Enacting person-centred care in home care services for people with dementia.

AIMS AND OBJECTIVES: To develop the theoretical understanding of the process of providing person-centred home care for people with dementia. BACKGROUND: People with dementia are increasingly cared for at home by family members and home care staff. Care of people with dementia should be person-centred; however, little is known about how home care staff understand and enact person-centred care in their daily work. DESIGN: Grounded theory. METHODS: Home care staff (n = 29) were recruited from home care services specialised in providing care for people with dementia. Group interviews were conducted, and a tentative theoretical model for providing person-centred home care to people with dementia was outlined. Nine of the participants were then individually interviewed to further develop the model. The analysis was conducted parallel to the data collection, and hypotheses concerning the evolving theoretical model were continuously tested in the following interviews. The COREQ checklist for qualitative studies was used in reporting the study. RESULTS: Person-centred home care of people with dementia was conceptualised as a series of processes: Getting ready, getting in, giving care, getting out and finalising the story, each with subprocesses. Theatre metaphors were used to describe how the care was provided. A core process, Enacting and re-enacting familiarity, was at centre in all processes. CONCLUSIONS: In the person-centred care of people with dementia, familiarity had to be established and continuously fostered. When familiarity was in place, the care recipient and the home care staff acted as a team to perform the care. The theoretical works of Goffman were used to interpret the results. RELEVANCE TO CLINICAL PRACTICE: The study provides a model for person-centred care of people with dementia at home that deepens the understanding of its processes, prerequisites and outcomes. The model can inform education and administration of home care for people with dementia.

Characteristics of nursing home units with high versus low levels of person-centred care in relation to leadership, staff- resident- and facility factors: findings from SWENIS, a cross-sectional study in Sweden.

BACKGROUND: The context of care consists of factors that determines the extent to which staff can offer person-centred care. However, few studies have investigated factors that can explain variation in levels of person-centred care among nursing home units. The aim of this study was to explore factors characterizing nursing home units with high and low degree of person-centred care, with focus on leadership, staff, resident and facility factors. METHODS: Cross-sectional data from residents, staff, and managers in 172 randomly selected nursing homes in Sweden were collected in 2014. Activities of Daily Living Index, Gottfries' cognitive scale, Person-centred Care Assessment Tool together with demographic information and estimations of leadership engagement was used. Independent samples t-test and Chi2 test were conducted. RESULTS: Highly person-centred units were characterised by leaders engaging in staff knowledge, professional development, team support and care quality. In highly person-centred units' staff also received supervision of a nurse to a larger extent. Highly person-centred units were also characterised as dementia specific units, units with fewer beds and with a larger proportion of enrolled nurses. No differences in degree of person-centred care were seen between public or private providers. CONCLUSIONS: This study provides guidance for practitioners when designing, developing and adapting person-centred units in aged care contexts. Managers and leaders have an important role to promote the movement towards a person-centred practice of care, by supporting their staff in daily care, and engaging in staff knowledge and professional development. Targeting and adjusting environmental factors, such as provide small and dementia adapted environments to match the residents' personal preferences and capacity are also important when striving towards person-centredness.

Effects of a person-centred and health-promoting intervention in home care services- a non-randomized controlled trial.

BACKGROUND: Home care recipients have reported little self-determination and opportunity to influence their own care. Person-centred care focusing on involvement has improved the quality of life of older adults in health care and nursing homes; however, knowledge about the effects of person-centred interventions in aged care at home is sparse. The aim of this study was to study the effects of a person-centred and health-promoting intervention, compared with usual care, on health-related quality of life, thriving and self-determination among older adults, and on job satisfaction, stress of conscience and level of person-centred care among care staff. METHODS: This is a non-randomized controlled trial with a before/after design. Participants from five home care districts in one municipality in northern Sweden were recruited to an intervention or control group. We evaluated health-related quality of life, thriving and self-determination among older home care recipients, and job satisfaction, person-centred care and stress of conscience among care staff. Evaluation was performed by questionnaires and responses were analysed using parametric and non-parametric statistical analyses. RESULTS: Eighty-one older adults and 48 staff were included in the study. A clinically moderate and statistically significant difference between the intervention and control groups was found in thriving and negative emotions among older adults. The intervention contributed to maintaining high thriving levels, in contrast to decreased thriving in the control group (intervention: + 1, control: - 4, p 0.026, CI: - 10. 766, - 0.717). However, the intervention group rated an increase in negative emotions, while the control group was unchanged (intervention: - 7 control: + - 0, p 0.048, CI: - 17.435, - 0.098). No significant effects were found among staff. CONCLUSIONS: The intervention contributed to maintaining high levels of thriving in contrast to low levels found in the control group, and it seems reasonable to consider the intervention focus on staff as more person-centred and health-promoting. The finding that the intervention group had increase in negative emotions is difficult to interpret, and warrants further exploration. Even though the results are sparse, the challenges discussed may be of importance for future studies in the context of HCS. TRIAL REGISTRATION: NCT02846246. Date of registration: 27 July 2016.

