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1.  A controlled trial of an intervention to increase resident choice in long-term care 
Objective
The purpose of this study was to evaluate an intervention to improve staff offers of choice to nursing home (NH) residents during morning care.
Design
A controlled trial with a delayed intervention design.
Setting
Four community, for-profit nursing homes.
Participants
A total of 169 long-stay NH residents who required staff assistance with morning care and were able to express their care preferences.
Intervention
Research staff held weekly training sessions with nurse aides (NAs) for 12 consecutive weeks focused on how to offer choice during four targeted morning care areas: when to get out of bed, when to get dressed/what to wear, incontinence care (changing and/or toileting), and where to dine. Training sessions consisted of brief video vignettes illustrating staff-resident interactions followed by weekly feedback about how often choice was being provided based on standardized observations of care conducted weekly by research staff.
Measurements
Research staff conducted standardized observations during a minimum of 4 consecutive morning hours per participant per week for 12-weeks of baseline and 12-weeks of intervention.
Results
There was a significant increase in the frequency that choice was offered for three of the four targeted morning care areas from baseline to intervention: (1) out of bed, 21% to 33% (p< .001); dressing, 20% to 32% (p< .001); incontinence care, 18% to 23%, (p< .014). Dining location (8% to 13%) was not significant. There was also a significant increase in the amount of NA staff time to provide care from baseline to intervention (8.01 ± 9.0 to 9.68 ± 9.9 minutes per person, p< .001).
Conclusion
A staff training intervention improved the frequency with which NAs offered choice during morning care but also required more time. Despite significant improvements, choice was still offered one-third or less of the time during morning care.
doi:10.1016/j.jamda.2012.11.013
PMCID: PMC3637865  PMID: 23294967
culture change; resident-directed care; quality of life
2.  Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial 
Background:
Sophisticated approaches are needed to improve the quality of care for elderly people living in residential care facilities. We determined the effects of multidisciplinary integrated care on the quality of care and quality of life for elderly people in residential care facilities.
Methods:
We performed a cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that included 340 participating residents with physical or cognitive disabilities. Five of the facilities applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by the disease management model, consisted of a geriatric assessment of functional health every three months. The assessment included use of the Long-term Care Facility version of the Resident Assessment Instrument by trained nurse-assistants to guide the design of an individualized care plan; discussion of outcomes and care priorities with the family physician, the resident and his or her family; and monthly multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the sum score of 32 risk-adjusted quality-of-care indicators.
Results:
Compared with the facilities that provided usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care indicators (mean difference − 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents.
Interpretation:
Multidisciplinary integrated care resulted in improved quality of care for elderly people in residential care facilities compared with usual care.
Trial registration:
www.controlled-trials.com trial register no. ISRCTN11076857.
doi:10.1503/cmaj.101498
PMCID: PMC3153543  PMID: 21708967
3.  Study protocol: translating and implementing psychosocial interventions in aged home care the lifestyle engagement activity program (LEAP) for life 
BMC Geriatrics  2013;13:124.
Background
Tailored psychosocial activity-based interventions have been shown to improve mood, behaviour and quality of life for nursing home residents. Occupational therapist delivered activity programs have shown benefits when delivered in home care settings for people with dementia. The primary aim of this study is to evaluate the effect of LEAP (Lifestyle Engagement Activity Program) for Life, a training and practice change program on the engagement of home care clients by care workers. Secondary aims are to evaluate the impact of the program on changes in client mood and behaviour.
Methods/design
The 12 month LEAP program has three components: 1) engaging site management and care staff in the program; 2) employing a LEAP champion one day a week to support program activities; 3) delivering an evidence-based training program to care staff. Specifically, case managers will be trained and supported to set meaningful social or recreational goals with clients and incorporate these into care plans. Care workers will be trained in and encouraged to practise good communication, promote client independence and choice, and tailor meaningful activities using Montessori principles, reminiscence, music, physical activity and play. LEAP Champions will be given information about theories of organisational change and trained in interpersonal skills required for their role. LEAP will be evaluated in five home care sites including two that service ethnic minority groups. A quasi experimental design will be used with evaluation data collected four times: 6-months prior to program commencement; at the start of the program; and then after 6 and 12 months. Mixed effect models will enable comparison of change in outcomes for the periods before and during the program. The primary outcome measure is client engagement. Secondary outcomes for clients are satisfaction with care, dysphoria/depression, loneliness, apathy and agitation; and work satisfaction for care workers. A process evaluation will also be undertaken.
