Quality of care in Norwegian nursing homes – deficiencies and their correlates

Background: Quality of care (QoC) in nursing homes has many aspects and various proxies have been used to evaluate it. In only a few studies several proxies for quality have been combined into a common variable. Objective: To explore which variables are associated with low QoC in few and several areas respectively. Methods: A structured interview of the patients’ primary carer of 1926 patients in 251 wards was carried out. Questions about different kinds of quality deficiencies during the last 7 days were recorded. Eight main types of quality deficiencies were used to construct a linear outcome variable called number of quality deficiencies (NQD) with values from zero to eight. Patient characteristics such as sex, age, function in activities of daily living (ADL), behaviour and mental capacity were recorded. Type of ward, staffing, size of ward, type of institution and formal education of the staff, were also recorded. Results: More than half of the patients in Norwegian nursing homes experienced two or more quality deficiencies in the care during 1 week. The variables that were strongest associated with NQD, were present of aggressive behaviour, low level of functioning in ADL and moderate‐to‐severe dementia. Staffing level and type of ward had also a significant influence on the model.     

The quality of care in Norwegian nursing homes

BACKGROUND: Promoting the quality of life is an importing aim of the long-term care for the elderly, and the quality of life is related to quality of care (QoC). This way the QoC in nursing homes, and its correlates, is an interesting subject. AIM: To describe to what degree Norwegian nursing homes provide services in line with the core areas of the 'regulation of care' and whether patient or ward characteristics are associated with the QoC. METHODS AND MATERIAL: Cross-sectional study where data were collected in structured interview of the nursing staff in 251 wards regarding 1926 patients. RESULTS: Most of the patients receive good basic care in Norwegian nursing homes, but taking part in leisure activities and having the opportunity to go out for a walk are more often neglected. Acceptable QoC had a strongly negative association with patient characteristics such as low function in mental capacity, low function in activities of daily living and aggressive behaviour. In most of the measured areas of QoC, ward characteristics, such as type of ward, size of ward and staffing ratio, do have an influence on QoC.     

Inadequate care in Norwegian nursing homes – as reported by nursing staff

Studies have shown that inadequate care, also referred to as abuse, violence, neglect and maltreatment occur in nursing homes in many countries. The aim of this study was to describe the frequency and types of inadequate care committed by staff in nursing homes. Another aim was to investigate if nursing staff reported differently depending on age, education level and years of experience working at nursing homes. A questionnaire survey was conducted among nursing staff (n = 616) in 16 nursing homes in the central part of Norway. Twenty items concerned staff behaviour in forms of acts of inadequate care. The respondents were asked to report how often they had observed colleagues commit acts and how often they themselves had committed such acts. The response rate was 79%. All in all, 91% of the nursing staff reported that they had observed at least one act of inadequate care and 87% reported that they had committed at least one act of inadequate care. Acts of negligent and emotional character were most frequently reported, both as observed and committed. Depending on the higher educational level that the nursing staff had more acts of all types were observed and committed. The oldest staff and those with longest experience at the present nursing home reported more observed and committed acts of physical character than did the others. The extent of inadequate care confirms that this is a common part of activities in nursing homes. Because emotional and negligent acts can be just as harmful as physical acts, more knowledge is needed about the reasons in order to take preventive actions.     

Examining practical nursing experiences to discover ways in which to retain and invigorate the remaining functions of the elderly with a demented and complex disability in nursing homes

Aim

The bedridden elderly with moderate‐to‐severe dementia account for a large proportion of the residents in nursing homes and form a specialized group requiring customized care in order to encourage their remaining functions, which determine the quality of their residual life. The purpose of this study was to search for ways to invigorate and foster the remaining functions of this complex‐disability group, based on practical nursing strategies in nursing homes.

Methods

The qualitative thematic analysis was done by conducting in‐depth interviews with 29 nurses working at 11 different nursing homes in South Korea.

Results

This study proposed four main themes and 19 sub themes as keys for providing specialized nursing care to the elderly with physical and cognitive disabilities. The main themes encourage the residents' remaining functions: (i) accurate identification of an elderly resident's physical, cognitive, and behavioral baseline is necessary in order to determine their functional levels; (ii) nurses provide meticulous management to support the remaining functions in order to prevent further deterioration; (iii) optimized know‐how, based on accumulated experience and knowledge, is reflected in nursing strategies that maximize the effects of nursing interventions; and (iv) steady compliance with nursing guidelines and standards in nursing homes creates the best therapeutic environment and brings unexpected positive changes in the elderly's status.

