Exploring home rehabilitation therapists' experiences of supporting older persons to physical exercise after acute hospitalization: a qualitative interview study.

PURPOSE: After hospitalization, older persons may face a decline in physical function and daily independence. In-hospital exercise interventions can mitigate this decline, and continued support from primary healthcare post-discharge may enhance sustainability. This study aimed to explore home rehabilitation therapists' experiences of supporting physical exercise after acute hospitalization, including exercise programs initiated during hospital stay. METHODS: This qualitative study was conducted alongside a randomized-controlled trial to investigate prerequisites for a transitional care intervention. Twelve interviews were conducted with physiotherapists, occupational therapists, and managers across seven rehabilitation therapy services in Stockholm, Sweden. Data were analyzed using reflexive thematic analysis. RESULTS: The analysis generated the theme Striving for individualized support for physical exercise, although limited resources and a fragmented home care risk to direct support away from those who need it the most. It was based on four subthemes: The starting point is always the patient's current needs, goals, and prerequisites, Continuing the exercise initiated during hospitalization by adapting it to the patient's situation at home, Work premises not tailored to patients with complex care needs, and A home care organization that lacks coordination and unified purpose. CONCLUSIONS: Interventions supporting older persons to physical exercise after acute hospitalization need to be tailored to the individual, support motivation, and be adapted to the patient's home situation. Challenges may arise when care recourses lack alignment with the patients' needs, and when the collaboration among care providers is limited. The findings contribute valuable insights for future studies incorporating transitional care interventions in similar context.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective.

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Trust and easy access to home care staff are associated with older adults' sense of security: a Swedish longitudinal study.

AIM: Older adults are increasingly encouraged to continue living in their own homes with support from home care services. However, few studies have focused on older adults' safety in home care. This study explored associations between the sense of security and factors related to demographic characteristics and home care services. METHODS: The mixed longitudinal design was based on a retrospective national survey. The study population consisted of individuals in Sweden (aged 65+ years) granted home care services at any time between 2016 and 2020 (n=82,834-94,714). Multiple ordinal logistic regression models were fitted using the generalised estimation equation method to assess the strength of relationship between the dependent (sense of security) and independent (demographics, health and care-related factors) variables. RESULTS: The sense of security tended to increase between 2016 and 2020, and was significantly associated with being a woman, living outside big cities, being granted more home care services hours or being diagnosed/treated for depression (cumulative odds ratio 2-9% higher). Anxiety, poor health and living alone were most strongly associated with insecurity (cumulative odds ratio 17-64% lower). Aside from overall satisfaction with home care services, accessibility and confidence in staff influenced the sense of security most. CONCLUSIONS: We stress the need to promote older adults' sense of security for safe ageing in place, as mandated by Swedish law. Home care services profoundly influence older adults' sense of security. Therefore, it is vital to prioritise continuity in care, establish trust and build relationships with older adults. Given the increasing shortage of staff, integrating complementary measures, such as welfare technologies, is crucial to promoting this sense of security.

Listen to the voices of nurses: the role of community chief nurses and registered nurses in the provision of care for older people in Sweden during the COVID-19 pandemic - a cross-sectional study.

BACKGROUND: During the pandemic in Sweden, the aim was to protect older people, especially those among them who were sick, frail and vulnerable in residential care facilities. A ban was put on visits at all residential care facilities in March 2020 to prevent the spread of infection among the older people. This study aims to describe the experiences of Community Chief Nurses and Registered Nurses who provided medical and nursing care for older people in residential care facilities and home care during the first wave of the COVID-19 pandemic, and to examine factors associated with the quality of care. METHODS: The study has a mixed method cross-sectional design (STROBE). Data were collected using a web-based survey that comprised two questionnaires, for Community Chief Nurses and Registered Nurses developed for the study. Data were analysed using descriptive statistics and logistic regression models, as well as qualitative content analyses. RESULTS: The majority of Community Chief Nurses reported adequate opportunities to work with management to handle the COVID-19 pandemic. The Registered Nurses reported that the quality of care, as well as the person's safety, was negatively affected during the pandemic. Factors associated with good care were as follows: information-sharing; ability to comply with hygiene practices; competence in how to care for older persons with COVID-19; a physician at bedside assessing their health; and support from frontline managers. CONCLUSION: The study highlights crucial facets that care organizations must address to enhance their readiness for future pandemics or disasters, ensuring the security and well-being of the older people.

