Related Articles

Older persons with mental disorders, excluding dementia disorders, constitute a vulnerable group of people. With the future international increase in the older population, mental disorders will increase as well, thus entailing new challenges for their caregivers. These older persons often remain in their own homes, and in Sweden they are cared for by nursing aides. With little previous research, an increased workload and facing new strenuous situations, it is important to make use of the knowledge the nursing aides possess and to deepen the understanding of their experiences. The study aimed at illuminating the meaning of caring for older persons with mental disorders as experienced by nursing aides in the municipal home help service. Interviews with nine female nursing aides were performed and analysed with a phenomenological hermeneutical research method inspired by the philosophy of Paul Ricoeur. Being altruistically egoistic emerged as a main theme in the nursing aides’ narratives. The nursing aides’ experiences could be interpreted as a movement between being altruistic and egoistic. The findings revealed a continuous distancing by the nursing aides and their struggle to redress the balance between their altruistic and egoistic actions. Caring for these older persons constitutes a complex situation where distancing functions as a recourse to prioritize oneself and to diminish the value of caring. The study suggests that an increased knowledge base on older persons with mental disorders, followed by continuous supervision, is necessary for the nursing aides to improve the quality of the care given.

Aim

To examine the association between nurses' reports of unmet nursing care needs and their reports of patients' receipt of the wrong medication or dose, nosocomial infections and patient falls with injury in hospitals.

Background

Because nursing activities are often difficult to measure, and data are typically not collected by health care organisations, there are few studies that have addressed the association between nursing activities and patient outcomes.

Design

Secondary analysis of cross-sectional data collected in 1999 from 10,184 staff nurses and 168 acute care hospitals in the US.

Methods

Multivariate linear regression models estimated the effect of unmet nursing care needs on adverse events given the influence of patient factors and the care environment.

Results

The proportion of necessary nursing care left undone ranged from 26% for preparing patients and families for discharge to as high as 74% for developing or updating nursing care plans. A majority of nurses reported that patients received the wrong medication or dose, acquired nosocomial infections, or had a fall with injury infrequently. However, nurses who reported that these adverse events occurred frequently varied considerably [i.e. medication errors (15%), patient falls with injury (20%), nosocomial infection (31%)]. After adjusting for patient factors and the care environment, there remained a significant association between unmet nursing care needs and each adverse event.

Conclusion

The findings suggest that attention to optimising patient care delivery could result in a reduction in the occurrence of adverse events in hospitals.

Relevance to clinical practice

The occurrence of adverse events may be mitigated when nurses complete care activities that require them to spend time with their patients. Hospitals should engage staff nurses in the creation of policies that influence human resources management to enhance their awareness of the care environment and patient care delivery.

Background:

Pain assessment in persons with dementia is well known as a challenging issue to professional caregivers, because of these patients´ difficulties in verbalising pain problems. Within municipal dementia care in Sweden, pain assessment has become problematic for registered nurses, as they have entered a new role in their nursing profession, from being clinical practitioners to becoming consultant advisers to other health care staff.

Aim:

To present municipal registered nurses´ view of pain assessment in persons with dementia in relation to their nursing profession as consultant advisers.

Methods:

Purposive sampling was undertaken with 11 nurses invited to participate. Data were collected by focus groups. Qualitative content analysis was used to analyse the data.

Findings:

Four categories were identified to describe registered nurses´ view of pain assessment: estrangement from practical nursing care, time consuming and unsafe pain documentation, unfulfilled needs of reflection possibilities, and collaboration and coordination.

Conclusions:

The performance of pain assessment through a consultant advising function is experienced as frustrating and as an uncomfortable nursing situation. The nurses feel resistance to providing nursing in this way. They view nursing as a clinical task demanding daily presence among patients to enable them to make accurate and safe assessments. However, due to the consultative model, setting aside enough time for the presence seems difficult to accomplish. It is necessary to promote the quality of systematic routines in pain assessment and reflection, as well as developing professional knowledge of how pain can be expressed by dementia patients, especially those with communication difficulties.

Objectives

The objectives of this study were to determine the prevalence of pain, describe its treatment, and determine factors associated with any pain in older residents assigned to a hospice specialty unit bed or receiving services from a hospice/palliative care/end-of-life special program in US nursing homes.