Discussion
LEAP for Life may prove a cost-effective way to improve client engagement and other outcomes in the community setting.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12612001064897.
doi:10.1186/1471-2318-13-124
PMCID: PMC3840642  PMID: 24238067
Home care; Psychosocial intervention; Engagement; Ethnic minority
4.  Lack of nutritional and functional effects of nutritional supervision by nurses: a quasi-experimental study in geriatric patients 
Background
Undernutrition affects recovery from disease and regaining functional abilities; however, it frequently occurs in elderly hospitalized patients.
Objective
To study whether identification of geriatric patients at nutritional risk followed by individualized nursing care could improve their nutritional and activities of daily living (ADL) status.
Design
The design was quasi-experimental. In total, 345 rehabilitation patients (aged 84±7 years, 72% women) were allocated, according to bed availability, to either an intervention or a control ward. Nurses on the intervention ward attended a short class on nutrition and were supervised in nutritional care by trained nurses. In the intervention unit, the nursing staff identified patients at risk of undernutrition through systematic assessment of risk factors, e.g. body mass index (BMI) <24 kgm−2, and treated them according to individual care plans. On the control ward routine nutritional care was offered. Functional status was assessed by the Barthel ADL index.
Results
Mean BMI was 24±5 on both wards. Fifty-five per cent of the patients had BMI <24. On average, patients were weight stable from admission to discharge, irrespective of allocation. No difference was found in ADL status as a result of the intervention. However, patients who gained weight improved more in ADL status than patients who remained stable or lost weight.
Conclusions
In this geriatric setting standard care and care by trained and supervised nurses were equally effective in maintaining weight stability and functionality in rehabilitation patients with a mean BMI of 24. Weight increase was associated with improved functionality.
doi:10.1080/17482970701256245
PMCID: PMC2606983
ADL; elderly; hospitalized; undernutrition; weight gain
5.  Back disorders and lumbar load in nursing staff in geriatric care: a comparison of home-based care and nursing homes 
Background
Back pain is one of the most frequent complaints in the nursing profession. Thus, the 12-month prevalence of pain in the lumbar spine in nursing staff is as high as 76%. Only a few representative studies have assessed the prevalence rates of back pain and its risk factors among nursing staff in nursing homes in comparison to staff in home-based care facilities. The present study accordingly investigates the prevalence in the lumbar and cervical spine and determines the physical workload to lifting and caring in geriatric care.
Methods
1390 health care workers in nursing homes and home care participated in this cross sectional survey. The nursing staff members were examined by occupational physicians according to the principals of the multistep diagnosis of musculoskeletal disorders. Occupational exposure to daily care activities with patient transfers was measured by a standardised questionnaire. The lumbar load was calculated with the Mainz-Dortmund dose model. Information on ergonomic conditions were recorded from the management of the nursing homes. Comparisons of all outcome variables were made between both care settings.
Results
Complete documentation, including the findings from the occupational physicians and the questionnaire, was available for 41%. Staff in nursing homes had more often positive orthopaedic findings than staff in home care. At the same time the values calculated for lumbar load were found to be significant higher in staff in nursing homes than in home-based care: 45% vs. 6% were above the reference value. Nursing homes were well equipped with technical lifting aids, though their provision with assistive advices is unsatisfactory. Situation in home care seems worse, especially as the staff often has to get by without assistance.
Conclusions
Future interventions should focus on counteracting work-related lumbar load among staff in nursing homes. Equipment and training in handling of assistive devices should be improved especially for staff working in home care.
doi:10.1186/1745-6673-4-33
PMCID: PMC2801493  PMID: 20003284
6.  The OPERA trial: protocol for a randomised trial of an exercise intervention for older people in residential and nursing accommodation 
Trials  2011;12:27.
Abstract
Background
Depression is common in residents of Residential and Nursing homes (RNHs). It is usually undetected and often undertreated. Depression is associated with poor outcomes including increased morbidity and mortality. Exercise has potential to improve depression, and has been shown in existing trials to improve outcomes among younger and older people. Existing evidence comes from trials that are short, underpowered and not from RNH settings. The aim of the OPERA trial is to establish whether exercise is effective in reducing the prevalence of depression among older RNH residents.
Method
OPERA is a cluster randomised controlled trial. RNHs are randomised to one of two groups with interventions lasting 12 months
Intervention group: a depression awareness and physical activity training session for care home staff, plus a whole home physical activation programme including twice weekly physiotherapist-led exercise groups. The intervention lasts for one year from randomisation, or
Control group: a depression awareness training session for care home staff.
