to-resident abuse. METHODS: A qualitative explorative design was used. The sample comprised 43 participants from two levels of nursing home leadership representing six municipalities and 21 nursing homes in Norway. Focus group interviews were conducted with 28 care managers, and individual interviews took place with 15 nursing home directors. The constant comparative method was used for the analyses. RESULTS: Nursing home leaders followed up incidents of staff-to-resident abuse on three different levels as follows: 1) on an individual level, leaders performed investigations and meetings, guidance, supervision, and occasionally relocated staff members; 2) on a group level, feedback, openness, and reflection for shared understanding were strategies leaders used; and 3) on an organisational level, the main solutions were to adjust to available resources, training, and education. We found that leaders had difficulties defining harm and a perceived lack of power to follow up on all levels. In addition, they did not have adequate tools for evaluating the effect of the measures that were taken. CONCLUSIONS: Nursing home leaders need to be clear about how they should follow up incidents of elder abuse on different levels in the organisation and about their role in preventing elder abuse. Evaluation tools that facilitate systematic organisational learning are needed. Nursing homes must operate as open, blame-free cultures that acknowledge that incidents of elder abuse in patient care arise not only from the actions of individuals but also from the complex everyday life of which they are a part and in which they operate.

Nursing home leaders' perception of factors influencing the reporting of elder abuse and neglect: a qualitative study.

PURPOSE: The purpose of this study is to explore the factors that influence the reporting of adverse events related to elder abuse and neglect in nursing homes from nursing home leaders' perspectives. Good leadership requires in-depth knowledge of the care and service provided and the ability to identify and address problems that can arise in clinical practice. DESIGN/METHODOLOGY/APPROACH: A qualitative explorative design with data triangulation was used. The sample consisted of 43 participants from two levels of nursing home leadership, representing six municipalities and 21 nursing homes in Norway. Focus group interviews were undertaken with 28 ward leaders and individual interviews with 15 nursing home directors. The constant comparative method was used for the analyses. FINDINGS: Both ward leaders and nursing home directors described formal and informal ways of obtaining information related to elder abuse and neglect. There were differences between their perceptions of the feasibility of obtaining formal reports about abuse in the nursing home. Three main categories of influencing factors emerged: (1) organisation structural factors, (2) cultural factors and (3) abuse severity factors. A main finding is that in its present form, the Norwegian adverse event reporting system is not designed to detect abuse and neglect. ORIGINALITY/VALUE: This paper provides an in-depth understanding of patient safety and factors related to reporting elder abuse in nursing homes in Norway.

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect.

BACKGROUND: The definition and understanding of elder abuse and neglect in nursing homes can vary in different jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge about nursing home leaders' perceptions of elder abuse and neglect is of particular interest since their understanding of the phenomenon will affect what they signal to staff as important to report and how they investigate adverse events to ensure residents' safety. The aim of the study was to explore nursing home leaders' perceptions of elder abuse and neglect. METHODS: A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role of care managers was conducted. Nursing home leaders' perceptions of different types of abuse within different situations were explored. The constant comparative method was used to analyse the data. RESULTS: The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three analytical categories emerged from the analyses: 1) Abuse from co-residents: 'A normal part of nursing home life'; resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had no strategy for handling it; 2) Abuse from relatives: 'A private affair'; relatives with abusive behaviour visiting nursing homes residents was described as difficult and something that should be kept between the resident and the relatives; 3) Abuse from direct-care staff: 'An unthinkable event'; staff-to-resident abuse was considered to be difficult to talk about and viewed as not being in accordance with the leaders' trust in their employees. CONCLUSIONS: Findings in the present study show that care managers lack awareness of elder abuse and neglect, and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes.

Staff experiences with implementing a case conferencing care model in nursing homes: a focus group study.