Conclusion

A practical nursing strategy to target the group with a demented and complex disability in nursing homes was developed through thematic analysis of the empirical knowledge of nurses. The findings provide new insights for developing specialized nursing interventions and practical nursing models in long‐term care facilities.     

'Patient participation' in everyday activities in special care units for persons with dementia in Norwegian nursing homes

helgesen a.k., larsson m. & athlin e. (2010) ‘Patient participation’ in everyday activities in special care units for persons with dementia in Norwegian nursing homes. International Journal of Older People Nursing 5 , 169–178 Aim. The aim of this study was to explore ‘patient participation’ in everyday activities for persons with dementia living in special care units in nursing homes. Background. Studies about how ‘patient participation’ appears in the context of special care units for persons with dementia are lacking. Design. The study has an explorative design. Method. Grounded theory was chosen. Data collection was carried out by means of open observations and additional conversations with residents and personnel. Simultaneously, data analysis was performed with open, axial and selective coding. Findings. The findings showed that ‘patient participation’ concerned ‘A matter of presence’ as the core category. The other categories described as ‘presence of personnel’ and ‘presence of residents’, were strongly connected to the core category as well as to each other. Presence of personnel comprised three levels; being there in body, which required physical presence; being there in mind, which required presence with all senses based on knowledge and competence; and being there in morality which was understood as being fully present, as it was based on humanistic values and included the two other levels. Presence of residents comprised ‘ability and wish’ and ‘adaptation’. The presence of the personnel had a huge impact on the ability and will to participate of the residents. Organizational conditions concerning leadership, amount of personnel and routines as well as housing conditions concerning architecture and shared accommodation, could stimulate or hinder ‘patient participation’. Conclusions and implications. The study highlighted the great impact of the personnel’s presence in body, mind and morality on the participation capacity of the residents. The great importance of the nurse leaders was stressed, as they were responsible for organizational issues and served as role models. Group supervision of the personnel and their leaders would be an implication to propose, as these kinds of reflection groups offer opportunities to reflect on values, actions and routines.     

Prevalence and characteristics of nursing homes residents requiring light-care

Rising nursing home (NH) costs and the poor quality of NH care make it important to recognize elders for whom NH care may be inappropriate. As a first step in developing a method to identify these elders, we examined the characteristics of NH residents requiring light-care and changes in their care level from NH admission to 12-months. Using data from the Missouri Minimal Data Set electronic database, we developed three care-level categories based on Resource Use Groups, Version III (RUG-III) and defined light-care NH residents as those requiring minimal assistance with late-loss ADLs (bed mobility, transfer, toilet use, or eating) and having no complex clinical problems. Approximately 16% of Missouri NH residents met the criteria for light-care. They had few functional problems with mobility, personal care, communication, or incontinence; approximately 33% had difficulty maintaining balance without assistance; and 50% of those admitted as light-care were still light-care at 12-months. Findings suggest that many NH residents classified as light-care by these criteria could be cared for in community settings offering fewer services than NHs.     

Female caregivers' experiences of exposure to violence in nursing homes

Although earlier studies have examined caregivers' experiences of exposure to violence, few have investigated female caregivers working in nursing homes with a specific focus on experiences throughout the entire scenario of a violent situation. This study illuminates female caregivers' experiences of being exposed to violence in nursing homes. Twenty caregivers working in three nursing homes located in northern Sweden were asked to narrate about a situation in which they had been exposed to violence. Their narratives were analysed by using qualitative content analysis. We found that the caregivers had preconceived ideas about violent behaviour, that they experienced a loss of control over the situation, and that they then strove to regain control. Experiences such as these may influence caregivers' interactions with residents who display violent behaviour. As a result of violent interactions, caregivers may distance themselves from the residents, an attitude that may decrease the quality of care. There is a risk that violence in nursing homes is accepted and normalized as a part of the job and hence persists.     