Malnutrition prevalence according to GLIM and its feasibility in geriatric patients: a prospective cross-sectional study.

PURPOSE: In 2019, the Global Leadership Initiative on Malnutrition (GLIM) suggested a 2-step diagnostic format for malnutrition including screening and diagnosis. Prospective validation and feasibility studies, using the complete set of the five GLIM criteria, are needed. The aims of this study were to determine the prevalence of malnutrition, and investigate how the prevalence varied with mode of screening. Furthermore, we assessed the feasibility of GLIM in geriatric patients. METHODS: Consecutive patients from two acute geriatric wards were included. For screening risk of malnutrition, the Mini Nutritional Assessment-Short Form (MNA-SF) or Malnutrition Screening Tool (MST) were used. In accordance with GLIM, a combination of phenotypic and etiologic criteria were required for the diagnosis of malnutrition. Feasibility was determined based on % data completeness, and above 80% completeness was considered feasible. RESULTS: One hundred patients (mean age 82 years, 58% women) were included. After screening with MNA-SF malnutrition was confirmed by GLIM in 51%, as compared with 35% after screening with MST (p = 0.039). Corresponding prevalence was 58% with no prior screening. Using hand grip strength as a supportive measure for reduced muscle mass, 69% of the patients were malnourished. Feasibility varied between 70 and 100% for the different GLIM criteria, with calf circumference as a proxy for reduced muscle mass having the lowest feasibility. CONCLUSION: In acute geriatric patients, the prevalence of malnutrition according to GLIM varied depending on the screening tool used. In this setting, GLIM appears feasible, besides for the criterion of reduced muscle mass.

The use of the evidence-based practice process by experienced registered nurses to inform and transform clinical practice during the COVID-19 pandemic: A longitudinal national cohort study.

BACKGROUND: During the COVID-19 pandemic, many registered nurses (RNs) worked on the frontline caring for severely ill patients. They did so with limited knowledge of how to treat and prevent the disease. This extreme situation puts pressure on RNs to find evidence on which to base the care of their patients. AIMS: To examine: (1) the extent to which evidence-based practice (EBP) process was applied by Swedish RN cohorts 15-19 years after graduation during the pandemic, (2) whether there was any change to their EBP process from pre-pandemic to late pandemic, (3) the relationship between RNs' use of the EBP process and the duration of exposure to work situations severely affected by the COVID-19 pandemic, and (4) whether level of education, position and care setting were associated with the extent of RNs' EBP process. METHODS: In 2021, the level of EBP activities was investigated among 2237 RNs 15-19 years after graduation. The scale used to measure EBP consisted of six items of the EBP process. Unpaired t-tests or one-way analysis of variance (ANOVA) were used in the analysis. RESULTS: RNs used the EBP process to a moderate extent to inform and transform their clinical practice. There was a minor but significant decrease in practicing the EBP process from pre-pandemic to late in the pandemic. RNs who were most affected by the pandemic scored higher on the scale than less-affected colleagues. RNs in nonclinical positions reported more EBP activities, as did RNs in management positions. RNs working in outpatient settings reported more EBP activities than their colleagues in hospitals. LINKING EVIDENCE TO ACTION: It is imperative that RNs hone their skills in EBP if they are to be prepared for future healthcare crises. Healthcare providers have a duty to facilitate the development of EBP and, in this regard, RNs in clinical positions in hospitals need particular support.

Approved or disregarded? Exploring arenas for narrative relations in geriatric care.

PURPOSE: The use of narration in healthcare has been accentuated as a response to the requested shift towards person-centred care. The notion of narrative relations refers to a process of involving several people in mutual and ongoing narrative exchange. This study aimed to explore how and where narrative relations may be adopted and enacted in everyday healthcare practice. METHODS: The study has a qualitative, explorative design. Seven interprofessional focus group discussions with healthcare staff were prompted by vignettes. A multidisciplinary team of healthcare staff (n = 31) were recruited on a geriatric ward. Data were analysed using a constant comparative method. RESULTS: A core theme shows how narrative relations are adopted and enacted both as part of an approved practice-the work procedures commonly approved as part of healthcare, and as a disregarded practice where covert but important narrative relations take place to support fundamental qualities of healthcare. Moreover, the findings consider arenas of healthcare practice where approved or disregarded practices are enacted in the clinic frontstage and the clinic backstage. CONCLUSIONS: Narrative relations may take place in different arenas of healthcare practice yet simultaneously become a cohesive force interconnecting those arenas and uphold continuity. Impeded narrative relations in one arena may have unintended consequences in another.

