Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study.

BACKGROUND: Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios. METHODS: A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics. RESULTS: Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions. CONCLUSIONS: Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

Exploring Goals and Functional Changes in Reablement for People with Fractures and People with Dizziness and Balance Problems.

Background: Although older people often have challenges with fractures and dizziness/balance problems, knowledge concerning the impact of reablement of people with these conditions is limited. Aim: To explore functional changes in reablement for older home-dwelling people with fractures and dizziness/balance problems regarding 1) occupational performance and satisfaction with performance, 2) physical function and 3) health-related quality of life, and 4) which occupations they prioritize as rehabilitation goals. Material and Methods: The sample is derived from a nationwide clinically controlled trial in Norway consisting of 149 participants with fractures and 113 with dizziness/balance problems who participated in a four to 10-week reablement program. Data were collected at baseline and at 10-week, 6-month, and 12-month follow-up and were analyzed with paired t-tests and analysis of covariance. Occupational priorities were categorized into sub-areas of occupation. Results: Both groups had significant short-, mid-, and long-term improvements in occupational performance and satisfaction with performance. Except for balance from baseline to 12-month follow-up, the fracture group showed significant improvements in physical function and health-related quality of life at all follow-ups. The results varied more in the group with dizziness/balance problems in physical function and health-related quality of life. Functional mobility was the highest prioritized occupational sub-area in both groups. Conclusion: The findings of this study provide extended knowledge about goals and functional changes in people with fractures and dizziness/balance problems following a reablement program. Significance: Tailoring and individual adjustments according to diagnosis may be important in person-centered care in reablement.

Intended, Unintended, Unanticipated? Consequences of Social Distancing Measures for Nursing Home Residents During the Covid-19 Pandemic.

During the outbreak of the COVID-19 pandemic, Norwegian health authorities introduced social distancing measures in nursing homes. The aim was to protect vulnerable residents from contracting the potentially deadly infection. Drawing on individual interviews with nursing home managers and physicians, and focus groups with nursing staff, we explore and describe consequences the social distancing measures had on nursing home residents' health and wellbeing. The analysis indicates that most residents became socially deprived, while some became calmer during the nursing home lockdown. Nursing home staff, physicians and managers witnessed that residents' health and functional capacity declined when services to maintain health, such as physiotherapy, were put on hold. In conclusion, we argue that although Norwegian health authorities managed to keep the infection rates low in nursing homes, this came at a high price for the residents however, as the social distancing measures also negatively impacted their health and wellbeing.

A qualitative study on promoting reablement among older people living at home in Norway: opportunities and constraints.

BACKGROUND: Healthcare services that traditionally have been provided in long-term care institutions in Norway are increasingly being delivered at home to a growing population of older people with chronic conditions and functional limitations. Fostering reablement among older people is therefore important if they are to live safety at home for as long as possible. This study examines how healthcare professionals and managers (staff) in Norwegian municipalities promote reablement among community-dwelling older people. METHODS: Face-to-face, semi-structured interviews lasting between 21 and 89 min were conducted between November 2018 and March 2019 with healthcare managers (N = 8) and professionals (N = 8 focus groups with 2-5 participants) in six municipalities in Norway. All interviews were audio-recorded, transcribed, and thematically coded inductively and analyzed with the aid of NVivo 12 software. RESULTS: Overall, healthcare staff in this study used several strategies to promote reablement, including: carrying out assessments to evaluate older people's functional status and needs (including for safe home environments), and to identify older people's wishes and priorities with regard to reablement training. Staff designed care plans informed by the needs assessments, and worked with older people on reablement training at a suitable pace. They promoted among older people and staff (within and across care-units) the principle of 'showing/doing with' versus 'doing for' the older person so as to not enable disablement. Additionally, they supported older people in the safe and responsible use of welfare technology and equipment. Even so, staff also reported constraints to their efforts to foster reablement, such as: heavy workload, high turnover, insufficient training in reablement care, and poor collaboration across care-units. CONCLUSION: Older people may be supported to live safely at home by meeting them as individuals with agency, identifying and tailoring services to their needs and wishes, and encouraging their functional abilities by 'showing/doing with' versus 'doing for them' when possible. The healthcare professionals and managers in this study were positive towards reablement care. However, meeting the resource demands of reablement care is a key challenge.