Participants are people aged 65 or over who are free of severe cognitive impairment and willing to participate in the study. Our primary outcome is the prevalence of depressive symptoms, a GDS-15 score of five or more, in all participants at the end of the one year intervention period. Our secondary depression outcomes include remission of depressive symptoms and change in GDS-15 scores in those with depressive symptoms prior to randomisation. Other secondary outcomes include, fear of falling, mobility, fractures, pain, cognition, costs and health related quality of life. We aimed to randomise 77 RNHs.
Discussion
Home recruitment was completed in May 2010; 78 homes have been randomised. Follow up will finish in May 2011 and results will be available late 2011.
Trial Registration
[ISRCTN: ISRCTN43769277]
doi:10.1186/1745-6215-12-27
PMCID: PMC3042949  PMID: 21288340
7.  The Economics of Dementia-Care Mapping in Nursing Homes: A Cluster-Randomised Controlled Trial 
PLoS ONE  2014;9(1):e86662.
Background
Dementia-care mapping (DCM) is a cyclic intervention aiming at reducing neuropsychiatric symptoms in people with dementia in nursing homes. Alongside an 18-month cluster-randomized controlled trial in which we studied the effectiveness of DCM on residents and staff outcomes, we investigated differences in costs of care between DCM and usual care in nursing homes.
Methods
Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training, a DCM organizational briefing day and conducted the 4-months DCM-intervention twice during the study. A single DCM cycle consists of observation, feedback to the staff, and action plans for the residents. We measured costs related to health care consumption, falls and psychotropic drug use at the resident level and absenteeism at the staff level. Data were extracted from resident files and the nursing home records. Prizes were determined using the Dutch manual of health care cost and the cost prices delivered by a pharmacy and a nursing home. Total costs were evaluated by means of linear mixed-effect models for longitudinal data, with the unit as a random effect to correct for dependencies within units.
Results
34 units from 11 nursing homes, including 318 residents and 376 nursing staff members participated in the cost analyses. Analyses showed no difference in total costs. However certain changes within costs could be noticed. The intervention group showed lower costs associated with outpatient hospital appointments over time (p = 0.05) than the control group. In both groups, the number of falls, costs associated with the elderly-care physician and nurse practitioner increased equally during the study (p<0.02).
Conclusions
DCM is a cost-neutral intervention. It effectively reduces outpatient hospital appointments compared to usual care. Other considerations than costs, such as nursing homes’ preferences, may determine whether they adopt the DCM method.
Trial Registration
Dutch Trials Registry NTR2314
doi:10.1371/journal.pone.0086662
PMCID: PMC3904939  PMID: 24489762
8.  Outcome measures for routine use in dementia services: some practical considerations. 
Quality in Health Care  1997;6(3):120-124.
OBJECTIVES: To work with specialist community teams to assess the practicality and acceptability of identified outcome measures for routine use in dementia services. SETTING: Seven specialist dementia services: four multidisciplinary teams, a specialist service for carers, a community psychiatric nurse team, and a day hospital. SUBJECTS: 20 members of staff from the specialist dementia services including psychiatry, community psychiatric nursing, social work, occupational therapy, Admiral nursing, ward management, geriatric nursing. MAIN MEASURE: A questionnaire designed to assess staff views on the use of six outcome measures in routine practice in terms of practicality, relevance, acceptability, and use in improving care. RESULTS: Each of the outcome measures took 15 to 30 minutes to administer. All were rated as easy to use and as relevant to dementia services and to carers. Staff commented that the measures could be useful in routine practice for structured assessment and service evaluation, but highlighted the need for sensitive use of measures with carers. CONCLUSIONS: These measures consider the main domains of functioning for people with dementia and their carers. The measures are suitable for use in routine practice in dementia services and are acceptable to staff and carers. The project underlined the need for management support, staff ownership of measures, and training in using outcome measures. Staff concerns about service evaluation need to be acknowledged.
PMCID: PMC1055472  PMID: 10173768
9.  The Use of Wireless E-Mail to Improve Healthcare Team Communication 
Objective
To assess the impact of using wireless e-mail for clinical communication in an intensive care unit (ICU).
Design
The authors implemented push wireless e-mail over a GSM cellular network in a 26-bed ICU during a 6-month study period. Daytime ICU staff (intensivists, nurses, respiratory therapists, pharmacists, clerical staff, and ICU leadership) used handheld devices (BlackBerry, Research in Motion, Waterloo, ON) without dedicated training. The authors recorded e-mail volume and used standard methods to develop a self-administered survey of ICU staff to measure wireless e-mail impact.
Measurements
The survey assessed perceived impact of wireless e-mail on communication, team relationships, staff satisfaction and patient care. Answers were recorded on a 7-point Likert scale; favorable responses were categorized as Likert responses 5, 6, and 7.