Design

Cross-sectional study of data from the 2004 National Nursing Home Survey.

Setting

The setting was 1174 US nursing homes.

Participants

Participants were 303 sampled patients, 65 years or older, representing 33,413 individuals receiving hospice/palliative care.

Measurements

Facility staff was asked if, in the past 7 days, the resident had reported or shown evidence of pain. Medication use data were derived from medication administration records. Information about demographics and health status was derived from Minimum Data Set records.

Results

Cancer was the primary diagnosis in only 11.4% of residents. Overall 36.6% had any pain in the previous week. Among those with any pain, 86.4% received some analgesic; specifically, 65.5% received opioids, whereas 31.7% received acetaminophen. Those with any pain compared with those without pain had shorter lengths of stay in hospice/palliative care (mean 123 days versus 161 days, P < .01), were more likely to be incontinent of bowel (76.2%, versus 60.3%, P < 0.01) and bladder (84.5% versus 71.8%, P = 0.01).

Conclusions

Pain symptoms were present in more than one third of older nursing home hospice/palliative care residents despite the use of opioids in two thirds of those who had reported or shown evidence of any pain. Additional future studies are needed to improve the management of pain in older residents receiving hospice/palliative care in US nursing homes.

Background

Little research has been done on patient call light use and staff response time, which were found to be associated with inpatient falls and satisfaction. Nurses' perspectives may moderate or mediate the aforementioned relationships. This exploratory study intended to understand staff's perspectives about call lights, staff responsiveness, and the reasons for and the nature of call light use. It also explored differences among hospitals and identified significant predictors of the nature of call light use.

Methods

This cross-sectional, multihospital survey study was conducted from September 2008 to January 2009 in four hospitals located in the Midwestern region of the United States. A brief survey was used. All 2309 licensed and unlicensed nursing staff members who provide direct patient care in 27 adult care units were invited to participate. A total of 808 completed surveys were retrieved for an overall response rate of 35%. The SPSS 16.0 Window version was used. Descriptive and binary logistic regression analyses were conducted.

Results

The primary reasons for patient-initiated calls were for toileting assistance, pain medication, and intravenous problems. Toileting assistance was the leading reason. Each staff responded to 6 to 7 calls per hour and a call was answered within 4 minutes (estimated). 49% of staff perceived that patient-initiated calls mattered to patient safety. 77% agreed that that these calls were meaningful. 52% thought that these calls required the attention of nursing staff. 53% thought that answering calls prevented them from doing the critical aspects of their role. Staff's perceptions about the nature of calls varied across hospitals. Junior staff tended to overlook the importance of answering calls. A nurse participant tended to perceive calls as more likely requiring nursing staff's attention than a nurse aide participant.

Conclusions

If answering calls was a high priority among nursing tasks, staff would perceive calls as being important, requiring nursing staff's attention, and being meaningful. Therefore, answering calls should not be perceived as preventing staff from doing the critical aspects of their role. Additional efforts are necessary to reach the ideal or even a reasonable level of patient safety-first practice in current hospital environments.

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.

Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.

Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.

Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

The aim of this study is to describe current post-operative pain management practices for patients with dementia and hip fracture in Finland. Older adults with hip fracture are at high risk of under treatment for pain, especially if they also have a cognitive disorder at the stage of dementia. Previous studies have provided limited information about the quality of acute pain treatment for persons with dementia. In this study data concerning current pain management practices was collected by questionnaire from 333 nursing staff. They worked in surgical wards of seven universities and ten city-centre hospitals. The response rate to the questionnaire was 53%. The data was analysed using factor analysis and parametric methods. Half the respondents (53%) considered that post-operative pain management was sufficient for patients with dementia. Less than one third of respondent nurses reported that pain scales were in use on their unit: the most commonly used scale was VAS. The use of pain scales was significantly related to the respondents’ opinion of the sufficiency of post-operative pain management in this patient group (p<0.001). The findings can be utilised in nursing practice and research when planning suitable complementary educational interventions for nursing staff of surgical wards. Further research is needed to explain the current situation of pain management practices from the viewpoint of patients with dementia.