Recognizing expressions of thriving among persons living in nursing homes: a qualitative study.

BACKGROUND: Thriving has emerged as a contemporary and health-promoting concept for older people living in nursing homes; however, there has been limited research to explore how nursing home staff identify thriving in their everyday practice. The aim of this study was to explore how staff recognize expressions of thriving among persons living in nursing homes. METHODS: Semi-structured interviews were conducted with 14 nurses working at a nursing home in Victoria, Australia. The interviews were audio-recorded, transcribed and analyzed using qualitative content analysis. RESULTS: The analysis resulted in six sub-categories and three main categories. Expressions of thriving were recognized in relation to how staff understood thriving, observed thriving and sensed thriving. Staff described comparing and contrasting clinical assessment indicators with their own personal and professional understandings of thriving, as well as their overall sense of the individual person within the wider situational and environmental context. CONCLUSIONS: Our results illuminate how staff recognize everyday expressions of thriving for people living in nursing homes and emphasizes the importance of utilizing person-centred care principles in clinical assessments. These findings have practical implications with regards to how thriving is identified and assessed in long-term care, and could be used to inform and guide staff education, person-centred care strategies, and organizational policies to better support and promote thriving in nursing homes.

Cardiovascular drug use among people with cognitive impairment living in nursing homes in northern Sweden.

PURPOSE: The aim of this study was to describe changes in the pattern of cardiovascular agents used in elderly people living in nursing homes between 2007 and 2013. Further, the aim was to analyse the use of cardiovascular drugs in relation to cognitive impairment and associated factors within the same population, where prescription of loop diuretics was used as a proxy for heart failure. METHODS: Two questionnaire surveys were performed including 2494 people in 2007 and 1654 people in 2013 living in nursing homes in northern Sweden. Data were collected concerning drug use, functioning in activities of daily living (ADL) and cognition, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The use of different drugs and drug classes among people at four different levels of cognitive function in 2007 and 2013 were compared. RESULTS: The proportion of people prescribed ASA and diuretics was significantly lower at all four levels of cognitive function in 2013 compared to 2007. Among people prescribed loop diuretics, the use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs) increased from 37.8 to 45.6%, ß-blockers from 36.0 to 41.8% and warfarin from 4.4 to 11.4%. The use of warfarin, ACEI/ARBs, ß-blockers and mineralocorticoid receptor antagonists (MRAs) were less common among individuals with more severe cognitive impairment. CONCLUSION: The results indicate that cardiovascular drug treatment has improved between 2007 and 2013, but there is room for further improvement, especially regarding adherence to guidelines for heart failure. Increasing cognitive impairment had an effect on treatment patterns for heart failure and atrial fibrillation.

Exploring person-centred care in relation to resource utilization, resident quality of life and staff job strain - findings from the SWENIS study.