BACKGROUND: A majority of nursing home residents have dementia, and many develop neuropsychiatric symptoms. These symptoms are often caused by neuropathological changes in the brain, but modifiable factors related to quality of care also have an impact. A team-based approach to care that include comprehensive geriatric assessments to facilitate clinical decision-making and structured case conference meetings could improve quality of care and quality of life for the residents. Despite recommendations to adopt this approach, dementia care does not reach standards of evidence-based practice. Better implementation strategies are needed to improve care. A cluster randomised controlled trial with a 12-month intervention was conducted, and the experiences of staff from the intervention nursing homes were explored in a qualitative study after the trial was completed. The aim of the present study was to describe: (i) staff's experiences with the intervention consisting of comprehensive geriatric assessments of nursing home residents and case conferencing, and (ii) enablers and barriers to implementing and sustaining the intervention. METHODS: Four focus groups with a total of 19 healthcare staff were interviewed, representing four out of eight intervention nursing homes. Thematic content analysis was used to interpret the transcribed data. RESULTS: Two major themes emerged: 1) learning experiences and 2) enablers and barriers to implementation. The participants had experienced learning both on an organisational level: improvements in care and an organisation that could adjust and facilitate change; and on an individual level: becoming more conscious of residents' needs and acquiring skills in resident assessments. Participants described important enabling factors such as managerial support, drivers for change, and feasibility of the intervention for the local nursing home. Barriers to implementing and sustaining the intervention were time constraints, lack of staff training, unsuitable electronic patient record system for care planning and high complexities of care and instabilities that are present in nursing homes. CONCLUSIONS: Quality improvements in nursing homes are difficult to sustain. In order to offer residents high quality of care that meet their individual needs, it is important for management and nursing home staff to be aware of and understand factors that enable or constrain change.

Care relationships at stake? Home healthcare professionals' experiences with digital medicine dispensers - a qualitative study.

BACKGROUND: Although digital technologies can mitigate the burdens of home healthcare services caused by an ageing population that lives at home longer with complex health problems, research on the impacts and consequences of digitalised remote communication between patients and caregivers is lacking. The present study explores how home healthcare professionals had experienced the introduction of digital medicine dispensers and their influence on patient-caregiver relationships. METHODS: The multi-case study comprised semi-structured interviews with 21 healthcare professionals whose home healthcare service involved using the digital medicine dispensers. The constant comparative method was used for data analyses. RESULTS: Altogether, interviewed healthcare professionals reported three main technology-related impacts upon their patient-caregiver relationships. First, national and local pressure to increase efficiency had troubled their relationships with patients who suspected that municipalities have sought to lower costs by reducing and digitalising services. Participants reported having to consider such worries when introducing technologies into their services. Second, participants reported a shift towards empowering patients. Digital technology can empower patients who value their independence, whereas safety is more important for other patients. Healthcare professionals needed to ensure that replacing care tasks with technology implies safe and improved care. Third, the safety and quality of digital healthcare services continues to depend upon surveillance and control mechanisms that compensate for less face-to-face monitoring. Participants did not consider the possibility that surveillance exposes information about patients' everyday lives to be problematic, but to constitute opportunities for adjusting services to meet patients' needs. CONCLUSIONS: Technologies such as digital medicine dispensers can improve the efficiency of healthcare services and enhance patients' independence when introduced in a way that empowers patients as well as safeguards trust and service quality. Conversely, the patient-caregiver relationship can suffer if the technology does not meet patients' needs and fails to offer safe and trustworthy services. Upon introducing technology, home healthcare professionals therefore need to carefully consider the benefits and possible disadvantages of the technology. Ethical implications for both individuals and societies need to be further discussed.

Exploring faecal incontinence in nursing home patients: a cross-sectional study of prevalence and associations derived from the Residents Assessment Instrument for Long-Term Care Facilities.

AIM: To explore prevalence and associations of faecal incontinence among nursing home patients, to examine the effect of clustering of observations and to study the variation in faecal incontinence rates on both the level of nursing home units and individual patients. BACKGROUND: Faecal incontinence affects 40-55% of the patients in nursing homes and is associated with increased risk of morbidity and reduced quality of life. There is a lack of studies investigating faecal incontinence with validated instruments. More studies need to include models of analyses that allow for clustering of observations. DESIGN: Cross-sectional. METHODS: Data on 261 patients from 20 nursing home units were collected during September-October 2014. The Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities was used. Mixed effect models were conducted. RESULTS: Prevalence of faecal incontinence was 42·1% or 54% depending on the frequency labelling chosen. The effect of clustering by nursing home unit was not statistically significant. Most of the variation in faecal incontinence rates was explained by differences in patient characteristics, the most important being deficiencies in activities of daily living, cognitive impairment, diarrhoea and not participating in activities. CONCLUSION: Nursing home patients should be offered individualized assessment and continence care matching their patient characteristics. The Resident Assessment Instrument for Long-Term Care Facilities is a useful instrument because of its' combination of a comprehensive range of individual items and scales allowing for comparison of immediate or long-term change in patients status. Studies evaluating interventions targeting faecal incontinence are warranted.

Constipation and Laxative Use among Nursing Home Patients: Prevalence and Associations Derived from the Residents Assessment Instrument for Long-Term Care Facilities (interRAI LTCF).