Cross-cultural adaption and inter-rater reliability of the Swedish version of the updated clinical frailty scale 2.0.

BACKGROUND: Worldwide, there is a large and growing group of older adults. Frailty is known as an important discriminatory factor for poor outcomes. The Clinical Frailty Scale (CFS) has become a frequently used frailty instrument in different clinical settings and health care sectors, and it has shown good predictive validity. The aims of this study were to describe and validate the translation and cultural adaptation of the CFS into Swedish (CFS-SWE), and to test the inter-rater reliability (IRR) for registered nurses using the CFS-SWE. METHODS: An observational study design was employed. The ISPOR principles were used for the translation, linguistic validation and cultural adaptation of the scale. To test the IRR, 12 participants were asked to rate 10 clinical case vignettes using the CFS-SWE. The IRR was assessed using intraclass correlation and Krippendorff's alpha agreement coefficient test. RESULTS: The Clinical Frailty Scale was translated and culturally adapted into Swedish and is presented in its final form. The IRR for all raters, measured by an intraclass correlation test, resulted in an absolute agreement value among the raters of 0.969 (95% CI: 0.929-0.991) and a consistency value of 0.979 (95% CI: 0.953-0.994), which indicates excellent reliability. Krippendorff's alpha agreement coefficient for all raters was 0.969 (95% CI: 0.917-0.988), indicating near-perfect agreement. The sensitivity of the reliability was examined by separately testing the IRR of the group of specialised registered nurses and non-specialised registered nurses respectively, with consistent and similar results. CONCLUSION: The Clinical Frailty Scale was translated, linguistically validated and culturally adapted into Swedish following a well-established standard technique. The IRR was excellent, judged by two established, separately used, reliability tests. The reliability test results did not differ between non-specialised and specialised registered nurses. However, the use of case vignettes might reduce the generalisability of the reliability findings to real-life settings. The CFS has the potential to be a common reference tool, especially when older adults are treated and rehabilitated in different care sectors.

Träning och protein för funktion och självtillit.

Exercise and protein for function and self-confidence - The OPEN model for community care of older persons Experiences from the COVID-19 pandemic indicate the need to introduce care routines for health promotion among recipients of care for older persons. A treatment model with daily repeated sit-to-stand exercises in combination with oral protein supplements twice daily has been evaluated in community care for older persons in the Stockholm Region; the Older Person's Exercise and Nutrition (OPEN) Study. The 3-month controlled study included 102 residents. A substantial part of the residents were able to follow the intervention, and to maintain or improve their chair-rising capacity, while also increasing their weight and muscle mass. Interview studies showed that the participants found the OPEN concept was easy to adopt, gave increased self-confidence and an increased sense of hope. The staff perceived the intervention as a potentially positive concept. The OPEN model is a method that may contribute to a health-promoting way of working in the care of older persons.

Clarity and adaptability of instructions preventing the spread of the COVID-19 virus and its association with individual and organisational factors regarding the psychosocial work environment: a cross-sectional study.

BACKGROUND: In Sweden, older people in residential care had the highest mortality rates, followed by those who received home care, during the coronavirus disease 2019 (COVID-19) pandemic. Staff working in the care of older people assumed responsibility for preventing the spread of the virus despite lacking the prerequisites and training. This study aimed to investigate the psychosocial work environment during the COVID-19 pandemic among staff in the care of older people and examine the factors associated with staff's perceptions of the clarity of instructions and the ability to follow them. METHODS: A cross-sectional study design was employed using a web survey. The staff's perceptions of their psychosocial environment were analysed using descriptive statistics. The association between organisational and individual factors, as well as the degree of clarity of the instructions and the staff's ability to follow them, were assessed using multivariate (ordinal) regression analysis. RESULTS: The main findings show that perceptions of the clarity and adaptability of the instructions were primarily correlated with organisational factors, as higher responses (positive) for the subscales focusing on role clarity, support and encouragement in leadership at work were associated with the belief that the instructions were clear. Similarly, those indicating high job demands and high individual learning demands were less likely to report that the instructions were clear. Regarding adaptability, high scores for demands on learning and psychological demands were correlated with lower adaptability, while high scores for role clarity, encouraging leadership and social support, were associated with higher adaptability. CONCLUSIONS: High job demands and individual learning demands were demonstrated to decrease the staff's understanding and adoption of instructions. These findings are significant on an organisational level since the work environment must be prepared for potential future pandemics to promote quality improvement and generally increase patient safety and staff health.