Results
Staff sent 5.2 (1.9) and received 8.9 (2.1) messages (mean [SD]) per day during 5 months of the 6-month study period; usage decreased after study completion. Most (106/125 [85%]) staff completed the questionnaire. The majority reported that wireless e-mail improved speed (92%) and reliability (92%) of communication, improved coordination of ICU team members (88%), reduced staff frustration (75%), and resulted in faster (90%) and safer (75%) patient care; Likert responses were significantly different from neutral (p < 0.001 for all). Staff infrequently (18%) reported negative effects on communication. There were no reports of radiofrequency interference with medical devices.
Conclusions
Interdisciplinary ICU staff perceived wireless e-mail to improve communication, team relationships, staff satisfaction, and patient care. Further research should address the impact of wireless e-mail on efficiency and timeliness of staff workflow and clinical outcomes.
doi:10.1197/jamia.M2299
PMCID: PMC2744721  PMID: 19567803
10.  Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation 
BMC Medicine  2014;12:1.
Background
The ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect.
Methods
The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known.
Results
Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises.
Conclusions
The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.
doi:10.1186/1741-7015-12-1
PMCID: PMC3882778  PMID: 24386900
Elderly residential care; Process evaluation; Exercise; Depression; Culture change; Cluster randomised controlled trial
11.  Practical Depression Screening in Residential Care/Assisted Living: Five Methods Compared to Gold Standard Diagnoses 
Objective
To test the accuracy of five practical depression screening strategies in older adults residing in residential care/assisted living (RC/AL).
Design
Cross-sectional screening study.
Setting
Four RC/AL communities in North Carolina.
Participants
112 residents aged ≥ 65 and 27 staff members involved in their care.
Measurements
Direct care staff was trained in and completed the Cornell Scale for Depression in Dementia, modified for use by long-term care staff (CSDD-M-LTCS). They additionally responded to a one-item question ‘Do you believe the resident is often sad or depressed?,’ and the Minimum Data Set Depression Rating Scale (DRS). Residents responded directly to the Geriatric Depression Scale (15-item version; GDS-15) and the Personal Health Questionnaire, 2-item version (PHQ-2). A geriatric psychiatrist performed gold standard diagnostic interviews using the Structured Clinical Interview for DSM-IV. Sensitivities and specificities were calculated for all instruments at pre-determined cutpoints.
Results
Gold standard diagnoses yielded 14% prevalence of major or minor depression. The CSDD-M-LTCS and one-item screen completed by caregivers failed to significantly discriminate depressed cases. The DRS yielded high specificity (0.85), but low sensitivity (0.47). For the two resident reported measures, the PHQ-2 had a sensitivity of 0.80 and specificity of 0.71, and the GDS-15, 0.60 and 0.75 respectively.
Conclusion
Measures completed by caregivers failed to adequately detect depression. Of the measures completed directly by residents, the PHQ-2 appears to have the best mix of brevity, sensitivity, and ease of administration.
PMCID: PMC3581039  PMID: 19554670
depression; screening; residential care/assisted living; long-term care; mental health
12.  Concordance of Family and Staff Member Reports About End of Life in Assisted Living and Nursing Homes 
The Gerontologist  2009;50(1):112-120.
Purpose: To identify differences in perspectives that may complicate the process of joint decision making at the end of life, this study determined the agreement of family and staff perspectives about end-of-life experiences in nursing homes and residential care/assisted living communities and whether family and staff roles, involvement in care, and interaction are associated with such agreement. Design and Methods: This cross-sectional study examined agreement in 336 family–staff pairs of postdeath telephone interviews conducted as part of the Collaborative Studies of Long-Term Care. Eligible deaths occurred in or within 3 days of leaving one of a stratified random sample of 113 long-term care facilities in four states and after the resident had lived in the facility ³15 days of the last month of life. McNemar p values and kappas were determined for each concordance variable, and mixed logistic models were run. Results: Chance-adjusted family–staff agreement was poor for expectation of death within weeks (66.9% agreement, κ = .33), course of illness (62.9%, 0.18), symptom burden (59.6%, 0.18), and familiarity with resident’s physician (59.2%, 0.05). Staff were more likely than family to expect death (70.2% vs 51.5%, p < .001) and less likely to report low symptom burden (39.6% vs 46.6%, p = .07). Staff involvement in care related to concordance and perspectives of adult children were more similar to those of staff than were other types of family members. Implications: Family and staff perspectives about end-of-life experiences may differ substantially; efforts can be made to improve family–staff communication and interaction for joint decision making.
doi:10.1093/geront/gnp089
PMCID: PMC2805807  PMID: 19549716
Communication; Caregivers; Decision making
13.  Evaluation of an evidence-based guidance on the reduction of physical restraints in nursing homes: a cluster-randomised controlled trial [ISRCTN34974819] 
BMC Geriatrics  2009;9:42.