The position of home-care nursing in primary health care: A critical analysis of contemporary policy documents.

Internationally, primary health care has in recent years gained a more central position in political priorities to ensure sustainable health care for the population. Thus, more people receive health care locally and in their own homes, where home-care nursing plays a large role. In this article, we investigate how home-care nursing is articulated and made visible in contemporary Norwegian policy documents. The study is a Fairclough-inspired critical discourse analysis seeking to uncover the position of nursing in the prevailing political ideologies on current primary health care. In the documents, we identified several complementary and conflicting understandings about home-care nursing. Home-care nursing is presented as a basic part of a municipality's health services, but at the same time, its content and contribution are unclear and almost invisible. We argue that the absence of nursing leads to significant perspectives being left out and tie this to the fact that some patient groups and tasks seem to be disadvantaged. The political placement of home-care nursing in the health-care landscape is thus not just about nursing as a professional practice but also concerns fundamental care values in our society in relation to disadvantaged groups and work tasks.

Home-care nurses' distinctive work: A discourse analysis of what takes precedence in changing healthcare services.

Ongoing changes in many Western countries have resulted in more healthcare services being transferred to municipalities and taking place in patients' homes. This greatly impacts nurses' work in home care, making their work increasingly diverse and demanding. In this study, we explore home-care nursing through a critical discourse analysis of focus group interviews with home-care nurses. Drawing on insights from positioning theory, we discuss the content and delineation of their work and the interweaving of contextual changes. Nurses hold a crucial position in home healthcare, particularly in ensuring care for sicker patients with complex needs. Assessing health needs, performing advanced care, and at the same time, providing customized solutions in various homes were identified as distinctive for home-care nurses' work. Changes have made nurses' work become driven by comprehensive tasks and acute medical needs that require much of their competence and time. Urgent care seems to take precedence in nurses' work, leaving less time and attention for other tasks such as conversations and support for coping with everyday life. This underlines the need to investigate and discuss the content and scope of nurses' work to help shape the further development of home-care nursing.

Expected deaths at home - a qualitative study of collaboration. / Forventet dødsfall i hjemmet ­ en kvalitativ studie om samarbeid.

BACKGROUND: It is a goal of health policy that more patients with serious illness should be able to die at home. This study elucidates the collaboration between healthcare personnel and undertakers immediately after the death, the dignity of the deceased patient and the bereaved relatives is challenged. MATERIAL AND METHOD: The study is primarily based on five focus group interviews with undertakers, GPs, nurses and healthcare workers in homecare nursing, a total of 23 participants in an urban municipality. RESULTS: The GPs and homecare nurses experienced concurrency conflicts which resulted in the downgrading of tasks concerning the deceased patient and bereaved relatives. Lack of clarity was identified concerning the doctors' verification of the death and completion of the death certificate, and the homecare nurses' personal care of the deceased patient. If the issuance of the death certificate was delayed, this had an impact on the way in which the deceased patient was dealt with by other parties involved. INTERPRETATION: The current GP system and the emergency primary health care scheme do not appear to have adequate resources for the doctor to be able to verify death and complete the death certificate, with potentially negative consequences for the subsequent work of undertakers and homecare nurses with the deceased patient and bereaved relatives.

Balancing contradictory requirements in homecare nursing-A discourse analysis.

Aim: To explore prevailing discourses on nursing competence in homecare nursing to boost understanding of practice within this field. Design: A qualitative study with a social constructivist perspective. Methods: Six focus-group interviews with homecare nurses in six different municipalities in Norway. Adapting a critical discourse analysis, data were linguistically, thematically and contextually analysed in the light of theories on competence, institutional logic and discourses. Results: The analysis found homecare nursing to be a diverse and contradictory practice with ever-increasing work tasks. Presented as binary oppositions, we identified the following prevailing discourses: individualized care versus organizing work; everyday-life care versus medical follow-up; and following rules versus using professional discretion. The binary oppositions represent contradictory requirements that homecare nurses strive to balance. The findings indicate that medical follow-up and organizational work have become more dominant in homecare nursing, leaving less time and attention paid to relational and everyday-life care.

Everyday occupations prioritised by older adults participating in reablement. A cross-sectional study.