Introduction. Constipation is a common, bothersome, and potentially dangerous condition among nursing home (NH) patients. Between 50 and 74% of NH patients use laxatives. Objective. To study prevalence and associations of laxative use and constipation using the comprehensive Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities. Methods. Cross-sectional study. Patients from 20 NH units were included. Logistic regression was used to analyze the results. Data collected in NHs might be clustered. Consequently, the multivariable models were tested against a mixed effects regression model to investigate variance both on the level of patients and on the level of NH units. Results. In all, 261 patients were included. The prevalence of constipation was 23.4%, and 67.1% used laxatives regularly. Balance problems, urinary incontinence, hypothyroidism, and Parkinson's disease were associated with constipation. Reduced ability to communicate and number of drugs were associated with laxative use. Antidementia-drugs and being involved in activities 1/3 to 2/3 of daytime were protective factors for laxative use. Mixed effects analyses identified variance on the level of NH units as nonsignificant. Conclusion. Constipation and laxative use are common. Variance is mainly explained by different patient characteristics/health deficiencies. Hence, patients might benefit from individualized care to compensate for deficiencies.

Understanding organizational and cultural premises for quality of care in nursing homes: an ethnographic study.

BACKGROUND: Internationally, there are concerns about the quality of care in nursing homes. The concept of 'corporate culture' as an internal variable could be seen as the means to improve quality of care and quality of life for the residents. The aim of this article was to describe the nursing home culture from the staff's perspective and to include how the residents describe quality of care. METHODS: An ethnographic design was employed. A purposive sample of four municipal public nursing homes in Norway with long-term care residents was included in the study. Data were collected by participant observation including informal conversation with the staff, and in-depth interviews with 15 residents using a narrative approach. RESULTS: The main findings were that organizational cultures could be seen as relatively stable corporate cultures described as 'personalities' with characteristics that were common for all nursing homes (conformity) and typical traits that were present in some nursing homes, but that they were also like no other nursing home (distinctiveness). Conformity ('Every nursing home is like all other nursing homes') meant that nursing home organizations formed their services according to a perception of what residents in general need and expect. Trait ('Every nursing home is like some other nursing homes') expressed typologies of nursing homes: residency, medical, safeguard or family orientation. The distinctness of each nursing home ('Every nursing home is like no other nursing home') was expressed in unique features of the nursing home; the characteristics of the nursing home involved certain patterns of structure, cultural assumptions and interactions that were unique in each nursing home. Nursing home residents experienced quality of care as 'The nursing home as my home' and 'Interpersonal care quality'. The resident group in the different types of nursing homes were unique, and the experience of quality of care seemed to depend on whether their unique needs and expectations were met or not. CONCLUSION: In order to create a sustainable nursing home service the service needs to be characterized by learning and openness to change and must actually implement practices that respond to the resident and his or her family's values.

Feasibility, acceptability, and adherence of two educational programs for care staff concerning nursing home patients' fecal incontinence: a pilot study preceding a cluster-randomized controlled trial.

BACKGROUND: Fecal incontinence has a high prevalence in the nursing home population which cannot be explained by co-morbidity or anatomic and physiological changes of aging alone. Our hypothesis is that fecal incontinence can be prevented, cured, or ameliorated by offering care staff knowledge of best practice. However, it is not clear which educational model is most effective. To assess the effect of two educational programs for care staff, we planned a three armed cluster-randomized controlled trial. There is a lack of research reporting effects of interventions targeting improved continence care processes in older patients. Thus, to improve the quality of the planned trial, we decided to carry out a pilot study to investigate the feasibility of the planned design, the interventions (educational programs) and the outcome measures, and to enable a power calculation. This paper reports the results from the pilot study. METHODS: Three nursing homes, representing each arm of the planned trial, were recruited. Criteria for assessing success of feasibility were pre-specified. Methods, outcome measures, acceptability, and adherence of the components of the intervention were evaluated by descriptive statistical analyses and qualitative content analysis of one focus group interview (n = 7) and four individual interviews. RESULTS: The main study is feasible with one major and some minor modifications. Due to challenges with recruitment and indications supporting the assumption that a single intervention with one workshop is not sufficient as an implementation strategy, the main study will be reduced to two arms: a multifaceted education intervention and control. The components of the multifaceted intervention seemed to work well together and need only minor modification. Important barriers to consider were sub-optimal use of skill-mix, problems of communicating important assessments and care plans, and isolated nurses with an indistinct nurse identity. CONCLUSIONS: Overall, the main study is feasible. The pedagogical approach needs to consider the identified barriers. Thus, it is essential to empower nurses in their professional role, to facilitate clinical reasoning and critical thinking among care staff, and to facilitate processes to enable care staff to find, report, and utilize information in the electronic patient record. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01939821.

Effect of a multifaceted educational program for care staff concerning fecal incontinence in nursing home patients: study protocol of a cluster randomized controlled trial.