Although approximately 50% of nursing home residents fall annually, the surrounding circumstances remain inadequately understood. This study explored nursing staff perspectives of person, environment, and interactive circumstances surrounding nursing home falls. Focus groups were conducted at two nursing homes in the mid-Atlantic region with the highest and lowest fall rates among corporate facilities. Two focus groups were conducted per facility: one with licensed nurses and one with geriatric nursing assistants. Thematic and content analysis revealed three themes and 11 categories. Three categories under the Person theme were Change in Residents’ Health Status, Decline in Residents’ Abilities, and Residents’ Behaviors and Personality Characteristics. There were five Nursing Home Environment categories: Design Safety, Limited Space, Obstacles, Equipment Misuse and Malfunction, and Staff and Organization of Care. Three Interactions Leading to Falls categories were identified: Reasons for Falls, Time of Falls, and High-Risk Activities. Findings highlight interactions between person and environment factors as significant contributors to resident falls.

Objective

The aim of this prospective study was to examine risk factors of falling in a very old home-dwelling population.

Design

A prospective study of home-dwelling elderly people.

Methods

Baseline data were collected by home-nursing staff through postal questionnaires and clinical tests. Data on falls were recorded in telephone interviews every other month during a follow-up of 11 months constituting 494 person years (PY). Negative binomial modeling was used to assess fall risk.

Setting

General community.

Subjects

A population sample of home-dwelling subjects aged 85 years or older (n = 555).

Main outcome measures

Fall rate and risk factors of falls.

Results

Altogether 512 falls occurred in 273 (49%) subjects, incidence rate 1.03/PY. According to a multivariate model, history of recurrent falling, trouble with vision when moving, use of antipsychotic drug, and feelings of anxiety, nervousness, or fear were independent risk factors for subsequent falls.

Conclusion

Appropriate care of poor vision and feelings of anxiety, nervousness, or fear, and avoidance of use of antipsychotic drugs might be useful in the prevention of falls among the most elderly home-dwellers.

Background

Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.

Methods/design

Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.

Discussion

By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.

Trial Registration

ClinicalTrials.gov: NCT00636675

We evaluated the efficacy of a brief staff-training procedure to increase the use of graduated prompting by 2 certified nursing assistants (CNAs) while they helped to dress 3 persons with dementia in a seven-bed dementia care unit. The multiple baseline design across participants showed that CNAs dressed residents with minimal resident involvement during baseline observations. Following brief in-service training, CNAs provided graduated prompts and praise appropriately, suggesting that CNAs can promote active involvement in personal care routines by older adults with dementia.

Aims

To describe nurse burnout, job dissatisfaction, and quality of care in Japanese hospitals, and to determine how these outcomes are associated with work environment factors.

Background

Nurse burnout and job dissatisfaction are associated with poor nurse retention and uneven quality of care in other countries but comprehensive data have been lacking on Japan.

Design

Cross-sectional survey of 5,956 staff nurses on 302 units in 19 acute hospitals in Japan.

Methods

Nurses provided information about years of experience, completed the Maslach Burnout Inventory, and reported on resource adequacy and working relations with doctors using the Nursing Work Index-Revised.

Results

56% of nurses scored high on burnout, 60% were dissatisfied with their jobs, and 59% ranked quality of care as only fair or poor. About one-third had fewer than 4 years of experience, and more than two-thirds had less than 10. Only one in five nurses reported there were enough RNs to provide quality care and more than half reported that teamwork between nurses and physicians was lacking. The odds on high burnout, job dissatisfaction and poor-fair quality of care were twice as high in hospitals with 50% inexperienced nurses than with 20% inexperienced nurses, and 40% higher in hospitals where nurses had less satisfactory relations with physicians. Nurses in poorly staffed hospitals were 50% more likely to exhibit burnout, twice as likely to be dissatisfied, and 75% more likely to report poor or fair quality care than nurses in better staffed hospitals.

Conclusions

Improved nurse staffing and working relationships with physicians may reduce nurse burnout, job dissatisfaction, and low nurse-assessed quality of care.

Relevance to clinical practice

Staff nurses should engage supervisors and medical staff in discussions about retaining more experienced nurses at the bedside, implementing strategies to enhance clinical staffing, and identifying ways to improve nurse-physician working relations.