Background
Physical restraints are regularly applied in German nursing homes. Their frequency varies substantially between centres. Beneficial effects of physical restraints have not been proven, however, observational studies and case reports suggest various adverse effects. We developed an evidence-based guidance on this topic. The present study evaluates the clinical efficacy and safety of an intervention programme based on this guidance aimed to reduce physical restraints and minimise centre variations.
Methods/Design
Cluster-randomised controlled trial with nursing homes randomised either to the intervention group or to the control group with standard information. The intervention comprises a structured information programme for nursing staff, information materials for legal guardians and residents' relatives and a one-day training workshop for nominated nurses. A total of 36 nursing home clusters including approximately 3000 residents will be recruited. Each cluster has to fulfil the inclusion criteria of at least 20% prevalence of physical restraints at baseline. The primary endpoint is the number of residents with at least one physical restraint at six months. Secondary outcome measures are the number of falls and fall-related fractures.
Discussion
If successful, the intervention should be implemented throughout Germany. In case the intervention does not succeed, a three-month pre-post-study with an optimised intervention programme within the control group will follow the randomised trial.
Trial registration
ISRCTN34974819
doi:10.1186/1471-2318-9-42
PMCID: PMC2749852  PMID: 19735564
14.  Improving assessment of postoperative pain in surgical wards by education and training 
Quality & safety in health care  2005;14(5):332-335.


Problem: There is a need to improve postoperative pain organisation and management in hospitals. One of the most important factors in achieving this is to improve active assessment of pain in the postoperative phase.
Design: Repeated audits on an annual basis over a 3 year period. Ward nurses, appointed as "pain control representatives", performed the data collection.
Setting: Departments of general surgery and orthopaedics in a university hospital with 1200 beds.
Key measure for improvement: Assessment of postoperative pain intensity using a numerical rating scale.
Strategies for change: On the basis of the first audit in 1999 the team decided to introduce a mandatory training programme in postoperative pain management for all involved staff, including surgeons and ward nurses. Guidelines for postoperative care were upgraded and made accessible through the intranet. Regular staff meetings in the surgical wards with representatives from the acute pain service team were introduced.
Effects of change: The assessment of pain according to protocols increased from 71% to 91% in the surgical wards and from 60% to 88% in the orthopaedic wards between 1999 and 2001/2.
Lessons learnt: To increase the awareness of pain and improve pain assessment, the importance of mandatory training, regular staff meetings and regular audits must be emphasised. It is also imperative to give feedback on the regular audits to the ward and staff members involved.
doi:10.1136/qshc.2004.010330
PMCID: PMC1744078  PMID: 16195565
15.  Staff Training in Assisted Living: Evaluating Treatment Fidelity 
Objectives
To investigate a protocol for identifying and evaluating treatment fidelity in STAR (Staff Training in Assisted-living Residences), a structured yet flexible program to train direct care staff to improve care of residents with dementia.
Design
Multi-site feasibility trial.
Setting
Assisted living facilities (ALFs).
Participants
44 direct care staff and 36 leadership staff.
Intervention
STAR is a comprehensive, dementia-specific training program to teach direct care staff in ALFs to improve care and reduce affective and behavioral problems in residents with dementia. It is conducted on-site over two months via 2 half-day group workshops and 4 individualized sessions.
Measures
Treatment fidelity was assessed following the National Institute of Health Behavior Change Consortium model utilizing observations and self-report of trainers, direct care staff and leadership.
Results
Each key area of treatment fidelity was identified, measured, and yielded significant outcomes. For example, significant increases included: direct care staff identifying ABCs (an essential component of training); understanding basics of dementia care; and applying STAR techniques.
Conclusions
Results support that STAR is ready to be translated and disseminated into practice. Because ALFs will continue to provide care for individuals with dementia, the need for effective, practical, and sustainable staff training programs is clear. STAR offers one such option. Hopefully, this report will encourage others to conduct comprehensive evaluations of the treatment fidelity of their programs and thereby increase the availability of such programs to enhance care.
doi:10.1097/JGP.0b013e3181c37b0e
PMCID: PMC3972022  PMID: 19910884
Assisted Living; Dementia Care; Staff Training
16.  ïSCOPE: Safer care for older persons (in residential) environments: A study protocol 
Background
The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life.
Aims
Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life.
Methods/design
The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking.
