The Perspective of Residents Living With Dementia Toward Their Built Environment: A Walking Interview Study in German Nursing Homes.

Background and Objectives: In long-term care, the built environment can help residents maintain activities of daily living and thus positively influence their quality of life. The adequacy of the built environment can be systematically assessed using assessment tools. The German Environmental Audit Tool (G-EAT) was translated and psychometrically tested for the German setting. Previous research has shown that the perspective of people living with dementia has not been fully considered in this adaptation. To explore the residents' perspective, the question of how residents living with dementia experience the built environment of nursing homes was investigated. Research Design and Methods: Walking interviews were conducted with residents. Inclusion criteria for participation were the presence of dementia (medically diagnosed or indicated by symptoms) and the ability to express themselves verbally in German. For data analysis, the audio material was transcribed and supplemented by the researchers' field notes and photographs. Data analysis followed an interpretative phenomenological approach. Results: Fourteen residents from 2 nursing homes participated in the walking interviews. A total of 3 themes were identified: (1) being able to maintain the feeling "to refurnish" or having to let it go, (2) experiencing the limits and potentials of being independent because of the built environment, and (3) living in a community of residents. Discussion and Implications: The perspective of the living environment of people living with dementia in nursing homes adds to the knowledge of assessment-based data. Boundaries between physical and social environments are experienced as fluid by residents. They do not see their living space as limited to their living unit but describe the nursing home as a living environment. This broadens the perspective of existing structural definitions in the setting.

Current situation, strengths and problems in intra- and interprofessional collaboration in German nursing homes - A holistic multiple case study.

BACKGROUND: The increasing care complexity of nursing home residents living with dementia requires new care models that strengthen professional collaboration. To contribute to the sustainable implementation of new care models, it is important that they are linked to the care reality. However, little is known about intra- and interprofessional organization and provision of care in German nursing homes. Therefore, the aim of this study was to explore the current care situation, problems and strengths regarding intra- and interprofessional collaboration in the care of residents living with dementia. METHODS: We conducted a holistic multiple case study. The individual care units in which residents living with dementia are cared for were defined as cases. The context was built by the respective nursing homes and their regional affiliation to the federal state of North Rhine-Westphalia. We used qualitative face-to-face interviews, documents and context questionnaires for data collection. The different sources of evidence served to capture complementary perspectives and to validate the findings. First, the collected qualitative data were analyzed using deductive-inductive content analysis. Second, similarities and differences between the cases were identified to elaborate case-specific and cross-case patterns and themes. The reporting followed the EQUATOR reporting guideline for organizational case studies. RESULTS: We included four care units comprising 21 professionals (nurses, physicians, social worker, physiotherapist, pharmacist) and 14 relatives of residents living with dementia. The analysis revealed four categories to describe current intra- and interprofessional collaboration in all cases: actors and their roles, service delivery, coordination and governance, and communication channel. Moreover, we identified three categories that relate to the strengths and problems of intra- and interprofessional collaboration in all cases: role understanding, teamwork, and communication and exchange. Although we examined similar care units, we found differences in the realization of professional collaboration and resulting problems and strengths that are connected to the organizational contexts and strategies used. CONCLUSIONS: Even though professional collaboration follows given patterns; these patterns do differ context-specifically and are perceived as problematic and fragmentary. Therefore, the identified differences and problems in collaboration need to be addressed in future research to develop and successfully implement tailored innovative care models.

Dementia-Sensitive Environmental Design of Living Units in German Nursing Homes: First Results of the German Environmental Audit Tool (G-EAT). / Demenzsensibilität der baulichen Umgebung langzeitstationärer Pflegeeinrichtungen in Deutschland: Erste Ergebnisse des German Environmental Audit Tool (G-EAT).

BACKGROUND: The built environment is a key component of dementia-specific care. Little is known about the characteristics of dementia-sensitive environmental elements in living units of nursing homes in Germany. The German Environmental Audit Tool (G-EAT) is a systematic assessment tool for describing these elements in detail. AIM OF THE STUDY: To describe the extent of dementia-sensitive design principles and environmental elements in a regionally limited sample of living units in Germany. METHODS: The built environment was assessed using G-EAT and analysed quantitatively and descriptively. Definitions of living units were developed based on site visits and analysed using qualitative content analysis. RESULTS: The 42 participating living units were heterogeneous in terms of space and composition. Dementia-sensitive design principles varied greatly in their implementation in the built environment; on average, 87.7% of the environmental elements were oriented towards a familiar environment. In contrast, visual accessibility was much less frequently enabled by the built environment (mean 37.3%). CONCLUSIONS: The characteristics of various dementia-sensitive environmental elements need to be further investigated against the background of the nursing home care concept and the homogeneity of the resident group to enable the initiation of tailored environmental adaptation that can be implemented by interdisciplinary teams in nursing homes. This also requires a follow-up study with a larger sample of living units to identify the factors that promote and inhibit the development of a dementia-sensitive environment.

Perspectives on sleep of people living with dementia in nursing homes: a qualitative interview study.

