Introducing a nursing guideline on depression in dementia: a multiple case study on influencing factors

Background

Successfully introducing care innovations depends on the type of care setting, the intervention and specific circumstances. In this study the factors influencing the introduction of an evidence based nursing guideline on depression in psychogeriatric nursing home residents were studied.

Methods

A mixed methods multiple case study design was used. The cases consisted of nine psychogeriatric wards participating in the intervention group of a controlled clinical trial. Eight types of data source (qualitative and quantitative) were used in the analyses. Triangulation of researchers, data and methods took place. Factors were categorized according to their organizational level: nursing home management (level 1), nursing team (level 2), CNAs (level 3), and residents (level 4).

Results

Factors influencing guideline introduction were mainly found at the levels of the nursing home management and the nursing team. Most factors concern stability of the organization and team (e.g. the inhibiting effects of reorganizations and other innovations), motivation (e.g. the facilitating presence of an opinion leader) and compatibility with current practice and vision (e.g. a facilitating emotion-oriented care vision). Factors influencing a successful application of the guideline are mainly found at CNA and resident level. At CNA level most factors relate to an emotion-oriented care vision (e.g. having a warm and creative personality). At resident level inhibiting factors mainly concern the residents’ health status (e.g. feeling sick and/or having much pain). Important facilitating factors are positive attitudes of relatives and observing a reduction of depression severity.

Conclusions

Special facilitating factors for the guideline introduction and application seem to be the presence of a local opinion leader and the positive attitudes of relatives. Together they can motivate a nursing team in using the guideline. After a successful introduction of the guideline it's important to focus on its consolidation in daily practice.     

Effects of group interventions on cognition and depression in nursing home residents.

The effects of cognitive-behavioral group therapy, focused visual imagery group therapy, and education-discussion groups on cognition, depression, hopelessness, and dissatisfaction with life were studied among depressed nursing home residents. Seventy-six depressed subjects with mild to moderate cognitive decline participated in nurse-led 24-week protocols. Data were collected 4 weeks before the interventions, 8 and 20 weeks after treatment initiation, and 4 weeks after treatment termination. There were no significant changes in depression, hopelessness, or life satisfaction scores for any of the three conditions. Participants in the cognitive-behavioral and focused visual imagery groups showed a significant improvement beginning 8 weeks after treatment initiation on cognitive scores. These findings are encouraging indications that cognitive-behavioral and focused visual imagery group therapies may reduce cognitive impairment in depressed nursing home residents with mild to moderate cognitive decline.     

Pain in the nursing home: assessment and treatment on different types of care wards

The assessment and management of pain in nursing homes have been shown to be suboptimal, but no study has evaluated differences in clinical setting within these homes. The prevalence and management of pain on different care wards (psychogeriatric, somatic, and rehabilitation) was studied on 562 newly admitted Dutch nursing home residents. Pain was measured according to the Nottingham Health Profile (perceived pain) and the Minimum Data Set pain observation items (frequency and intensity). Pain frequency differed significantly across the different ward types: on psychogeriatric wards (n=247), it was 27.1%; on somatic wards (n=181), 53.9%; and on rehabilitation wards (n=129), 57.8%. Being admitted on a psychogeriatric ward was significantly related to less pain compared to being admitted on a somatic ward, even when adjusted for possible confounders such as age, gender, cognitive status, activities of daily living, pain-related disorders, and depression (odds ratio [OR] 0.38 [95% confidence interval (CI)=0.23-0.62]). Patients on psychogeriatric wards who had pain received less pain medication, adjusted for frequency and intensity of pain (OR 0.37 [95% CI=0.23-0.59]), compared to patients on somatic wards. We conclude that admission to a psychogeriatric care ward, independent of cognition, is associated with lower pain prevalence, and also with lower levels of pain treatment.     

Risk profiles for nursing home placement of rural elderly: A cluster analysis of psychogeriatric indicators

In an effort to better understand the clinical and functional status of pattients served by our Rural Elder Outreach Program, more effectively identify risk groups, and more efficiently target services, we performed a cluster analysis on 92 older adults served by our program. The first cluster included patients with very poor health, mild cognitive impairment, very high care demands, and migrating toward active risk for institutionalization. The second cluster included patients with poor physical but good mental health, intact cognition, high care demands, and at passive risk. The third cluster comprised patients with high functional, physical, and cognitive impairment, intensive care demands, moderate mental health problems, poor insight into their situation, and at active risk for institutionalization.     

The elderly coping at home: a study of continuity of nursing care

Thirty-three elderly clients who had been hospitalized and required continued care at home were studied for 3 months, with 836 visits made. Coping at home was studied in relationship to their certainty/uncertainty scores, perceived level of health, and perceived satisfaction with nursing care services. The relationship between coping and certainty/uncertainty was significant at P less than 0.001 and P less than 0.005 (first and second visits); the relationship between coping and perceived level of health was significant at P less than 0.001 and P less than 0.05 (first and second visits); and the relationship between coping and perception of care was not significant. This study presents significant data to contribute to nursing knowledge in the care of elderly people at home.     

Preventing the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards: a cluster-randomized trial

Background

Although there is an urgent need for restraint-free care, the number of randomized clinical trials on preventing or reducing physical restraints has been limited.

Objectives

To investigate the effectiveness of an educational intervention to prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards.

Design

Cluster-randomized trial.

Setting

Fourteen Dutch psycho-geriatric nursing home wards.

Participants

138 residents admitted to 14 psycho-geriatric nursing home wards after baseline measurement of the trial were selected, out of which 33 residents died or informed consent had not been obtained. A total of 105 residents were included in the analyses.

Methods

The nursing home wards were randomly assigned to either educational intervention or control status. The educational intervention consisted of an educational programme for nurses combined with a nurse specialist's consultation. The data were collected at 1, 4 and 8 months post-intervention. The use of physical restraints was measured by blinded, trained observers on four separate occasions over a 24-h period. The Minimum Data Set was used to determine residents’ characteristics, such as their cognitive status.

Results

During the study period, no statistically significant differences between the experimental group and the control group regarding restraint status, restraint intensity, multiple restraints and types of restraints were found. One month post-intervention, 38% of the residents newly admitted to the experimental wards were restrained. Bilateral bedrails were the most frequently used restraints at Post-test 1 (24%), Post-test 2 (23%) and Post-test 3 (28%), followed by the use of infrared systems at Post-tests 2 and 3.

Conclusion

An educational programme combined with the consultation of a nurse specialist does not prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards. Although other studies have shown promising results with the effectiveness of these types of intervention on restraint reduction, the development of additional interventions to prevent restraint usage is recommended.     

不同病房老年病人抑郁症状的比较与分析

应用ＣＥＳ－Ｄ量表对１３７例老年内科住院病人的抑郁症状进行问卷调查。结果显示,不同病房老年病人发生抑郁症状的程度不同;普遍病房较高于病房的老年病人抑郁症状发生率高,程度重（Ｐ〈０．０５）,且以肾脏内科及神经内科的老年人尤为明显（Ｐ〈０．０１）。