BACKGROUND: A critical challenge facing elderly care systems throughout the world is to meet the complex care needs of a growing population of older persons. Although person-centred care has been advocated as the "gold standard" and a key component of high-quality care, the significance of care utilisation in person-centred units as well as the impact of person-centred care on resident quality of life and staff job strain in nursing home care has yet to be explored. The aim of this study was to explore person-centred care and its association to resource use, resident quality of life, and staff job strain. DESIGN: A cross-sectional national survey. METHODS: Data on 4831 residents and 3605 staff were collected by staff working in nursing homes in 35 randomly selected Swedish municipalities in 2014. Descriptive statistics and regression modelling were used to explore associations between person-centred care and resource use, resident quality of life, and staff job strain. RESULTS: No association was found between person-centred care and resource use. Person-centred care was positively associated with resident quality of life and was negatively associated with staff perception of job strain. CONCLUSION: Person-centred care does not increase resource utilisation in nursing homes, but beneficially impacts resident quality of life and alleviates the care burden in terms job strain among staff.

Effects of a staff education programme about person-centred care and promotion of thriving on relatives' satisfaction with quality of care in nursing homes: a multi-centre, non-equivalent controlled before-after trial.

BACKGROUND: As part of a nursing home intervention study, the aim of this paper was 1) to evaluate the effects of a staff education programme about person-centred care and promotion of thriving on relatives' satisfaction with quality of care and their perceptions of the person-centredness of the environment, and 2) to outline factors of importance to explain the variance in relatives' satisfaction with quality of care. Relatives are often referred to as vital for the operationalisation of person-centredness in nursing homes, representing an important source of information for care planning and quality of care assessments. However, the evidence for effects of person-centredness in nursing homes on relatives' experiences is sparse and little is known on what could explain their satisfaction with the quality of care. METHODS: A multi-centre, non-equivalent controlled group before-after design with study sites in Australia, Norway and Sweden. Staff in the intervention group participated in a 14-month education on person-centredness, person-centred care, thriving and caring environment. Staff in the control group received a one-hour lecture before the intervention period. Data were collected at baseline, after the intervention and six months after the end of the intervention, and analysed using descriptive statistics, a generalised linear model and hierarchical multiple regression. RESULTS: In general, relatives from both the intervention and control nursing homes were satisfied with the quality of care, and no statistically significant overall between-group-effects of the intervention were revealed on satisfaction with quality of care or perceptions of the person-centredness of environment. A person-centred environment in terms of safety and hospitality were identified as factors of prominent importance for the relatives' satisfaction with the quality of care. CONCLUSION: The findings of this paper provide a foundation for future research in terms of intervention design in nursing home contexts. Staff availability, approachability, competence and communication with relatives may be important factors to consider to improve quality of care from the perspective of relatives, but more research both with and for relatives to people living in nursing homes is necessary to identify the keys to success. TRIAL REGISTRATION: ClinicalTrials.gov- NCT02714452 . Registered on March 19, 2016.

Thriving among older people living at home with home care services-A cross-sectional study.

AIM: To explore the level of thriving and associated factors among older adults living at home with support from home care services. DESIGN: An exploratory, cross-sectional survey design. METHOD: A sample of 136 participants (mean 82 years) responded to a survey about thriving, health, psychosocial and care-related factors in 2016. Descriptive analysis and multiple logistic regression analysis with a stepwise backwards elimination procedure were performed. RESULT: The results showed that the level of thriving was relatively high among adults living at home with support from home care services, with dimensions concerning engaging in activities and peer relations and keeping in touch with people and places being rated the lowest. Regression analysis showed that participating in social relations and experiencing self-determination in activities in and around the house were associated with thriving. CONCLUSION: Facilitating social relations and creating opportunities for self-determination seem necessary to support thriving among older adults living at home with support from home care services. IMPACT: The findings in this study add important knowledge about place-related well-being when living at home with home care services.

Well-being and thriving in sheltered housing versus ageing in place: Results from the U-age sheltered housing study.

AIMS: To explore to what extent type of residence (sheltered housing or ageing in place) contributes to thriving and well-being in older adults, when controlling for age, sex, living alone, being a widow and adjusting for functional status, self-rated health, and depressive mood. DESIGN: A matched cohort study. METHODS: A self-report survey was sent out to a total population of residents in all sheltered housings in Sweden and a matched control group ageing in place (N = 3,805). The data collection took place between October 2016-January 2017. RESULTS: The interaction analyses related to thriving showed that with increasing level of depressive mood and decreasing levels of self-rated health and functional status, those residing in sheltered housing generally reported higher levels of thriving, as compared with those ageing in place. Well-being was not found to be significantly associated with type of accommodation. CONCLUSION: There may be features in sheltered housing that are associated with resident thriving especially among individuals with impairments of function, health or mood, although further studies are required to identify these specific features. IMPACT: This study informs staff and policymakers about thriving and well-being in sheltered housing accommodations. These findings may be used to further the development of sheltered housing accommodations.