Background: Little knowledge exists regarding which occupations older adults prioritize as rehabilitation goals in reablement and what factors are associated with their preferences.Objectives: To explore which occupations older people with functional decline find important to improve, which of these they prioritize as their rehabilitation goals, and what factors are associated with these priorities.Materials and methods: A cross-sectional study was undertaken with a sample of 738 older adults from a nationwide trial evaluating the effects of reablement in Norway. The nine occupational sub-areas of the Canadian Occupational Performance Measure were used as a framework for analyses.Results: Participants identified a multitude of occupations as challenging. Functional mobility was the most frequently identified and prioritized sub-area. Significant associations were found between prioritized occupations and health condition, sex, living status, education, walking speed and motivation.Conclusions: This study found both abundance and diversity in the occupational problems and prioritized goals of older adults, with mobility being a key priority regardless of health condition.Significance: It is important that reablement continues to be a person-centered intervention embracing the possibility to choose meaningful occupations. Occupational Therapists and other health professionals should address mobility when improving occupational performance in older adults.

Reablement teams' roles: a qualitative study of interdisciplinary teams' experiences.

INTRODUCTION: Reablement is a service for home-dwelling older people experiencing a decline in health and function. The focus of reablement is the improvement of the person's function and coping of his or he valued daily activities. The health care professionals and the home care personnel are working together with the older person toward his goals. In reablement, health care personnel are organized in an interdisciplinary team and collaborate with the older person in achieving his goals. This organizing changes the roles of home care personnel from working almost alone to collaborating with different health care professionals. There is little scientific knowledge describing the roles of different health care professionals and home care personnel in the context of reablement. This study's objective is to explore and describe the roles of interdisciplinary teams in reablement services in a Norwegian setting. METHOD: Two interdisciplinary teams consisting of 17 health care professionals (i.e. occupational therapists, physiotherapists, nurses, and social educators) and ten home care personnel (auxiliary nurses and nursing assistants) participated in three focus group discussions. In addition, three interviews were conducted with occupational therapists, physiotherapists, nurses, and auxiliary nurses. The focus group discussions and the interviews were all digitally recorded, transcribed verbatim and analyzed using the qualitative content analysis. RESULTS: The health care professionals' main role was to be consultants and advisors, consisting of (1) planning, adjusting, and conducting follow-ups of the intervention; (2) delegating tasks; and (3) supervising the home care personnel. The home care personnel's main role was to be personal trainers, consisting of (1) encouraging and counseling the older adults to perform everyday activities; and (2) conveying a sense of security while they performed everyday activities. The role of interdisciplinary collaboration was a common role for both the health care professionals and the home care personnel. CONCLUSION: The health care professionals established the setting, and had the main roles of supervision, delegating tasks, and main responsibility for the intervention. The home care personnel accepted the delegations and had a main role as personal trainers. Their work changed from body care to encouraging and counseling the older person to perform activities themselves in a safe way. The health care professionals and the home care personnel collaborated closely across roles. The home care personnel experienced a shift in role from home care to a person-centered care. This was perceived as strengthening the health care identity of their role.

Experiences and challenges of home care nurses and general practitioners in home-based palliative care - a qualitative study.

BACKGROUND: Norway has one of the lowest home death rates in Europe. However, it is the health authorities´ ambition to increase this by facilitating palliative care at home. The aim of this study was to achieve more insight, through home care nurses and general practitioners, of conditions that facilitate or hamper more time at home and more home deaths for patients with terminal disease and short life expectancy. METHODS: We used a qualitative research design with four focus groups with a total of 19 participants, of either home care nurses or general practitioners, using semi-structured question guides. The data were processed by systematic text condensation and encompassed thematic analysis of meaning and content of data across cases, which included four steps of analysis. RESULTS: Three main themes were identified: 1) The importance of a good start for the patient and family with five sub-themes, 2) 'Passing the baton' - the importance of collaboration across the health system with four sub-themes, and 3) Avoiding new hospitalization by establishing collaboration and competence within primary health care with four sub-themes. CONCLUSIONS: This study demonstrates that optimum palliative care at home depends on close collaboration and dialogue between the patient, family, home care nurses and general practitioner. It suggests the need for safer discharge routines and planning when hospitals transfer patients with terminal disease to their homes. A good start for the patient and family, where the initial interdisciplinary collaboration meeting takes place in the patient's home, is crucial for a good result. The general practitioners' perception of their 'disconnection' during hospitalization and prior to discharge has the potential to reduce patient safety. The family seems to be fundamental in gaining more time at home for the patient and supporting the patient to eventually die at home. Home-based palliative care demands experience and competence as well as regular supportive mentoring.