Pain in patients living in Norwegian nursing homes

The aims of this study were to describe the pain and use of pain medication in nursing home patients and examine which variables that were associated with pain. Inpatients (n = 307) older than 64 years from nursing homes were included. Pain was measured with a 4-point verbal rating scale in the self-reported group (SRG) and Doloplus-2 in the proxy-rated group (PRG). The mean age was 86 years (SD, 7), and more than two-thirds were female. A total of 128 (60%) patients were able to self-report their pain. Approximately 50% of the SRG reported 'pain now', and of these, nearly 50% reported moderate or severe pain intensity. Better cognitive function was associated with higher pain and receiving more potent pain medication in the SRG. The pain prevalence in the PRG was higher than in the SRG (67.5% vs 51%), but no variable was associated with proxy-rated pain. Nearly 30% in the SRG and 40% in the PRG did not receive pain medication in spite of pain. Pain is still a huge problem in the nursing homes, and more research is needed on pain management in nursing home residents.     

The Use of Physical Restraints in Elder Care in Relation to Fall Risk

Physical restraints are a frequently used but disputed method to prevent falls. The aim of the present study was to investigate how the use of restraints in institutional elder care relates to previous falls and to the estimated fall risk of the individual patient. A total of 1 142 patients, mean age 82 years, were included in the study. A questionnaire, the Multi-Dimensional Dementia Assessment Scale (MDDAS), was used to measure motor function, vision, hearing, ADL performance, behavioral symptoms, psychiatric symptoms, cognitive impairment and use of medication. Questions concerning the use of physical restraints and known previous falls were added to the instrument. Based on data from the questionnaire (MDDAS), a score on the Downton Fall Risk Index was calculated for each patient. All in all, 248 (22%) of the patients had been subject to restraints and for 155 of them (14%) such measures had been taken to prevent falls. Only weak connections were found between the restraining of patients to prevent falls and the prevalence of known previous falls during hospital stay (? = 0.05), and estimated fall risk (? = 0.07). The results indicate that the use of physical restraints is poorly connected with the estimated fall risk. Therefore, this study may point to a possible overuse of these measures.     

Prevalence and nursing staff awareness of hearing impairment in older hospital patients

? This paper reports on a research study carried out on three Health Care of the Elderly wards in Nottinghamshire. ? Two cross‐sectional surveys were undertaken to determine nursing competence in relation to the assessment and care of hearing impaired elderly patients. ? Using pure‐tone audiometry, 90.5% of the sample were found to have a hearing impairment of ≥25 dBHL in the better‐hearing ear. ? Results indicated that nurses possessed the relevant theoretical knowledge but that their practical skills were limited.     

Occupational stress amongst care staff working in nursing homes: an empirical investigation

• ? A questionnaire survey of care staff in nursing homes examined staff stress. Staff completed questionnaires covering Type A behaviour, job satisfaction, psychological well-being, relaxation behaviour, coping skills and demographic details.
• ? A specific measure of nursing home stress was developed following a pilot study. From a total sample of 375, 112 (30%) responses were obtained. On the stress questionnaire the major stressors were found to be ‘unsatisfactory wages’, ‘shortage of essential resources’, ‘not enough staff per shift’, ‘feeling undervalued by management’, ‘lifting heavy patients’ and ‘working with colleagues who are happy to let others do the work’.
• ? Factor analysis of stress questionnaire responses identified five major stress groupings. These were, ‘differing expectations about patient care’, ‘management factors’, ‘lack of support from other staff’, ‘feeling inadequately trained to deal with job demands’ and ‘home–work conflicts’.
• ? Examination of stress outcomes showed that many staff were under pressure, with high levels of smoking and alcohol intake.
• ? Given the increasing importance of nursing home care for the elderly the present study is timely. The implications of the findings for further research, and for the training of staff in nursing homes are considered.