Resource use and its association to cognitive impairment, ADL functions, and behavior in residents of Swedish nursing homes: Results from the U-Age program (SWENIS study).

OBJECTIVES: We aimed to investigate resource use and its association to cognitive impairment, activities of daily living, and neuropsychiatric symptoms in residents of Swedish nursing homes. METHODS: Data were collected in 2014 from a Swedish national sample of nursing home residents (n = 4831) and were collected by staff in the facility. The sample consists of all nursing homes in 35 of 60 randomly selected Swedish municipalities. Demographic data and data on resource use, cognitive and physical function as well as neuropsychiatric symptoms were collected through proxies. Descriptive statistics and regression modeling were used to investigate this association. RESULTS: We found that cognitive impairment, activities of daily living, and neuropsychiatric symptoms were associated with 23 hours per week increase in total resource use versus cognitively intact persons. This was also the case for being dependent in activities of daily living. Being totally dependent increased the amount of resource use by 25 hours per week. The sex of a resident did not influence the resource use. Annual costs of resource use with no functional dependency were 359 685 SEK, and in severely cognitive impaired resident, the cost was 825 081 SEK. CONCLUSION: Being cognitively impaired as well as functionally dependent increases the resource use significantly in nursing homes. This has implications for differentiation of costs in institutional settings in health economic evaluations.

Perceptions of self-determination and quality of life among Swedish home care recipients - a cross-sectional study.

BACKGROUND: It is acknowledged that preservation of self-determination is very important in order for older adults to experience good quality of life, but to what degree and in what areas people receiving help from home care service experience self-determination is unknown. Few studies have examined the perception of self-determination in relation to quality of life among older adults living at home with help from home care services. Thus, the aim of this study was to explore perceptions of self-determination among older adults living at home with the support of home care services, and to test whether older adults who perceive a higher degree of self-determination also feel they have a better quality of life. METHODS: This cross-sectional study was conducted in one municipality in northern Sweden. A total of 134 older adults (≥ 65 years) were included. Data were collected by means of a survey including questionnaires about background characteristics, self-determination, and health-related quality of life. Descriptive statistics regarding background characteristics for groups with high and low self-determination respectively were presented and the differences between the groups were analyzed using the Chi-square test and the Mann-Whitney U test. RESULTS: Our main finding shows that the majority of older adults with support from home care services experience self-determination in the dimensions use of time, and self-care. However, a wide variation was found in self-reported self-determination in all dimensions. Results also show that the group with higher self-reported self-determination also reported a greater degree of experienced quality of life in comparison with the group with lower self-reported self-determination. CONCLUSIONS: In line with earlier research, our results found a positive relation between self-determination and quality of life. The results are relevant for the care of older adults and indicate a need of further research. The results presented in this paper could serve as a guide when planning for improved self-determination among older adults in home care service. TRIAL REGISTRATION: NCT02846246 .

Constipation and laxative use among people living in nursing homes in 2007 and 2013.