Discordance in Frailty Measures in Old Community Dwelling People with Multimorbidity - A Cross-Sectional Study.

Purpose: Assessment of frailty is a key method to identify older people in need of holistic care. However, agreement between different frailty instrument varies. Thus, groups classified as frail by different instruments are not completely overlapping. This study evaluated differences in sociodemographic factors, cognition, functional status, and quality of life between older persons with multimorbidity who were discordantly classified by five different frailty instruments, with focus on the Clinical Frailty Scale (CFS) and Fried's Frailty Phenotype (FP). Participants and Methods: This was a cross-sectional study in a community-dwelling setting. Inclusion criteria were as follows: ≥75 years old, ≥3 visits to the emergency department the past 18 months, and ≥3 diagnoses according to ICD-10. 450 participants were included. Frailty was assessed by CFS, FP, Short Physical Performance Battery (SPPB), Grip Strength and Walking Speed. Results: 385 participants had data on all frailty instruments. Prevalence of frailty ranged from 34% (CFS) to 75% (SPPB). Nine percent of participants were non-frail by all instruments, 20% were frail by all instruments and 71% had discordant frailty classifications. Those who were frail according to CFS but not by the other instruments had lower cognition and functional status. Those who were frail according to FP but not CFS were, to a larger extent, women, lived alone, had higher cognitive ability and functional status. Conclusion: The CFS might not identify physically frail women in older community-dwelling people with multimorbidity. They could thus be at risk of not be given the attention their frail condition need.

Missed nursing care in relation to registered nurses' level of education and self-reported evidence-based practice.

BACKGROUND: Patient safety is one of the cornerstones of high-quality healthcare systems. Evidence-based practice is one way to improve patient safety from the nursing perspective. Another aspect of care that directly influences patient safety is missed nursing care. However, research on possible associations between evidence-based practice and missed nursing care is lacking. AIM: The aim of this study was to examine associations between registered nurses' educational level, the capability beliefs and use of evidence-based practice, and missed nursing care. METHODS: This study had a cross-sectional design. A total of 228 registered nurses from adult inpatient wards at a university hospital participated. Data were collected with the MISSCARE Survey-Swedish version of Evidence-Based Practice Capabilities Beliefs Scale. RESULTS: Most missed nursing care was reported within the subscales Basic Care and Planning. Nurses holding a higher educational level and being low evidence-based practice users reported significantly more missed nursing care. They also scored significantly higher on the Evidence-based Practice Capabilities Beliefs Scale. The analyses showed a limited explanation of the variance of missed nursing care and revealed that being a high user of evidence-based practice indicated less reported missed nursing care, while a higher educational level meant more reported missed nursing care. LINKING EVIDENCE TO ACTION: Most missed nursing care was reported within the subscales Planning and Basic Care. Thus, nursing activities are deprioritized in comparison to medical activities. Nurses holding a higher education reported more missed nursing care, indicating that higher education entails deeper knowledge of the consequences when rationing nursing care. They also reported varied use of evidence-based practice, showing that higher education is not the only factor that matters. To decrease missed nursing care in clinical practice, and thereby increase the quality of care, educational level, use of evidence-based practice, and organizational factors must be considered.

Family Members' Experiences of Young-Onset Dementia: Becoming Responsible Yet Feeling Powerless.