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.

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.

Background

The effectiveness and efficiency of nursing-home dementia care are suboptimal: there are high rates of neuropsychiatric symptoms among the residents and work-related stress among the staff. Dementia-care mapping is a person-centred care method that may alleviate both the resident and the staff problems. The main objective of this study is to evaluate the effectiveness and cost-effectiveness of dementia-care mapping in nursing-home dementia care.

Methods/Design

The study is a cluster-randomised controlled trial, with nursing homes grouped in clusters. Studywise minimisation is the allocation method. Nursing homes in the intervention group will receive a dementia-care-mapping intervention, while the control group will receive usual care. The primary outcome measure is resident agitation, to be assessed with the Cohen-Mansfield Agitation Inventory. The secondary outcomes are resident neuropsychiatric symptoms, assessed with the Neuropsychiatric Inventory - Nursing Homes and quality of life, assessed with Qualidem and the EQ-5D. The staff outcomes are stress reactions, job satisfaction and job-stress-related absenteeism, and staff turnover rate, assessed with the Questionnaire about Experience and Assessment of Work, the General Health Questionnaire-12, and the Maastricht Job Satisfaction Scale for Health Care, respectively. We will collect the data from the questionnaires and electronic registration systems. We will employ linear mixed-effect models and cost-effectiveness analyses to evaluate the outcomes. We will use structural equation modelling in the secondary analysis to evaluate the plausibility of a theoretical model regarding the effectiveness of the dementia-care mapping intervention. We will set up process analyses, including focus groups with staff, to determine the relevant facilitators of and barriers to implementing dementia-care mapping broadly.

Discussion

A novelty of dementia-care mapping is that it offers an integral person-centred approach to dementia care in nursing homes. The major strengths of the study design are the large sample size, the cluster-randomisation, and the one-year follow-up. The generalisability of the implementation strategies may be questionable because the motivation for person-centred care in both the intervention and control nursing homes is above average. The results of this study may be useful in improving the quality of care and are relevant for policymakers.

Trial registration

The trial is registered in the Netherlands National Trial Register: NTR2314.

Clinical nursing expertise is central to quality patient care. Research on factors that contribute to expertise has focused largely on individual nurse characteristics to the exclusion of contextual factors. To address this, we examined effects of hospital contextual factors and individual nurse education and experience on clinical nursing expertise in a cross-sectional analysis of data from 8,611 registered nurses. In a generalized ordered logistic regression analysis, the composition of the hospital staff, particularly the proportion of nurses with at least a bachelor of science in nursing degree, was associated with significantly greater odds of a nurse reporting a more advanced expertise level. Our findings suggest that, controlling for individual characteristics, the hospital context significantly influences clinical nursing expertise.

Background

Objective measurements can be used to identify people with risks of falls, but many frail elderly adults cannot complete physical performance tests. The study examined the relationship between a subjective risk rating of specific tasks (SRRST) to screen for fall risks and falls and fall-related fractures in frail elderly people.

Methods

The SRRST was investigated in 5,062 individuals aged 65 years or older who were utilized day-care services. The SRRST comprised 7 dichotomous questions to screen for fall risks during movements and behaviours such as walking, transferring, and wandering. The history of falls and fall-related fractures during the previous year was reported by participants or determined from an interview with the participant's family and care staff.

Results

All SRRST items showed significant differences between the participants with and without falls and fall-related fractures. In multiple logistic regression analysis adjusted for age, sex, diseases, and behavioural variables, the SRRST score was independently associated with history of falls and fractures. Odds ratios for those in the high-risk SRRST group (≥ 5 points) compared with the no risk SRRST group (0 point) were 6.15 (p < 0.01) for a single fall, 15.04 (p < 0.01) for recurrent falls, and 5.05 (p < 0.01) for fall-related fractures. The results remained essentially unchanged in subgroup analysis accounting for locomotion status.

Conclusion

These results suggest that subjective ratings by care staff can be utilized to determine the risks of falls and fall-related fractures in the frail elderly, however, these preliminary results require confirmation in further prospective research.