A mixed method study of an education intervention to reduce use of restraint and implement person-centered dementia care in nursing homes.

BACKGROUND: People living with dementia in nursing homes are most likely to be restrained. The primary aim of this mixed-method education intervention study was to investigate which factors hindered or facilitated staff awareness related to confidence building initiatives based on person-centred care, as an alternative to restraint in residents with dementia in nursing homes. The education intervention, consisting of a two-day seminar and monthly coaching sessions for six months, targeted nursing staff in 24 nursing homes in Western Norway. The present article reports on staff-related data from the study. METHODS: We employed a mixed-method design combining quantitative and qualitative methods. The P-CAT (Person-centred Care Assessment Tool) and QPS-Nordic (The General Nordic questionnaire for psychological and social factors at work) instruments were used to measure staff effects in terms of person-centred care and perception of leadership. The qualitative data were collected through ethnographic fieldwork, qualitative interviews and analysis of 84 reflection notes from eight persons in the four teams who facilitated the intervention. The PARIHS (Promoting Action on Research Implementation in Health Services) theoretical framework informed the study design and the data analysis. Six nursing homes were selected for ethnographic study post-intervention. RESULTS: Qualitative data indicated increased staff awareness related to using restraint - or not- in the context of person-centered care. A slight increase in P-CAT supported these findings. Thirteen percent of the P-CAT variation was explained by institutional belonging. Qualitative data indicated that whether shared decisions of alternative measures to restraint were applied was a function of dynamic interplay between facilitation and contextual elements. In this connection, the role of the nursing home leaders appeared to be a pivotal element promoting or hindering person-centered care. However, leadership-staff relations varied substantially across individual institutions, as did staff awareness related to restraint and person-centeredness. CONCLUSIONS: Leadership, in interplay with staff culture, turned out to be the most important factor hindering or promoting staff awareness related to confidence building initiatives, based on person-centered care. While quantitative data indicated variations across institutions and the extent of this variation, qualitative data offered insight into the local processes involved. A mixed method approach enabled understanding of dynamic contextual relationships. TRIAL REGISTRATION: The trial is registered at Clinical Trials gov. reg. 2012/304 NCT01715506.

Interdisciplinary collaboration in reablement - a qualitative study.

BACKGROUND: In-depth knowledge regarding interdisciplinary collaboration, a key feature in reablement, is scarce. OBJECTIVE: To elucidate how the interdisciplinary collaboration in reablement worked in a Norwegian context. SAMPLE AND METHODS: Seven focus group interviews were conducted with 33 health care providers working in interdisciplinary reablement teams in seven municipalities across the country. The focus group interviews were transcribed and an hermeneutical analysis was conducted. RESULTS: The analysis resulted in four main themes: "participant's own goals as a common interdisciplinary platform", "a positive professional community", "learning from each other's skills and competencies" and "new roles and joint efforts but specific competencies". The results show that interdisciplinary collaboration in reablement depends on participants defining their own rehabilitation goals, which function as a professional unifying platform for the interdisciplinary collaboration. The challenges for participants in reablement are often complex and include assessments, effort and a need for close collaboration between several different professionals. A tight interdisciplinary collaboration causes major changes in roles, often from a particular role to a more general role with broader job tasks. Although different professionals perform the same rehabilitation tasks, it is important that each professional contributes their unique competence and thus together they complete each other's competencies. CONCLUSION: Factors that have a positive impact on interdisciplinary collaboration in reablement are participants' definitions of their goals, number and variety of professionals involved, how closely these professionals collaborate, the amount of time for communication and shared planning and decision making.

Predictors of outcomes following reablement in community-dwelling older adults.