Discussion
There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector.
doi:10.1186/1748-5908-6-71
PMCID: PMC3155478  PMID: 21745382
17.  Psychotropic Medication Monitoring Checklists: Use and Utility for Children in Residential Care 
Objective:
To develop side effect (SE) monitoring checklists for four categories of psychotropic medications (antipsychotics, mood stabilizers, stimulants, and selective serotonin-reuptake inhibitors), to improve residential direct care staff’s confidence and competence in SE monitoring, and to facilitate communication of potential observed SE to medical personnel (e.g., nurse, physician).
Methods:
Seventy-two staff members (three nurses, 69 child/youth workers) from five residential units at a tertiary mental health centre utilized the Psychotropic Medication Monitoring Checklists (PMMC) for eight weeks and completed pre- and post-test measures of staff characteristics and PMMC satisfaction.
Results:
The use of PMMC led to significant changes in direct care staff’s awareness and beliefs associated with medication monitoring. An increase in staff-physician communication with direct care staff was marginally significant. Further investigation into the educational qualities of the PMMC revealed that staff with very little prior formal medication education showed greater change compared to those staff reporting greater formal medication instruction. Staff ratings of the PMMC exceeded mild levels of satisfaction, indicating that the checklists were a well-received and useful tool for monitoring SE in a residential care setting.
Conclusions:
The PMMC are useful as an educational SE monitoring tool for direct care staff in child residential care settings, with potential utility for multiple types of healthcare settings.
PMCID: PMC3917668  PMID: 24516476
children; side effects; psychotropic medication monitoring checklist; residential care; enfants; effets secondaires; liste de surveillance des médicaments psychotropes; soins résidentiels
18.  An evaluation of a "best practices" musculoskeletal injury prevention program in nursing homes 
Injury Prevention  2004;10(4):206-211.
Objective: To conduct an intervention trial of a "best practices" musculoskeletal injury prevention program designed to safely lift physically dependent nursing home residents.
Design: A pre-post intervention trial and cost benefit analysis at six nursing homes from January 1995 through December 2000. The intervention was established in January 1998 and injury rates, injury related costs and benefits, and severity are compared for 36 months pre-intervention and 36 months post-intervention.
Participants: A dynamic cohort of all nursing staff (n = 1728) in six nursing homes during a six year study period.
Intervention: "Best practices" musculoskeletal injury prevention program consisting of mechanical lifts and repositioning aids, a zero lift policy, and employee training on lift usage.
Main outcome measures: Injury incidence rates, workers' compensation costs, lost work day injury rates, restricted work day rates, and resident assaults on caregivers, annually from January 1995 through December 2000.
Results: There was a significant reduction in resident handling injury incidence, workers' compensation costs, and lost workday injuries after the intervention. Adjusted rate ratios were 0.39 (95% confidence interval (CI) 0.29 to 0.55) for workers' compensation claims, 0.54 (95% CI 0.40 to 0.73) for Occupational Safety and Health Administration (OSHA) 200 logs, and 0.65 (95% CI 0.50 to 0.86) for first reports of employee injury. The initial investment of $158 556 for lifting equipment and worker training was recovered in less than three years based on post-intervention savings of $55 000 annually in workers' compensation costs. The rate of post-intervention assaults on caregivers during resident transfers was down 72%, 50%, and 30% based on workers' compensation, OSHA, and first reports of injury data, respectively.
Conclusions: The "best practices" prevention program significantly reduced injuries for full time and part time nurses in all age groups, all lengths of experience in all study sites.
doi:10.1136/ip.2004.005595
PMCID: PMC1730104  PMID: 15314046
19.  Design and pilot results of a single blind randomized controlled trial of systematic demand-led home visits by nurses to frail elderly persons in primary care [ISRCTN05358495] 
BMC Geriatrics  2005;5:11.
Background
The objective of this article is to describe the design of an evaluation of the cost-effectiveness of systematic home visits by nurses to frail elderly primary care patients. Pilot objectives were: 1. To determine the feasibility of postal multidimensional frailty screening instruments; 2. to identify the need for home visits to elderly.
Methods
Main study: The main study concerns a randomized controlled in primary care practices (PCP) with 18 months follow-up and blinded PCPs. Frail persons aged 75 years or older and living at home but neither terminally ill nor demented from 33 PCPs were eligible. Trained community nurses (1) visit patients at home and assess the care needs with the Resident Assessment Instrument-Home Care, a multidimensional computerized geriatric assessment instrument, enabling direct identification of problem areas; (2) determine the care priorities together with the patient; (3) design and execute interventions according to protocols; (4) and visit patients at least five times during a year in order to execute and monitor the care-plan. Controls receive usual care. Outcome measures are Quality of life, and Quality Adjusted Life Years; time to nursing home admission; mortality; hospital admissions; health care utilization.