BACKGROUND: Constipation is a common condition among older people, particularly among people living in nursing homes, and the use of drugs such as opioids is one of many factors that contribute to its high prevalence. The aim of this study was to compare the prevalence of constipation and the use of laxatives between 2007 and 2013, to analyze constipation and laxative use among people who are prescribed opioids, and to identify factors associated with constipation. METHODS: In 2007 and 2013, two surveys were performed in the county of Västerbotten in Northern Sweden, comprising all those living in nursing homes. The Multi-Dimensional Dementia Assessment Scale was used to collect data regarding laxative, opioid and anticholinergic drug use, functioning in activities of daily living (ADL), cognition and symptoms of constipation. A comparison was made between 2820 people from 2007 and 1902 people from 2013. RESULTS: The prevalence of symptoms of constipation among people living in nursing homes increased from 36% in 2007 to 40% in 2013. After controlling for age, sex, ADL, cognitive impairment and use of opioid and anticholinergic drugs, this difference was found to be statistically significant. When controlled for demographic changes, there was a statistically significant difference in the regular use of laxatives between the respective years, from 46% in 2007 to 59% in 2013. People prescribed opioids and anticholinergic drugs were at increased risk of constipation, while people with a higher ADL score were at decreased risk. Further, among people prescribed opioids and rated as constipated, 35% in 2007 and 20% in 2013 were not prescribed laxatives for regular use, a difference that was found to be statistically significant. CONCLUSIONS: The prevalence of symptoms of constipation increased between 2007 and 2013. Although there was a decrease between the years, there were still a number of people being prescribed with opioids and rated as constipated who were not treated with laxatives. This study therefore indicates that constipation remains a significant problem among people in nursing homes and also indicates that those prescribed opioids could benefit from an increased awareness of the risk of constipation and treatment, if required.

Associations between person-centred climate and perceived quality of care in nursing homes: A cross-sectional study of relatives' experiences.

AIMS: To explore the extent to which a more person-centred climate could explain the variation in quality of care, as rated by relatives to nursing home residents in three countries. DESIGN: A cross-sectional, correlational, anonymous questionnaire study. METHODS: Questionnaires were administered to 346 relatives to residents in six nursing homes in Australia, Norway and Sweden between April-June 2016. Relatives (N = 178) agreed to participate. Data were analysed using descriptive statistics and hierarchical multiple regression. RESULTS: The results showed that the relatives' experiences of a more person-centred climate were associated with higher ratings of the quality of care. A person-centred climate of safety had the strongest unique association with the quality of care, explaining 14% of the variance in quality of care. In addition, the results indicated that the relatives in general were satisfied with the quality of care and that children to the residents rated the quality of care higher than partners or other relatives. CONCLUSION: This study advances the understanding of the relationship between person-centredness in nursing homes and quality of care, showing that person-centred climate aspects of safety and hospitality have a significant role in the quality of care as perceived by relatives. IMPACT: Person-centredness in nursing homes is often mentioned as a quality of care indicator, but the empirical evidence for this suggestion is limited. This study expanded the evidence-base for person-centredness as a significant aspect of relatives' experiences of the quality of care in nursing homes.

The thriving of older people assessment scale: Psychometric evaluation and short-form development.

AIM: To evaluate the psychometric properties and performance of the 32-item Thriving of Older People Assessment Scale (TOPAS) and to explore reduction into a short-form. BACKGROUND: The 32-item TOPAS has been used in studies of place-related well-being as a positive measure in long-term care to assess nursing home resident thriving; however, item redundancy has not previously been explored. DESIGN: Cross-sectional study. METHOD: Staff members completed the 32-item TOPAS as proxy raters for a random sample of Swedish nursing home residents (N = 4,831) between November 2013 - September 2014. Reliability analysis, exploratory factor analysis and item response theory-based analysis were undertaken. Items were systematically identified for reduction using statistical and theoretical analysis. Correlation testing, means comparison and model fit evaluation confirmed scale equivalence. RESULTS: Psychometric properties of the 32-item TOPAS were satisfactory and several items were identified for scale reduction. The proposed short-form TOPAS exhibited a high level of internal consistency (α = 0.90) and strong correlation (r = 0.98) to the original scale, while also retaining diversity among items in terms of factor structure and item difficulties. CONCLUSION: The 32-item and short-form TOPAS' indicated sound validity and reliability to measure resident thriving in the nursing home context. IMPACT: There is a lack of positive life-world measures for use in nursing homes. The short-form TOPAS indicated sound validity and reliability to measure resident thriving, providing a feasible measure with enhanced functionality for use in aged care research, assessments and care planning for health-promoting purposes in nursing homes.

Associations between job satisfaction, person-centredness, and ethically difficult situations in nursing homes-A cross-sectional study.