BACKGROUND: Reablement is a rehabilitation intervention for community-dwelling older adults, which has recently been implemented in several countries. Its purpose is to improve functional ability in daily occupations (everyday activities) perceived as important by the older person. Performance and satisfaction with performance in everyday life are the major outcomes of reablement. However, the evidence base concerning which factors predict better outcomes and who receives the greatest benefit in reablement is lacking. OBJECTIVE: The objective of this study was to determine the potential factors that predict occupational performance and satisfaction with that performance at 10 weeks follow-up. METHODS: The sample in this study was derived from a nationwide clinical controlled trial evaluating the effects of reablement in Norway and consisted of 712 participants living in 34 municipalities. Multiple linear regression was used to investigate possible predictors of occupational performance (COPM-P) and satisfaction with that performance (COPM-S) at 10 weeks follow-up based on the Canadian Occupational Performance Measure (COPM). RESULTS: The results indicate that the factors that significantly predicted better COPM-P and COPM-S outcomes at 10 weeks follow-up were higher baseline scores of COPM-P and COPM-S respectively, female sex, having a fracture as the major health condition and high motivation for rehabilitation. Conversely, the factors that significantly predicted poorer COPM-P and COPM-S outcomes were having a neurological disease other than stroke, having dizziness/balance problems as the major health condition and having pain/discomfort. In addition, having anxiety/depression was a predictor of poorer COPM-P outcomes. The two regression models explained 38.3% and 38.8% of the total variance of the dependent variables of occupational performance and satisfaction with that performance, respectively. CONCLUSION: The results indicate that diagnosis, functional level, sex and motivation are significant predictors of outcomes following reablement.

The relatives' voice: how do relatives experience participation in reablement? A qualitative study.

BACKGROUND: Reablement is an early and time-limited home-based model of rehabilitation intervention with an emphasis on intensive, goal-oriented, and multidisciplinary assistance for persons experiencing functional decline. When rehabilitation in general takes place in the person's own home, in contrast to an institution, relatives may have larger responsibilities in helping and supporting the family member. Although there is evidence, showing that family caregivers, such as spouses and children, experience burdens and demanding situations related to their caregiving role, there are currently few publications exploring relatives' experiences of participating in reablement. The aim of our study was to explore and describe how relatives in a community setting in Norway experienced participation in the reablement process. METHODS: Six relatives participated in semi-structured interviews. Qualitative systematic text condensation was used as the analysis strategy. RESULTS: Five themes emerged that summarized the relatives' experiences with reablement: 1) a wish to give and receive information, wish to be involved; 2) wish to be a resource in reablement process; 3) conflicting expectations; 4) have more free time to themselves; and 5) a lack of follow-up programs. CONCLUSION: Our findings highlight the involvement and collaborative process between health professionals, older adults, and relatives and have practical significance for health care services. To advance collaborative practices, the municipal health and social care services should consider establishing a system or a routine to foster this collaboration in reablement. Follow-up programs should be included.

Driving forces for home-based reablement; a qualitative study of older adults' experiences.

As a result of the ageing population worldwide, there has been a growing international interest in a new intervention termed 'reablement'. Reablement is an early and time-limited home-based intervention with emphasis on intensive, goal-oriented and interdisciplinary rehabilitation for older adults in need of rehabilitation or at risk of functional decline. The aim of this qualitative study was to describe how older adults experienced participation in reablement. Eight older adults participated in semi-structured interviews. A qualitative content analysis was used as the analysis strategy. Four main themes emerged from the participants' experiences of participating in reablement: 'My willpower is needed', 'Being with my stuff and my people', 'The home-trainers are essential', and 'Training is physical exercises, not everyday activities'. The first three themes in particular reflected the participants' driving forces in the reablement process. Driving forces are intrinsic motivation in interaction with extrinsic motivation. Intrinsic motivation was based on the person's willpower and responsibility, and extrinsic motivation was expressed to be strengthened by being in one's home environment with 'own' people, as well as by the co-operation with the reablement team. The reablement team encouraged and supported the older adults to regain confidence in performing everyday activities as well as participating in the society. Our findings have practical significance for politicians, healthcare providers and healthcare professionals by contributing to an understanding of how intrinsic and extrinsic motivation influence reablement. Some persons need apparently more extrinsic motivational support also after the time-limited reablement period is completed. The municipal health and care services need to consider individualised follow-up programmes after the intensive reablement period in order to maintain the achieved skills to perform everyday activities and participate in society.

The reablement team's voice: a qualitative study of how an integrated multidisciplinary team experiences participation in reablement.