Pilot 1: Three brief postal multidimensional screening measures to identify frail health among elderly persons were tested on percentage complete item response (selected after a literature search): 1) Vulnerable Elders Screen, 2) Strawbridge's frailty screen, and 3) COOP-WONCA charts.
Pilot 2: Three nurses visited elderly frail patients as identified by PCPs in a health center of 5400 patients and used an assessment protocol to identify psychosocial and medical problems. The needs and experiences of all participants were gathered by semi-structured interviews.
Discussion
The design holds several unique elements such as early identification of frail persons combined with case-management by nurses.
From two pilots we learned that of three potential postal frailty measures, the COOP-WONCA charts were completed best by elderly and that preventive home visits by nurses were positively evaluated to have potential for quality of care improvement.
doi:10.1186/1471-2318-5-11
PMCID: PMC1242228  PMID: 16150147
20.  REFINE (Reducing Falls in In-patient Elderly) - a randomised controlled trial 
Trials  2009;10:83.
Background
Falls in hospitals are common, resulting in injury and anxiety to patients, and large costs to NHS organisations. More than half of all in-patient falls in elderly people in acute care settings occur at the bedside, during transfers or whilst getting up to go to the toilet. In the majority of cases these falls are unwitnessed. There is insufficient evidence underpinning the effectiveness of interventions to guide clinical staff regarding the reduction of falls in the elderly inpatient. New patient monitoring technologies have the potential to offer advances in falls prevention. Bedside sensor equipment can alert staff, not in the immediate vicinity, to a potential problem and avert a fall. However no studies utilizing this assistive technology have demonstrated a significant reduction in falls rates in a randomised controlled trial setting.
Methods/Design
The research design is an individual patient randomised controlled trial of bedside chair and bed pressure sensors, incorporating a radio-paging alerting mode to alert staff to patients rising from their bed or chair, across five acute elderly care wards in Nottingham University Hospitals NHS Trust. Participants will be randomised to bedside chair and bed sensors or to usual care (without the use of sensors). The primary outcome is the number of bedside in-patient falls.
Discussion
The REFINE study is the first randomised controlled trial of bedside pressure sensors in elderly inpatients in an acute NHS Trust. We will assess whether falls can be successfully and cost effectively reduced using this technology, and report on its acceptability to both patients and staff.
Trial Registration
ISRCTN trial number: ISRCTN44972300.
doi:10.1186/1745-6215-10-83
PMCID: PMC2753618  PMID: 19744323
21.  Effects of Dementia-Care Mapping on Residents and Staff of Care Homes: A Pragmatic Cluster-Randomised Controlled Trial 
PLoS ONE  2013;8(7):e67325.
Background
The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention.
Methods
Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents’ neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects.
Results
34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI −2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects.
Conclusions
Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect.
Trial Registration
Dutch Trials Registry NTR2314.
doi:10.1371/journal.pone.0067325
PMCID: PMC3699562  PMID: 23844003
22.  The effect of foot massage on long-term care staff working with older people with dementia: a pilot, parallel group, randomized controlled trial 
BMC Nursing  2013;12:5.
Background
Caring for a person with dementia can be physically and emotionally demanding, with many long-term care facility staff experiencing increased levels of stress and burnout. Massage has been shown to be one way in which nurses’ stress can be reduced. However, no research has been conducted to explore its effectiveness for care staff working with older people with dementia in long-term care facilities.
Methods
This was a pilot, parallel group, randomized controlled trial aimed at exploring feasibility for a larger randomized controlled trial. Nineteen staff, providing direct care to residents with dementia and regularly working ≥ two day-shifts a week, from one long-term care facility in Queensland (Australia), were randomized into either a foot massage intervention (n=9) or a silent resting control (n=10). Each respective session lasted for 10-min, and participants could receive up to three sessions a week, during their allocated shift, over four-weeks. At pre- and post-intervention, participants were assessed on self-report outcome measures that rated mood state and experiences of working with people with dementia. Immediately before and after each intervention/control session, participants had their blood pressure and anxiety measured. An Intention To Treat framework was applied to the analyses. Individual qualitative interviews were also undertaken to explore participants’ perceptions of the intervention.