AIM: To explore the associations between job satisfaction and perceived person-centredness and ethically difficult situations among staff in nursing homes (NHs). BACKGROUND: Previous studies have indicated that person-centredness and few ethically difficult situations can contribute positively to NH staff's job satisfaction. However, empirical evidence of these associations is lacking. DESIGN: Cross-sectional survey design. METHOD: Nursing home staff (N = 341) in six NHs in Australia, Norway, and Sweden completed the questionnaire measuring job satisfaction, person-centredness, and ethically difficult situations. Data were collected between April - June 2016. Univariate analysis was used to describe the sample, one-way analysis of variance examined differences between variables. Bivariate correlation tested the relationships between variables and hierarchical multiple regression explored the extent to which person-centredness and ethically difficult situations could explain job satisfaction among staff. RESULTS: After controlling for socio-demographic variables in a regression model, three variables of person-centredness and "ethically difficult situations" were significantly associated with job satisfaction. A "climate of community" contributed the most, followed by the "amount of organizational and environmental support," "a climate of everydayness," and few "ethically difficult situations." CONCLUSION: The results support the theoretical foundation and previous findings suggesting that establishing NHs organizations based on person-centredness will increase staff job satisfaction. However, this is a cross-sectional study and the causality may go in both directions and should be further explored.

Prevalence of pain and pharmacological pain treatment among old people in nursing homes in 2007 and 2013.

PURPOSE: Many elderly people living in nursing homes experience pain and take analgesic medication. The aim of this study was to analyze the prevalence of pain and pharmacological pain treatment among people living in nursing homes in Sweden, in two large, comparable, samples from 2007 to 2013. METHODS: Cross-sectional surveys were performed in 2007 and 2013, including all residents in nursing homes in the county of Västerbotten, Sweden. A total of 4933 residents (2814 and 2119 respectively) with a mean age of 84.6 and 85.0 years participated. Of these, 71.1 and 72.4% respectively were cognitively impaired. The survey was completed by the staff members who knew the residents best. RESULTS: The prescription of opioids became significantly more common while the use of tramadol decreased significantly. The staff reported that 63.4% in 2007 and 62.3% in 2013 had experienced pain. Of those in pain, 20.2% in 2007 and 16.8% in 2013 received no treatment and 73.4 and 75.0% respectively of those with pain, but no pharmacological treatment, were incorrectly described by the staff as being treated for pain. CONCLUSIONS: There has been a change in the pharmacological analgesic treatment between 2007 and 2013 with less prescribing of tramadol and a greater proportion taking opioids. Nevertheless, undertreatment of pain still occurs and in many cases, staff members believed that the residents were prescribed analgesic treatment when this was not the case.

Insomnia symptoms among old people in nursing homes.

BACKGROUND: Insomnia symptoms are common among old people, and hypnotics and sedative drugs are often prescribed in spite of small benefits. The aim of this study was to estimate the prevalence of insomnia symptoms and to analyze the association between insomnia symptoms, cognitive level, and prescription of hypnotics and sedatives among old people living in nursing homes. METHODS: The study comprised 2,135 people living in nursing homes in the county of Västerbotten, Sweden. Data concerning hypnotic and sedative drugs, cognitive function, and prevalence of insomnia symptoms were collected, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). RESULTS: The three most common insomnia symptoms were "sleeps for long periods during the day," "interrupted night-time sleep," and "wakes up early in the morning" with 57.8%, 56.4%, and 48.0%, respectively, of the residents exhibiting the symptoms at least once a week. Different insomnia symptoms showed different association patterns with sex and age. Most insomnia symptoms were more common among people with cognitive impairment compared to those with no cognitive impairment and seemed to reach their peak prevalence in people with moderate to severe cognitive impairment, subsequently decreasing with further cognitive decline. Of the study population, 24.0% were prescribed hypnotics and sedatives. Prescriptions were more common among those without cognitive impairment, and among those exhibiting the symptom "difficulty initiating sleep." CONCLUSIONS: Insomnia symptoms and prescription of hypnotics and sedatives are common among old people living in nursing homes. Considering the risk of adverse effects, it is important to regularly re-evaluate the need for these drugs.

Factors contributing to serious adverse events in nursing homes.