Purpose: Dementia is often associated with old age but can also occur in midlife. The latter is commonly referred to as young-onset dementia (YOD). The diagnosis not only has an impact on the persons with YOD but also on their family members. For family members, the diagnosis changes their lives, as responsibilities and roles alter when the care and wellbeing of the relative increasingly come into focus. The aim of this study was to explore family members' experiences of sharing lives with a relative diagnosed with YOD - from onset of symptoms until the person relocated to a nursing home. Patients and Methods: The study has a qualitative approach with in-depth interviews. In total, the study included 15 family members aged ≥18 years participated, all with a relative diagnosed with dementia before the age of 65. At the time of the interview, all had a relative living in a nursing home. The interviews were analyzed using thematic analysis. Results: Two key themes were identified: Becoming responsible and Dealing with the situation. Family members found themselves increasingly responsible for many parts of their relatives' lives and forced to make decisions on their behalf. This was experienced as being lonely, as family members wished to share their responsibility. Despite of their efforts to control and deal with their situation, family members reported a lack of power to influence certain factors, such as access to appropriate healthcare services, causing feelings of distress. Conclusion: These findings emphasize the need of improved and tailored support and guidance for family members of persons with YOD. Further, the findings highlight the importance of increased knowledge and awareness among social workers and other healthcare professionals regarding support to family members of persons with YOD.

Translation and Validation of the Swedish Version of the Tilburg Frailty Indicator.

The Tilburg Frailty Indicator (TFI) is a questionnaire with 15 questions designed for screening for frailty in community-dwelling older people. TFI has a multidimensional approach to frailty, including physical, psychological, and social dimensions. The aim of this study was to translate TFI into Swedish and study its psychometric properties in community-dwelling older people with multimorbidity. A cross-sectional study of individuals 75 years and older, with ≥3 diagnoses of the ICD-10 and ≥3 visits to the Emergency Department in the past 18 months. International guidelines for back-translation were followed. Psychometric properties of the TFI were examined by determining the reliability (inter-item correlations, internal consistency, test-retest) and validity (concurrent, construct, structural). A total of 315 participants (57.8% women) were included, and the mean age was 83.3 years. The reliability coefficient KR-20 was 0.69 for the total sum. A total of 39 individuals were re-tested, and the weighted kappa was 0.7. TFI correlated moderately with other frailty measures. The individual items correlated with alternative measures mostly as expected. In the confirmatory factor analysis (CFA), a three-factor model fitted the data better than a one-factor model. We found evidence for adequate reliability and validity of the Swedish TFI and potential for improvements.

Study protocol for the 'preventing functional decline in acutely hospitalised older patients (PREV_FUNC)' study: effects of two multicomponent exercise programmes on physical function - a three-armed randomised controlled trial.

INTRODUCTION: Acutely hospitalised older patients often live with frailty and have an increased risk of impaired physical function. Previous studies suggest that exercise might mitigate the risk of physical impairment; however, further research is needed to compare the effect of different types of exercise interventions. In this paper, we report a protocol for a trial that aims to examine (1) if multicomponent exercise interventions (interventions that include both mobility and strengthening exercises) have effects on physical function compared with usual care in older adults and (2) if a comprehensive multicomponent exercise programme is more effective than a simple multicomponent exercise programme that only include walking and sit-to-stand exercises. METHODS AND ANALYSIS: This is a three-armed randomised controlled trial, with two intervention groups (comprehensive and simple exercise programme) and a control group receiving usual care. We will include 320 participants aged ≥75 years from geriatric medical departments of four hospitals in Stockholm, Sweden. Assessments will be conducted at hospital admission, discharge and 3 months thereafter concerning physical function (primary outcome), activities of daily living, health-related quality of life, sarcopenia and falls. The number of readmissions will be registered up to 1 year after discharge. Data will be analysed with linear mixed effects models, according to the intention-to-treat approach. ETHICS AND DISSEMINATION: Ethical approval for this trial has been granted by the Swedish Ethical Review Authority (approval number 2022-03032-01). Data collection will consider the information requirement, the requirement of consent, confidentiality obligations and the utilisation requirement. Trial findings will be disseminated through multiple channels, including scientific publications and conferences, and workshops with healthcare professionals and the public. TRIAL REGISTRATION NUMBER: NCT05366075.

Investigating the Connections Between Delivery of Care, Reablement, Workload, and Organizational Factors in Home Care Services: Mixed Methods Study.