Background

Fall prevention programs for hospitalized patients have had limited success, and the effect of programs on decreasing total falls and fall-related injuries is still inconclusive. This exploratory multi-hospital study examined the unique contribution of call light response time to predicting total fall rates and injurious fall rates in inpatient acute care settings. The conceptual model was based on Donabedian's framework of structure, process, and health-care outcomes. The covariates included the hospital, unit type, total nursing hours per patient-day (HPPDs), percentage of the total nursing HPPDs supplied by registered nurses, percentage of patients aged 65 years or older, average case mix index, percentage of patients with altered mental status, percentage of patients with hearing problems, and call light use rate per patient-day.

Methods

We analyzed data from 28 units from 4 Michigan hospitals, using archived data and chart reviews from January 2004 to May 2009. The patient care unit-month, defined as data aggregated by month for each patient care unit, was the unit of analysis (N = 1063). Hierarchical multiple regression analyses were used.

Results

Faster call light response time was associated with lower total fall and injurious fall rates. Units with a higher call light use rate had lower total fall and injurious fall rates. A higher percentage of productive nursing hours provided by registered nurses was associated with lower total fall and injurious fall rates. A higher percentage of patients with altered mental status was associated with a higher total fall rate but not a higher injurious fall rate. Units with a higher percentage of patients aged 65 years or older had lower injurious fall rates.

Conclusions

Faster call light response time appeared to contribute to lower total fall and injurious fall rates, after controlling for the covariates. For practical relevance, hospital and nursing executives should consider strategizing fall and injurious fall prevention efforts by aiming for a decrease in staff response time to call lights. Monitoring call light response time on a regular basis is recommended and could be incorporated into evidence-based practice guidelines for fall prevention.

Objective To examine the practice of concealing drugs in patients' foodstuff in nursing homes.

Design Cross sectional study with data collected by structured interview.

Setting All five health regions in Norway.

Participants Professional carers of 1362 patients in 160 regular nursing home units and 564 patients in 90 special care units for people with dementia.

Main outcome measures Frequency of concealment of drugs; who decided to conceal the drugs; how this practice was documented in the patients' records; and what types of drugs were given this way.

Results 11% of the patients in regular nursing home units and 17% of the patients in special care units for people with dementia received drugs mixed in their food or beverages at least once during seven days. In 95% of cases, drugs were routinely mixed in the food or beverages. The practice was documented in patients' records in 40% (96/241) of cases. The covert administration of drugs was more often documented when the physician took the decision to hide the drugs in the patient's foodstuff (57%; 27/47) than when the person who made the decision was unknown or not recorded (23%; 7/30). Patients who got drugs covertly more often received antiepileptics, antipsychotics, and anxiolytics compared with patients who were given their drugs openly.

Conclusions The covert administration of drugs is common in Norwegian nursing homes. Routines for such practice are arbitrary, and the practice is poorly documented in the patients' records.

Introduction:

Today, anxiety is one of the most common problems of mankind, to the extent that we could claim that it predisposes human to many physical illnesses, mental disorders, behavioral disturbances, and inappropriate reactions. The intensive care unit is a stressful environment for its staff, especially physicians and nurses. These stresses may have negative effects on the mental health and performance of the nurses and physicians. But the complications caused by this stress can be prevented by training emotional intelligence components. In this study, the impact of training emotional intelligence components on stress and anxiety in nurses and expert physicians is examined.

Methodology:

A cross-interventional, pre- to post-, case and control group design was used and inferential study design was implemented. Our study included 150 registered hospitals physicians and nurses, who were widely distributed. In the study, a ten-question demographic questionnaire, a 20-question situational anxiety Berger (overt) questionnaire, and a 133-question Bar-on emotional intelligence questionnaire were used.

Results:

Research results indicate that average score for the situational anxiety of the case group in nurses was 47.20 before the intervention and it was reduced to 42.00 after the intervention, and in physicians was 40.46 before the intervention and it decreased to 33.66 after implementation of training items of emotional intelligence, which indicates the impact of training of emotional intelligence components on reduction of situational anxiety. The average score of situational anxiety of control group nurses was 46.73 before the intervention and it decreased to 45.70. In physicians, it was 38.33 before the intervention and it increased to 39.40 during post-test. However, t-test did not confirmed a statistically significant difference between the average score of situational anxiety of both case and control groups before the intervention, and there was a statistically significant difference between the average score of both case and control groups after training components of emotional intelligence (P = 0.000).