AIMS AND OBJECTIVES: To identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to the improvement of safe nursing care. BACKGROUND: There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable. DESIGN: This was a retrospective study, with a total sample of data regarding adverse events (n = 173) in nursing homes, concerning nursing care reported by healthcare providers in Sweden to the Health and Social Care Inspectorate. The reports were analysed with content analysis, and the frequencies of the adverse events, and their contributing factors, were described with descriptive statistics. RESULTS: Medication errors, falls, delayed or inappropriate intervention and missed nursing care contributed to the vast majority (89%) of the serious adverse events. A total of 693 possible contributing factors were identified. The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication. CONCLUSIONS: The contributing factors frequently interacted yet they varied between different groups of serious adverse events. The resident's safety depends on the availability of staff's competence as well as adequate documentation about the resident's condition. Lack of competence was underestimated by healthcare providers. RELEVANCE TO CLINICAL PRACTICE: Registered nurses and assistant nurses need to have awareness of contributing factors to adverse events in nursing care. A holistic approach to improve patient safety in nursing homes requires competence of the staff, safe environments as well as resident's and relative's participation.

Dysphoric symptoms in relation to other behavioral and psychological symptoms of dementia, among elderly in nursing homes.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are common and varied in the elderly. The aim of the current study was to explore associations between BPSD and dysphoric symptoms at different levels of cognitive impairment. METHODS: Assessments of 4397 elderly individuals living in nursing homes in Sweden were performed. Data on cognitive function and BPSD were collected using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The relationships between dysphoria and eight BPSD factors were plotted against cognitive function to investigate how dysphoria affects BPSD throughout the dementia disease. RESULTS: Overall, dysphoric symptoms were most prevalent in persons with moderate cognitive impairment. However, moderate to severe dysphoric symptoms showed no clear variation with cognitive impairment. Furthermore, aggressive behavior, verbally disruptive/attention-seeking behavior, hallucinatory symptoms and wandering behavior were more common with concurrent dysphoria regardless of cognitive function. In contrast, passiveness was more common with concurrent dysphoria in mild cognitive impairment but not in moderate to severe cognitive impairment. CONCLUSIONS: BPSD, including aggressive behavior and hallucinations, were more common with concurrent dysphoric symptoms, providing insight into behavioral and psychological symptoms among individuals with cognitive impairment. Apathy was more commonly associated with concurrent dysphoria at early stages of cognitive decline but not at later stages, indicating that apathy and dysphoria represent separate syndromes among elderly patients with moderate to severe cognitive impairment.

Effects and meanings of a person-centred and health-promoting intervention in home care services - a study protocol of a non-randomised controlled trial.

BACKGROUND: The literature indicates that current home care service are largely task oriented with limited focus on the involvement of the older people themselves, and studies show that lack of involvement might reduce older people's quality of life. Person-centred care has been shown to improve the satisfaction with care and quality of life in older people cared for in hospitals and nursing homes, with limited published evidence about the effects and meanings of person-centred interventions in home care services for older people. This study protocol outlines a study aiming to evaluate such effects and meanings of a person-centred and health-promoting intervention in home aged care services. METHODS/DESIGN: The study will take the form of a non-randomised controlled trial with a before/after approach. It will include 270 older people >65 years receiving home care services, 270 relatives and 65 staff, as well as a matched control group of equal size. All participants will be recruited from a municipality in northern Sweden. The intervention is based on the theoretical concepts of person-centredness and health-promotion, and builds on the four pedagogical phases of: theory apprehension, experimental learning, operationalization, and clinical supervision. Outcome assessments will focus on: a) health and quality of life (primary outcomes), thriving and satisfaction with care for older people; b) caregiver strain, informal caregiving engagement and relatives' satisfaction with care: c) job satisfaction and stress of conscience among care staff (secondary outcomes). Evaluation will be conducted by means of self-reported questionnaires and qualitative research interviews. DISCUSSION: Person-centred home care services have the potential to improve the recurrently reported sub-standard experiences of home care services, and the results can point the way to establishing a more person-centred and health-promoting model for home care services for older people. TRIAL REGISTRATION: NCT02846246 .