     

Psycholeptic use in aged care homes in Tasmania,Australia

Background and objective: Although non‐drug techniques are recommended to manage sleep disturbance, anxiety and challenging behaviours associated with dementia, several studies in Australia and overseas have noted a high use of psycholeptics (anxiolytics/hypnotics and antipsychotics) in aged care homes to treat these conditions. The aim of this study was to examine the current pattern of psycholeptic use in Tasmanian aged care homes and compare this data with other Australasian research. Methods: Cross‐sectional study of residents’ psycholeptic use from 40 aged care homes throughout Tasmania during November 2005–January 2007. Results: Two thousand three hundred and eighty‐nine residents were included in the study. Of the residents, over half were taking at least one psycholeptic medication regularly; over one‐fifth of residents were taking antipsychotics (21%) and 43% were taking anxiolytics/hypnotics. Conclusion: In comparison with other recent Australasian studies, the current level of benzodiazepine use in Tasmanian aged care homes is of major concern, at approximately three times that reported in Sydney and New Zealand. There is also substantial use of multiple psycholeptic agents. Interventions to reduce benzodiazepine use and improve psycholeptic utilization in Tasmania need to be developed urgently. The results demonstrate the value of regular auditing of prescribing to highlight problem areas in prescribing.     

Elderly persons' experiences of striving to receive care on their own terms in nursing homes

Anderberg P, Berglund A-L. International Journal of Nursing Practice 2010; 16 : 64–68
Elderly persons' experiences of striving to receive care on their own terms in nursing homes
Elderly persons' participation in and decisions about their own care need more attention. The aim of this study was to gain a deeper understanding of elderly persons' experiences of care and help, and how their lives change in nursing homes. Fifteen elderly persons living in four nursing homes were interviewed about their experiences of needing care and help in their daily life. The interviews were analysed using van Manen's phenomenological approach. Elderly persons' experiences of care and help were described as: a balance between sorrow and relief, a struggle to maintain control and connectedness, managing to live in the present and yet worrying about the future, and an attempt to hide one's vulnerability in order to be accepted and create an inner calm in an exposed situation. In conclusion, important issues were raised concerning elderly persons' perspectives on care and help in daily life in nursing homes.     

Psychiatric and behavioural symptoms and the use of psychotropic medication in Special Care Units and Regular Units in Norwegian nursing homes

Background: In a number of countries Special Care Units (SCUs) have been established to meet the particular needs of patients with dementia. The criteria for SCUs are poorly defined and often not met. Aim: To assess the frequency distributions of dementia, psychiatric and behavioural symptoms and the use of psychotropic medication in SCUs and Regular Units (RUs) across different regions. Methods and material: By means of a structured interview, comprising the Neuropsychiatric Inventory, the Clinical Dementia Rating Scale and Lawton’s Physical Self‐maintenance scale, a representative sample of 1163 nonselected nursing home patients was assessed. In addition, information was collected from the patients’ records. Results: Overall SCU patients were significantly more likely to be younger, to have higher level of functioning, to have dementia, to exhibit clinically significant psychiatric and behavioural symptoms and to receive psychotropic medication. There were significant differences across regions in terms of psychiatric and behavioural symptoms and the use of psychotropic medication. The ratio of accommodation in SCUs to that in RUs varied across the regions. Conclusion: Patients in SCUs and patients in RUs are distinct nursing home populations. Regional differences, which might be due to diverse ratios of SCUs, are evident.     

Prevalence of heart failure in nursing homes: a systematic literature review

Scand J Caring Sci; 2010; 24; 202–208
Prevalence of heart failure in nursing homes: a systematic literature review
Introduction:  Heart failure is an important problem in western countries. In nursing home residents heart failure is expected to be highly prevalent. However, accurate diagnosis of heart failure in these patients is often hampered due to atypical findings and concomitant co-morbidity. In order to deliver adequate nursing care and medical treatment, it is important to get insight into the prevalence of heart failure in this target group of patients.
Objectives:  To assess the prevalence of heart failure as well as the co-morbidity interfering with heart failure in nursing home residents.
Methods and results:  A systematic literature review was conducted in Medline, Embase, Cinahl and the Cochrane Library. Ten studies were ultimately included. Findings indicate that the mean prevalence of heart failure is 20% (range 15–45%) and that there is a significant level of co-morbidity (dementia, diabetes mellitus and chronic obstructive pulmonary disease) in nursing home residents with heart failure.
Conclusion:  The reported prevalence of heart failure in nursing home residents is higher than in the general population and is associated with considerably co-morbidity. However there are also indications that the prevalence of heart failure in nursing home residents is underestimated, negatively affecting quality of life and quality of care. Therefore, prospective prevalence studies and studies aiming to improve the care for nursing home residents with heart failure are warranted.