Conclusion:

Training emotional intelligence components reduces situational anxiety of nurses and physicians working in intensive care units and their emotional intelligence score increased and situational anxiety score was significantly reduced.

Background

Hip fractures are a major public health burden. In industrialized countries about 20% of all femoral fractures occur in care dependent persons living in nursing care and assisted living facilities. Preventive strategies for these groups are needed as the access to medical services differs from independent home dwelling older persons at risk of osteoporotic fractures. It was the objective of the study to evaluate the effect of a fall and fracture prevention program on the incidence of femoral fracture in nursing homes in Bavaria, Germany.

Methods

In a translational intervention study a fall prevention program was introduced in 256 nursing homes with 13,653 residents. The control group consisted of 893 nursing homes with 31,668 residents. The intervention consisted of staff education on fall and fracture prevention strategies, progressive strength and balance training, and on institutional advice on environmental adaptations. Incident femoral fractures served as outcome measure.

Results

In the years before the intervention risk of a femoral fracture did not differ between the intervention group (IG) and control group (CG). During the one-year intervention period femoral fracture rates were 33.6 (IG) and 41.0/1000 person years (CG), respectively. The adjusted relative risk of a femoral fracture was 0.82 (95% CI 0.72-0.93) in residents exposed to the fall and fracture prevention program compared to residents from CG.

Conclusions

The state-wide dissemination of a multi-factorial fall and fracture prevention program was able to reduce femoral fractures in residents of nursing homes.

Introduction

Falling is one of the most common geriatric syndromes threatening the independence of older persons. Falls result from a complex and interactive mix of biological or medical, behavioral and environmental factors, many of which are preventable. Studying these diverse risk factors would aid early detection and management of them at the primary care level.

Methods

This is a cross sectional study about risk factors of falls was conducted to 340 elders in Urban Suez. Those are all patients over 60 who attended two family practice centers in Urban Suez.

Results

When asked about falling during the past 12 months, 205 elders recalled at least one incident of falling. Of them, 36% had their falls outdoors and 24% mentioned that stairs was the most prevalent site for indoor falls. Falls were also reported more among dependant than independent elderly. Using univariate regression analysis, almost all tested risk factors were significantly associated with falls in the studied population. These risk factors include: living alone, having chronic diseases, using medications, having a physical deficit, being in active, and having a high nutritional risk. However, the multivariate regression analysis proved that the strongest risk factors are low level of physical activity with OR 0.6 and P value 0.03, using a cane or walker (OR 1.69 and P value 0.001) and Impairment of daily living activities (OR 1.7 and P value 0.001).

Conclusion

Although falls is a serious problem among elderly with many consequences, it has many preventable risk factors. Health care providers should advice people to remain active and more research is needed in such an important area of Family Practice.

Executive Summary

In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.

After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.

Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.

Aging in the Community: Summary of Evidence-Based Analyses

Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis

Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis

Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis

Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis

The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)

This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections:

Introduction

Caregiver-Directed Interventions for Dementia

Patient-Directed Interventions for Dementia

Economic Analysis of Caregiver- and Patient-Directed Interventions for Dementia

Caregiver-Directed Interventions for Dementia

Objective

To identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community.

Clinical Need: Target Population and Condition

Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization.

Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC.

Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia.

It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions.

Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside.

Description of Interventions

The 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver’s needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends.

Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions.

Methods of Evidence-Based Analysis

A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients.

Questions

Section 2.1

Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?

Do respite care services impact on rates of institutionalization of these seniors?

Section 2.2

Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?

Which interventions reduce the risk for institutionalization of seniors with dementia?

Outcomes of Interest

any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one’s situation), reactivity to behaviour problems, etc.;

rate of institutionalization; and

cost-effectiveness.

Assessment of Quality of Evidence

The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:

Summary of Findings

Conclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report.

Summary of Conclusions on Caregiver-Directed Interventions

There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.

There is considerable qualitative evidence of the perceived benefits of respite care.

Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.

Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)

There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.

There is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.

RCT indicates randomized controlled trial.