BACKGROUND: Reablement is an early and time-limited home-based rehabilitation intervention that emphasizes intensive, goal-oriented, and multidisciplinary assistance for people experiencing functional decline. Few empirical studies to date have examined the experiences of the integrated multidisciplinary teams involved in reablement. Accordingly, the aim of this study was to explore and describe how an integrated multidisciplinary team in Norway experienced participation in reablement. METHODS: An integrated multidisciplinary team consisting of health care professionals with a bachelor's degree (including a physiotherapist, a social educator, occupational therapists, and nurses) and home-based care personnel without a bachelor's degree (auxiliary nurses and nursing assistants) participated in focus group discussions. Qualitative content analysis was used to analyze the resulting data. RESULTS: Three main themes emerged from the participants' experiences with participating in reablement, including "the older adult's goals are crucial", "a different way of thinking and acting - a shift in work culture", and "a better framework for cooperation and application of professional expertise and judgment". The integrated multidisciplinary team and the older adults collaborated and worked in the same direction to achieve the person's valued goals. The team supported the older adults in performing activities themselves rather than completing tasks for them. To facilitate cooperation and application of professional expertise and judgment, common meeting times and meeting places for communication and supervision were necessary. CONCLUSION: Structural factors that promote integrated multidisciplinary professional decisions include providing common meeting times and meeting places as well as sufficient time to apply professional knowledge when supervising and supporting older persons in everyday activities. These findings have implications for practice and suggest future directions for improving health care services. The shift in work culture from static to dynamic service is time consuming and requires politicians, community leaders, and health care systems to allocate the necessary time to support this approach to thinking and working.

Facilitating change from a distance - a story of success? A discussion on leaders' styles in facilitating change in four nursing homes in Norway.

AIM: To examine the influence of leadership when facilitating change in nursing homes. BACKGROUND: The study is a part of an education intervention for care staff to prevent the use of restraint in nursing home residents with dementia in 24 nursing homes (NHs) in Norway. Leadership is known to be a fundamental factor for success of evidence-based practice (EBP) implementation in health services. However, the type of leadership that strengthens the processes of change remains to be clarified. METHOD: A multi-site comparative ethnography was performed in four nursing homes to investigate how contextual factors influenced the implementation. The analysis was informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and in particular the sub-element of leadership. RESULTS: Different leadership styles to facilitate change were identified. Paradoxically, a strong collective and collaborative leadership style was found to hamper change in one particular home, whereas a remote leadership style combined with almost no cooperation with staff proved successful in another setting. CONCLUSIONS: The study indicates that leadership cannot be understood on a low-high continuum as suggested by the PARIHS framework, but rather as a factor characterised by diversity. IMPLICATION FOR NURSING MANAGEMENT: Our study indicates, as a minimum, that a leader's presence is necessary to facilitate the internal processes in order more successfully to implement EBP.

Modeling and evaluating evidence-based continuing education program in nursing home dementia care (MEDCED)--training of care home staff to reduce use of restraint in care home residents with dementia. A cluster randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a tailored 7-month training intervention "Trust Before Restraint," in reducing use of restraint, agitation, and antipsychotic medications in care home residents with dementia. METHODS: This is a single-blind cluster randomized controlled trial in 24 care homes within the Western Norway Regional Health Authority 2011-2013. RESULTS: From 24 care homes, 274 residents were included in the study, with 118 in the intervention group and 156 in the control group. Use of restraint was significantly reduced in both the intervention group and the control group despite unexpected low baseline, with a tendency to a greater reduction in the control group. There was a significant reduction in Cohen-Mansfield Agitation Inventory score in both the intervention group and the follow-up group with a slightly higher reduction in the control group, although this did not reach significance and a small nonsignificant increase in use of antipsychotics (14.1-17.7%) and antidepressants (35.9-38.4%) in both groups. CONCLUSIONS: This study reports on the statistically significant reduction in use of restraint in care homes, both prior and during the 7-month intervention periods, in both intervention and control groups. When interpreted within the context of the current climate of educational initiatives to reduce restraint and a greater focus on the importance of person-centered care, the study also highlights the potential success achieved with national training programs for care staff and should be further evaluated to inform future training initiatives both in Norway and internationally.