BACKGROUND: Fecal incontinence has a high prevalence in the older population, which cannot be explained by comorbidity or the anatomical or psychological changes of aging alone. Fecal incontinence leads to a high economic burden to the healthcare system and is an important cause of institutionalization. In addition, fecal incontinence is associated with shame, social isolation and reduced quality of life. The importance of identifying treatable causes in the frail elderly is strongly emphasized. It is recommended that an assessment of fecal incontinence should be implemented as part of an evaluation of older patients. Although there is a substantial evidence base to guide choice of implementation activities targeting healthcare professionals, little implementation research has focused on the care of older people nor involved care processes or care personnel. This study is based on the assumption that fecal incontinence among nursing home patients can be prevented, cured or ameliorated by offering care staff knowledge of best practice through a multifaceted educational program. The primary objective is to test the hypothesis that a multifaceted educational program for nursing home care staff on assessment and treatment of fecal incontinence reduces patients' frequency of fecal incontinence. METHODS/DESIGN: The study is a two-armed, parallel cluster-randomized controlled trial. Primary outcome is the frequency of fecal incontinence among patients. Sample size calculations resulted in a need for a total sample of 240 patients. Twenty nursing home units in one city in Norway will be recruited and allocated to intervention or control by an independent statistician using computer-generated tables. The intervention is a multifaceted educational program. Units in the control arm will provide care as usual. The intervention period is 3 months. Data will be collected at baseline, 3, and 6 months. Data will be analyzed using mixed effect models with the cluster treated as a random effect. DISCUSSION: This study is the first randomized controlled trial specifically focusing on this neglected area. The result of the study will give evidence for best practice for continence care in nursing homes, and organizational advice concerning implementation strategies. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02183740 , registered June 2014.

Ambiguities: residents' experience of 'nursing home as my home'.

BACKGROUND: Residential care in nursing homes continues to be necessary for those individuals who are no longer able to live at home. Uncovering what nursing home residents' view as quality of care in nursing homes will help further understanding of how best to provide high quality, person-centred care. AIM: To describe residents' experiences of living in a nursing home related to quality of care. DESIGN: The study utilises a descriptive exploratory design. METHOD: In-depth interviews were undertaken with 15 residents who were not cognitively impaired, aged 65 and over and living in one of four nursing homes. The interviews were transcribed verbatim and analysed by categorising of meaning. RESULTS: Residents perceived the nursing home as their home, but at the same time not 'a home'. This essential ambiguity created the tension from which the categories of perceptions of quality emerged. Four main categories of quality of care experience were identified: 'Being at home in a nursing home', 'Paying the price for 24-hour care', 'Personal habits and institutional routines', and 'Meaningful activities for a meaningful day'. CONCLUSIONS: Ambiguities concerning the nursing home as a home and place to live, a social environment in which the residents experience most of their social life and the institution where professional health service is provided were uncovered. High-quality care was when ambiguities were managed well and a home could be created within the institution. Implication for practice. Achieving quality care in nursing homes requires reconciling the ambiguities of the nursing home as a home. This implies helping residents to create a private home distinct from the professional home, allowing residents' personal habits to guide institutional routines and supporting meaningful activities. Using these resident developed quality indicators is an important step in improving nursing home services.

Quality of care in Norwegian nursing homes - typology of family perceptions.

AIM AND OBJECTIVE: This study aimed to elucidate the understandings and beliefs about quality held by family members of residents of Norwegian nursing homes. The objective reported in the study considers how family member judge factors that enhance or hamper high care quality. BACKGROUND: The percentage of those who will require care in a nursing home some time before the end of their lives will increase dramatically in the next 20 years. Therefore, anticipating this pressure to expand nursing home availability, it is urgent that these services are developed from a keen understanding of what creates the best value. Care quality from the family's perspective is just one piece of the nursing home experience that must be understood for optimal value in care to be realised. DESIGN: Qualitative methodology. METHOD: Three focus group interviews; purposive sampling was used to recruit the 16 family members of residents in nursing homes. RESULTS: Three domains emerged that served as anchors for a typology of family perceptions of the quality care continuum: resident contentment, suitability of staff and environmental context. Each domain was developed with categories describing high- to low-quality markers, which were then clarified by enhancing and hindering factors. CONCLUSIONS: This typology provides a family perspective framework that may be useful to nursing leadership at all levels of the nursing home organisation to identify important quality of care strengths as well as markers of poor care. RELEVANCE TO CLINICAL PRACTICE: Overall, the typology is offered to expand nurses' understanding of quality, both practically and conceptually, to provide the best value in nursing care.