Patient-Directed Interventions for Dementia

Objective

The section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions:

3.1 Physical Exercise for Seniors with Dementia – Secondary Prevention

What is the effectiveness of physical exercise for the improvement or maintenance of basic activities of daily living (ADLs), such as eating, bathing, toileting, and functional ability, in seniors with mild to moderate dementia?

3.2 Nonpharmacologic and Nonexercise Interventions to Improve Cognitive Functioning in Seniors With Dementia – Secondary Prevention

What is the effectiveness of nonpharmacologic interventions to improve cognitive functioning in seniors with mild to moderate dementia?

3.3 Physical Exercise for Delaying the Onset of Dementia – Primary Prevention

Can exercise decrease the risk of subsequent cognitive decline/dementia?

3.4 Cognitive Interventions for Delaying the Onset of Dementia – Primary Prevention

Does cognitive training decrease the risk of cognitive impairment, deterioration in the performance of basic ADLs or instrumental activities of daily living (IADLs),1 or incidence of dementia in seniors with good cognitive and physical functioning?

Clinical Need: Target Population and Condition

Secondary Prevention2

Exercise

Physical deterioration is linked to dementia. This is thought to be due to reduced muscle mass leading to decreased activity levels and muscle atrophy, increasing the potential for unsafe mobility while performing basic ADLs such as eating, bathing, toileting, and functional ability.

Improved physical conditioning for seniors with dementia may extend their independent mobility and maintain performance of ADL.

Nonpharmacologic and Nonexercise Interventions

Cognitive impairments, including memory problems, are a defining feature of dementia. These impairments can lead to anxiety, depression, and withdrawal from activities. The impact of these cognitive problems on daily activities increases pressure on caregivers.

Cognitive interventions aim to improve these impairments in people with mild to moderate dementia.

Primary Prevention3

Exercise

Various vascular risk factors have been found to contribute to the development of dementia (e.g., hypertension, hypercholesterolemia, diabetes, overweight).

Physical exercise is important in promoting overall and vascular health. However, it is unclear whether physical exercise can decrease the risk of cognitive decline/dementia.

Nonpharmacologic and Nonexercise Interventions

Having more years of education (i.e., a higher cognitive reserve) is associated with a lower prevalence of dementia in crossectional population-based studies and a lower incidence of dementia in cohorts followed longitudinally. However, it is unclear whether cognitive training can increase cognitive reserve or decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs or reduce the incidence of dementia.

Description of Interventions

Physical exercise and nonpharmacologic/nonexercise interventions (e.g., cognitive training) for the primary and secondary prevention of dementia are assessed in this review.

Evidence-Based Analysis Methods

A comprehensive search strategy was used to identify systematic reviews and RCTs that examined the effectiveness, safety and cost effectiveness of exercise and cognitive interventions for the primary and secondary prevention of dementia.

Questions

Section 3.1: What is the effectiveness of physical exercise for the improvement or maintenance of ADLs in seniors with mild to moderate dementia?

Section 3.2: What is the effectiveness of nonpharmacologic/nonexercise interventions to improve cognitive functioning in seniors with mild to moderate dementia?

Section 3.3: Can exercise decrease the risk of subsequent cognitive decline/dementia?

Section 3.4: Does cognitive training decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs, or reduce the incidence of dementia in seniors with good cognitive and physical functioning?

Assessment of Quality of Evidence

The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology. As per GRADE the following definitions apply:

Summary of Findings

Table 2 summarizes the conclusions from Sections 3.1 through 3.4.

Summary of Conclusions on Patient-Directed Interventions*

Previous systematic review indicated that “cognitive training” is not effective in patients with dementia.

A recent RCT suggests that CST (up to 7 weeks) is effective for improving cognitive function and quality of life in patients with dementia.

Regular leisure time physical activity in midlife is associated with a reduced risk of dementia in later life (mean follow-up 21 years).

Regular physical activity in seniors is associated with a reduced risk of cognitive decline (mean follow-up 2 years).

Regular physical activity in seniors is associated with a reduced risk of dementia (mean follow-up 6–7 years).

Evidence that cognitive training for specific functions (memory, reasoning, and speed of processing) produces improvements in these specific domains.