BACKGROUND: Disturbed sleep among people living with dementia in nursing homes is widespread and is associated with diseases and all-cause mortality. This study examined the sleep of people living with dementia from their perspectives in nursing homes and that of the nurses who care for people living with dementia. METHODS: A qualitative cross-sectional study was conducted. A total of 15 people living with dementia and 15 nurses in 11 German nursing homes were enrolled in this study. Data was collected between February and August 2021 through semistructured interviews, which were audio recorded and transcribed. Thematic analyses were performed by three independent researchers. Thematic mind maps and controversial findings were discussed with the Research Working Group of People with Dementia of the German Alzheimer Association. RESULTS: Thematic analysis identified five overarching themes from the nursing home participants regarding sleep patterns: (1) characteristics of good sleep, (2) characteristics of bad sleep, (3) personal influences of people living with dementia on sleep, (4) environmental factors on sleep, and (5) sleep strategies of people living with dementia. Analysis also identified five overarching themes from the nurses participants: (1) characteristics of good sleep, (2) characteristics of bad sleep, (3) personal influences on sleep, (4) environmental factors on sleep, and (5) interventions for sleep promotion. CONCLUSIONS: The thematic analyses demonstrated that the perspectives of people living with dementia and nurses indicate the need to give more consideration to psychosocial factors and individual aspects of sleep in clinical practice. The results could also be helpful for the development of targeted assessment instruments and complex non-pharmacological interventions to promote sleep.

Core elements and potential of nurse-led care models in residential long-term care: A scoping review.

AIMS AND OBJECTIVE: To identify and summarise core elements, resident-, staff- and process-related outcomes and challenges of nurse-led care models in residential long-term care. BACKGROUND: Due to demographic trends, the complexity of residential long-term care has increased. To address this complexity, the implementation of nurse-led care models has been recommended. DESIGN: Scoping review. METHODS: A systematic search was conducted of English and German articles in CINAHL via EBSCO, MEDLINE via PubMed, Cochrane Library and Scopus. Forward and backward citation tracking via reference lists and Google Scholar supplemented the search. The final update was made on 19 January 2021. To draw conclusions about the potential of nurse-led care models, evaluation studies of the described models for residents in nursing homes were included. Full texts were independently screened and assessed for methodological quality. Data were extracted and summarised in tables and synthesised for analysis. The core elements of the models were described using the Sustainable intEgrated chronic care modeLs for multimorbidity: delivery, FInancing and performancE (SELFIE) framework. The review followed the PRISMA-ScR guideline. RESULTS: We included 13 studies of 12 nurse-led care models. The different models comprised many of the core elements suggested in the SELFIE framework, particularly in the components service delivery, workforce, and leadership and governance. The studies reported a broad range of resident-, staff- and process-related outcomes and challenges considered relevant to the success of the models. CONCLUSIONS: Studies evaluating nurse-led care models in nursing homes are limited and of moderate quality. This review demonstrates that nurse-led care models include many elements for care coordination and could improve resident-, staff- and process-related outcomes. RELEVANCE TO CLINICAL PRACTICE: This review highlights that nurse-led care models share common core elements despite their heterogeneity. It also shows that highly qualified nurses in nurse-led care models can advance nursing practice in nursing homes.

Feasibility, Interrater Reliability and Internal Consistency of the German Environmental Audit Tool (G-EAT).

Dementia-specific environmental design has the potential to positively influence capabilities for daily living and quality of life in people with dementia living in nursing homes. To date, no reliable instrument exists for systematically assessing the adequacy of these built environments in Germany. This study aimed to test the adapted version of the Environmental Audit Tool-High Care (EAT-HC)-the German Environmental Audit Tool (G-EAT)-with regard to its feasibility, interrater reliability and internal consistency. The G-EAT was applied as a paper-pencil version in the German setting; intraclass correlation coefficients at the subscale level ranged from 0.662 (III) to 0.869 (IV), and 42% of the items showed at least substantial agreement (Cohen's kappa ≥ 0.60). The results indicate the need to develop supplementary material in a manual that illustrates the meaning of the items and practical implications regarding dementia-specific environmental design. Furthermore, the intersectionality of built and physical environments must be considered when interpreting G-EAT results in future research and applications to residential long-term care practice.

Relationship between the severity of agitation and quality of life in residents with dementia living in German nursing homes - a secondary data analysis.

BACKGROUND: Severe agitation and its relation to single dimensions of quality of life are not well understood. The aim of this study was to gain more knowledge about severe agitation and to examine the relationships between the severity of agitation and single dimensions of quality of life among residents with dementia living in German nursing homes. METHODS: This exploratory secondary analysis included data from 1947 residents of 66 German nursing homes from the DemenzMonitor study. The construct of agitation was defined as a composite score of the items agitation/aggression, irritability/lability and disinhibition from the Neuropsychiatric Inventory Questionnaire (NPI-Q); the resident was classified as severely agitated if at least one of these symptoms was rated as 'severe'. The single dimensions of quality of life were measured with the short version of the QUALIDEM instrument. To avoid selection bias, two controls with mild or no agitation were selected for each resident with severe agitation using propensity score matching. Mixed linear regression models were then generated to determine the differences in the dimensions of quality of life for the severity of agitation and the defining items. RESULTS: For four out of five dimensions of quality of life of the short version of QUALIDEM, residents with severe agitation had significantly lower values than residents without severe agitation. Converted to scale size, the greatest difference between both groups was found in the dimension social isolation with 23.0% (-2.07 (95% CI: -2.57, -1.57)). Further differences were found in the dimensions restless tense behaviour with 16.9% (-1.52 (95% CI: -2.04, -1.00)), positive affect with 14.0% (-1.68 (95% CI: -2.28, -1.09)) and social relations with 12.4% (-1.12 (95% CI: -1.54, -0.71)). CONCLUSIONS: Severe agitation is a relevant phenomenon among nursing home residents with dementia and is associated with lower values of quality of life in the dimensions social isolation, restless tense behaviour, positive affect and social relations from the QUALIDEM instrument. Therefore, more attention should be paid to severe agitation in nursing practice and research. Moreover, care strategies used to reduce severe agitation should be considered in terms of their impact on the dimensions of quality of life.