BACKGROUND: Home care is facing increasing demand due to an aging population. Several challenges have been identified in the provision of home care, such as the need for support and tailoring support to individual needs. Goal-oriented interventions, such as reablement, may provide a solution to some of these challenges. The reablement approach targets adaptation to disease and relearning of everyday life skills and has been found to improve health-related quality of life while reducing service use. OBJECTIVE: The objective of this study is to characterize home care system variables (elements) and their relationships (connections) relevant to home care staff workload, home care user needs and satisfaction, and the reablement approach. This is to examine the effects of improvement and interventions, such as the person-centered reablement approach, on the delivery of home care services, workload, work-related stress, home care user experience, and other organizational factors. The main focus was on Swedish home care and tax-funded universal welfare systems. METHODS: The study used a mixed methods approach where a causal loop diagram was developed grounded in participatory methods with academic health care science research experts in nursing, occupational therapy, aging, and the reablement approach. The approach was supplemented with theoretical models and the scientific literature. The developed model was verified by the same group of experts and empirical evidence. Finally, the model was analyzed qualitatively and through simulation methods. RESULTS: The final causal loop diagram included elements and connections across the categories: stress, home care staff, home care user, organization, social support network of the home care user, and societal level. The model was able to qualitatively describe observed intervention outcomes from the literature. The analysis suggested elements to target for improvement and the potential impact of relevant studied interventions. For example, the elements "workload" and "distress" were important determinants of home care staff health, provision, and quality of care. CONCLUSIONS: The developed model may be of value for informing hypothesis formulation, study design, and discourse within the context of improvement in home care. Further work will include a broader group of stakeholders to reduce the risk of bias. Translation into a quantitative model will be explored.

Transitions: Experiences of younger persons recently diagnosed with Alzheimer-type dementia.

Receiving a diagnosis of dementia before the age of 65 has a huge impact on everyday life. Previously, the disease trajectory has mainly been described from the perspective of older persons. However, young persons with dementia are confronted with specific challenges, influencing the type of life-changing events, or 'critical points' that they may experience. The aim of this study was therefore to describe experiences of persons recently being diagnosed with young-onset dementia. In total, 14 participants with dementia due to Alzheimer's disease (10 woman/4 men) with an average age of 59 were included in the study. Interviews were conducted within 2 months after receiving the diagnosis and analyzed using qualitative content analysis with an inductive approach, resulting in three categories: (1) A life changing moment, (2) An ongoing process, and (3) Remaining in control. The findings show that receiving such a diagnosis was experienced by participants as a life changing moment, followed by them seeking to come to terms with the diagnosis and reflecting on its meaning, in which various strategies were adopted to remain in control. The current study highlights three critical points considering the diagnosis of young-onset dementia that warrant special attention and provides insight into factors related to delay in healthy transitioning after receiving the diagnosis, as well as factors that may facilitate successful transitions.

Engaging in narrative relations in everyday work on a geriatric ward: A qualitative study with healthcare professionals.

AIMS AND OBJECTIVES: To explore healthcare professionals' experiences and reflections about narration in their everyday work. BACKGROUND: The need for integrated and people-centred healthcare for older adults has highlighted the relevance of narration in healthcare practice. Although theoretical foundations vary, different frameworks building on narration have been proposed for translating person-centredness philosophies into practice. However, to understand how theoretical knowledge on narration can be adopted into clinical work, we need to learn how healthcare staff understand narration from their experiential knowledge and practice. DESIGN: The research process followed guidelines from Constructivist Grounded Theory as described by Charmaz. The study adheres to the COREQ guidelines. METHODS: Data collection entailed interprofessional focus groups discussions with healthcare staff (n = 31). Vignettes depicting realistic scenarios were used to encourage participants to reflect on clinical practice. Data were analysed via a constant comparative method. RESULTS: One core theme arose from the analysis. The core theme showed how narration was a relational process that people engaged in to pursue and uphold several foundational qualities in healthcare practice presented in the following subthemes: preventing simplistic understandings of people and situations; supporting trustful relations; supporting continuity and coherence; and learning from coworkers. However, a minor theme raised awareness of narrative relations as a double-edged sword. CONCLUSIONS: By acknowledging the mutual and multifacetted nature of narration in everyday practice, this study shows how healthcare professionals' engagement in narrative relations may contribute to upholding several foundational qualities which resonate with philosophies of person-centredness in everyday healthcare practice. RELEVANCE TO CLINICAL PRACTICE: Recognition of both the advantages and possible risks embedded in narrative relations in healthcare practice emphasises the obligation to collectively reflect on the repercussions of narrative relations in any local context. PATIENT OR PUBLIC CONTRIBUTION: Healthcare professionals contributed by sharing their experiential knowledge and reflections on narration in practice.