Limited inconclusive evidence that cognitive training can offset deterioration in the performance of self-reported IADL scores and performance assessments.

1° indicates primary; 2°, secondary; CST, cognitive stimulation therapy; IADL, instrumental activities of daily living; RCT, randomized controlled trial.

Benefit/Risk Analysis

As per the GRADE Working Group, the overall recommendations consider 4 main factors:

the trade-offs, taking into account the estimated size of the effect for the main outcome, the confidence limits around those estimates, and the relative value placed on the outcome;

the quality of the evidence;

translation of the evidence into practice in a specific setting, taking into consideration important factors that could be expected to modify the size of the expected effects such as proximity to a hospital or availability of necessary expertise; and

uncertainty about the baseline risk for the population of interest.

The GRADE Working Group also recommends that incremental costs of health care alternatives should be considered explicitly alongside the expected health benefits and harms. Recommendations rely on judgments about the value of the incremental health benefits in relation to the incremental costs. The last column in Table 3 reflects the overall trade-off between benefits and harms (adverse events) and incorporates any risk/uncertainty (cost-effectiveness).

Overall Summary Statement of the Benefit and Risk for Patient-Directed Interventions*

Economic Analysis

Budget Impact Analysis of Effective Interventions for Dementia

Caregiver-directed behavioural techniques and patient-directed exercise programs were found to be effective when assessing mild to moderate dementia outcomes in seniors living in the community. Therefore, an annual budget impact was calculated based on eligible seniors in the community with mild and moderate dementia and their respective caregivers who were willing to participate in interventional home sessions. Table 4 describes the annual budget impact for these interventions.

Annual Budget Impact (2008 Canadian Dollars)

Assumed 7% prevalence of dementia aged 65+ in Ontario.

Assumed 8 weekly sessions plus 4 monthly phone calls.

Assumed 12 weekly sessions plus biweekly sessions thereafter (total of 20).

Assumed 2 sessions per week for first 5 weeks. Assumed 90% of seniors in the community with dementia have mild to moderate disease. Assumed 4.5% of seniors 65+ are in long-term care, and the remainder are in the community. Assumed a rate of participation of 60% for both patients and caregivers and of 41% for patient-directed exercise. Assumed 100% compliance since intervention administered at the home. Cost for trained staff from Ministry of Health and Long-Term Care data source. Assumed cost of personal support worker to be equivalent to in-home support. Cost for recreation therapist from Alberta government Website.

Note: This budget impact analysis was calculated for the first year after introducing the interventions from the Ministry of Health and Long-Term Care perspective using prevalence data only. Prevalence estimates are for seniors in the community with mild to moderate dementia and their respective caregivers who are willing to participate in an interventional session administered at the home setting. Incidence and mortality rates were not factored in. Current expenditures in the province are unknown and therefore were not included in the analysis. Numbers may change based on population trends, rate of intervention uptake, trends in current programs in place in the province, and assumptions on costs. The number of patients was based on patients likely to access these interventions in Ontario based on assumptions stated below from the literature. An expert panel confirmed resource consumption.

Emotional support is considered to be important to older patients because it is a contributing factor to experiencing good health and it has been shown that it can prevent depression after a hip fracture. Opinions differ on whether emotional support falls within the field of nursing, and studies also show that nurses in an elderly home care setting fail when it comes to giving emotional support. The aim of this study was to explore reasons for registered nurses to give emotional support to older patients in a municipal home care setting. The study was conducted using Grounded Theory. Data collection was carried out through interviews with 16 registered nurses. The inclusion criteria were emotional support given to patients aged 80 years and above living in ordinary or sheltered housing and who were in need of help from both the home help service and registered nurses. The results show that the main concern of emotional support was “Trying to relieve the patient from their emotions so they are able to cope with everyday life.” This core category illustrates how registered nurses tried to support the patients’ own strength, so that they were able to move forward. Registered nurses consider that they could support the patients because they give them access to, or could create access to, their emotions, but there were also times when they felt helplessness and as a result, consciously opted out. The results also indicate that registered nurses were keen to give emotional support. To develop patient-centered elderly care, more knowledge of emotional support and the elderly's need for this support is required.

Background

Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.

Methods/Design

A multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.

This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.

Discussion

RN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.