Results
The results indicate the feasibility of undertaking such a study in terms of: recruitment; the intervention; timing of intervention; and completion rates. A change in the intervention indicated the importance of a quiet, restful environment when undertaking a relaxation intervention. For the psychological measures, although there were trends indicating improvement in mood there was no significant difference between groups when comparing their pre- and post- scores. There were significant differences between groups for diastolic blood pressure (p= 0.04, partial η2=0.22) and anxiety (p= 0.02, partial η2=0.31), with the foot massage group experiencing greatest decreases immediately after the session. The qualitative interviews suggest the foot massage was well tolerated and although taking staff away from their work resulted in some participants feeling guilty about taking time out, a 10-min foot massage was feasible during a working shift.
Conclusions
This pilot trial provides data to support the feasibility of the study in terms of recruitment and consent, the intervention and completion rates. Although the outcome data should be treated with caution, the pilot demonstrated the foot massage intervention showed trends in improved mood, reduced anxiety and lower blood pressure in long-term care staff working with older people with dementia. A larger study is needed to build on these promising, but preliminary, findings.
Trial registration
ACTRN: ACTRN12612000659808.
doi:10.1186/1472-6955-12-5
PMCID: PMC3598869  PMID: 23414448
Anxiety; Blood pressure; Care staff; Complementary and alternative medicine; Dementia; Long-term care; Massage; Mood state; Pilot; Randomized controlled trial
23.  Improving the Capture of Fall Events in Hospitals: Combining a Service for Evaluating Inpatient Falls with an Incident Report System 
OBJECTIVES
To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care.
DESIGN
Six-month observational study.
SETTING
Sixteen adult nursing units (349 beds) in an urban, academically affiliated, community hospital.
PARTICIPANTS
Patients admitted to the study units during the study period.
INTERVENTION
Nursing staff identifying falls were instructed to notify, using a pager, a trained nurse ‘‘fall evaluator.’’ Fall evaluators provided 24-hour-per-day 7-day-per-week coverage throughout the study. Data on patient falls gathered by fall evaluators were compared with falls data obtained through the hospital’s incident reporting system.
RESULTS
During 51,180 patient-days of observation, 191 falls were identified according to incident reports (3.73 falls/1,000 patient-days), whereas the evaluation service identified 228 falls (4.45 falls/1,000 patient-days). Combining falls reported from both data sources yielded 266 falls (5.20 falls/1,000 patient-days), a 39% relative rate increase compared with incident reports alone (P<.001). For falls with injury, combining data from both sources yielded 79 falls (1.54 injurious falls/1,000 patient-days), compared with 57 falls (1.11 injurious falls/1,000 patient-days) filed in incident reports—a 28% increase (P = .06). In the 16 nursing units, the relative percentage increase of captured fall events using the combined data sources versus the incident reporting system alone ranged from 13% to 125%.
CONCLUSION
Incident reports significantly underestimate both injurious and noninjurious falls in acute care settings and should not be used as the sole source of data for research or quality improvement initiatives.
doi:10.1111/j.1532-5415.2007.01605.x
PMCID: PMC2361382  PMID: 18205761
incident reporting; falls identification; reporting system; patient falls
24.  A More Efficient Use of Hospital Beds? 
British Medical Journal  1974;3(5922):27-30.
Faced with a shortage of trained nursing staff and a high wastage rate among learners the management of a district general hospital decided to close some of its acute beds. A beds committee attempted to minimize the effects of these closures by introducing a bed bureau, “pooling,” and a simple system for forecasting waiting list admissions.
The figures for recruitment and wastage of nurses improved, and a very high turnover per available bed was achieved. This increased efficiency in numerical terms was not mirrored by an improvement in the morale of the doctors and nurses working on the wards, who were subjected to new pressures and considered that at times the standard of patient care deteriorated.
PMCID: PMC1611337  PMID: 4858178
25.  Exploring Interventions to Reduce Cognitive Decline in Aging 
As the population ages, risks for cognitive decline threaten independence and quality of life for older adults and present challenges to the health care system. Nurses are in a unique position to advise clients about cognitive health promotion and to develop interventions that optimize cognition in the growing aging population. A literature review was completed to provide nurses working in mental health and geriatric care with an overview of research related to the promotion of successful cognitive aging for older adults. Research evaluating cognitively stimulating lifestyles and the effects on cognitive function of older adults of interventions targeting cognitive training, physical activity, social engagement, and nutrition were reviewed. Overall research findings support positive effects of cognitive and physical activity, social engagement, and therapeutic nutrition in optimizing cognitive aging. However, the strength of the research evidence is limited by research designs. Conclusions include recommended applications for health promotion to optimize cognitive aging and future direction for research.
doi:10.3928/02793695-20100331-03
PMCID: PMC2923489  PMID: 20415290
Cognition and Aging; Interventions; Health Promotion

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