Self-reported documentation of goals and outcomes of nutrition care - A cross-sectional survey study of Scandinavian dietitians.

BACKGROUND: The documentation of goals and outcomes of nutrition care in Electronic Health Records is insufficient making further exploration of this of particular interest. Identifying common features in documentation practice among Scandinavian dietitians might provide information that can support improvement in this area. AIMS: To explore the associations between clinical dietitians' self-reported documentation of patients' goals and outcomes and demographic factors, self-reported implementation of the systematic framework the Nutrition Care Process 4th step (NCP) and its associated terminology, and factors associated with the workplace. METHODS: Data from a cross-sectional study based on a previously tested web-based survey (INIS) disseminated in 2017 to dietitians in Scandinavia (n = 494) was used. Respondents were recruited through e-mail lists, e-newsletters and social media groups for dietitians. Associations between countries regarding the reported documentation of goals and outcomes, implementation levels of the NCP 4th step, demographic information and factors associated with the workplace were measured through Chi-square test. Associations between dependent- and independent variables were measured through logistic regression analysis. RESULTS: Clinically practicing dietitians (n = 347) working in Scandinavia, Sweden (n = 249), Norway (n = 60), Denmark (n = 38), who had completed dietetic education participated. The reported documentation of goals and outcomes from nutrition intervention was highly associated with the reported implementation of NCP 4th step terminology (OR = 5.26; p = 0.009, OR = 3.56; p = 0.003), support from the workplace (OR = 4.0, p < 0.001, OR = 8.89, p < 0.001) and area of practice (OR = 2.02, p = 0.017). Years since completed dietetic training and educational level did not have any significant associations with documentation practice regarding goals and outcomes. CONCLUSION: Findings highlight strong associations between the implementation of the NCP 4th step terminology and the documentation of goals and outcomes. Strategies to support dietitians in using standardized terminology and the development of tools for comprehensive documentation of evaluation of goals and outcome are required.

Two Years with COVID-19: The Electronic Frailty Index Identifies High-Risk Patients in the Stockholm GeroCovid Study.

INTRODUCTION: Frailty, a measure of biological aging, has been linked to worse COVID-19 outcomes. However, as the mortality differs across the COVID-19 waves, it is less clear whether a medical record-based electronic frailty index (eFI) that we have previously developed for older adults could be used for risk stratification in hospitalized COVID-19 patients. OBJECTIVES: The aim of the study was to examine the association of frailty with mortality, readmission, and length of stay in older COVID-19 patients and to compare the predictive accuracy of the eFI to other frailty and comorbidity measures. METHODS: This was a retrospective cohort study using electronic health records (EHRs) from nine geriatric clinics in Stockholm, Sweden, comprising 3,980 COVID-19 patients (mean age 81.6 years) admitted between March 2020 and March 2022. Frailty was assessed using a 48-item eFI developed for Swedish geriatric patients, the Clinical Frailty Scale, and the Hospital Frailty Risk Score. Comorbidity was measured using the Charlson Comorbidity Index. We analyzed in-hospital mortality and 30-day readmission using logistic regression, 30-day and 6-month mortality using Cox regression, and the length of stay using linear regression. Predictive accuracy of the logistic regression and Cox models was evaluated by area under the receiver operating characteristic curve (AUC) and Harrell's C-statistic, respectively. RESULTS: Across the study period, the in-hospital mortality rate decreased from 13.9% in the first wave to 3.6% in the latest (Omicron) wave. Controlling for age and sex, a 10% increment in the eFI was significantly associated with higher risks of in-hospital mortality (odds ratio = 2.95; 95% confidence interval = 2.42-3.62), 30-day mortality (hazard ratio [HR] = 2.39; 2.08-2.74), 6-month mortality (HR = 2.29; 2.04-2.56), and a longer length of stay (ß-coefficient = 2.00; 1.65-2.34) but not with 30-day readmission. The association between the eFI and in-hospital mortality remained robust across the waves, even after the vaccination rollout. Among all measures, the eFI had the best discrimination for in-hospital (AUC = 0.780), 30-day (Harrell's C = 0.733), and 6-month mortality (Harrell's C = 0.719). CONCLUSION: An eFI based on routinely collected EHRs can be applied in identifying high-risk older COVID-19 patients during the continuing pandemic.