December 17, 2018

Pain and functional limitations can severely impede older adults’ quality of life. In Chinese residential care facilities, limited research suggests that residents potentially have significant unmet care needs with pain and related functional limitations. Therefore, we aimed to explore residents’ challenges and self-management strategies in these two areas. This knowledge is essential to developing care interventions to improve quality of care and quality of life in Chinese residential care facilities. Research Design and Methods: We conducted semi-structured open-ended interviews with residents (n = 21) in two facilities in eastern and central China and assessed their pain and functional status using self-report measures from Minimum Data Set 3.0. We applied descriptive statistics to the self-reported data and analyzed the interview data using thematic analysis by drawing on the Adaptive Leadership Framework. This framework proposes that individuals living with chronic conditions need to engage in work to address their complex health concerns and that they need support from the environment to facilitate problem-solving. Results: Residents described significant unmet care needs with pain and functional limitations. To address these care needs, they adopted a substantial number of self-management strategies. While doing so, they faced significant barriers, including service gaps and inadequate direct care. Discussion and Implications: The findings suggest further research to explore long-term care policy change that is needed to provide comprehensive health and medical services and adequate direct care in these facilities. The importance of establishing various types of long-term care facilities is also highlighted.

Participatory research approaches improve the use of evidence in policy, programmes and practice. Few studies have addressed ways to scale up participatory research for wider system improvement or the intensity of effort required. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to analyse implementation of an interactive dissemination process engaging stakeholders with continuous quality improvement (CQI) data from Australian Indigenous primary healthcare centres. This paper reports lessons learnt about scaling knowledge translation research, facilitating engagement at a system level and applying the i-PARIHS framework to a system-level intervention. METHODS: Drawing on a developmental evaluation of our dissemination process, we conducted a post-hoc analysis of data from project records and interviews with 30 stakeholders working in Indigenous health in different roles, organisation types and settings in one Australian jurisdiction and with national participants. Content-analysed data were mapped onto the i-PARIHS framework constructs to examine factors contributing to the success (or otherwise) of the process. RESULTS: The dissemination process achieved wide reach, with stakeholders using aggregated CQI data to identify system-wide priority evidence-practice gaps, barriers and strategies for improvement across the scope of care. Innovation characteristics influencing success were credible data, online dissemination and recruitment through established networks, research goals aligned with stakeholders’ interest in knowledge-sharing and motivation to improve care, and iterative phases of reporting and feedback. The policy environment and infrastructure for CQI, as well as manager support, influenced participation. Stakeholders who actively facilitated organisational- and local-level engagement were important for connecting others with the data and with the externally located research team. Developmental evaluation was facilitative in that it supported real-time adaptation and tailoring to stakeholders and context. CONCLUSIONS: A participatory research process was successfully implemented at scale without intense facilitation efforts. These findings broaden the notion of facilitation and support the utility of the i-PARIHS framework for planning participatory knowledge translation research at a system level. Researchers planning similar interventions should work through established networks and identify organisational- or local-level facilitators within the research design. Further research exploring facilitation in system-level interventions and the use of interactive dissemination processes in other settings is needed.

Within the “wicked” concept of ageing, this paper aims to primarily model an integrated approach to identifying and evaluating opportunities that deliver innovative outcomes in Ageing Well Practice, Health and Economic Policy and Research Actions using a collaborative and entrepreneurial mindset. The strategic focus is on a ?Boomer? (user)-driven and facilitated Network ? that brings together health professionals, research specialists, technologists, ageing well providers, ?encore? career specialists, life-style providers, community groups, wealth creation specialists and industry innovators to streamline the progression of identified concepts to valued users and markets and enhance the economy. Design/methodology/approach Using the unit of analysis for innovation, i.e. the ?added-value? as perceived by the user and not simply a product or a technology, the identified ?opportunity-outcome? will embed a new service concept or intervention, which embraces and promotes ageing well, independent living or resident-centred care in the community and delivers direct and indirect economic benefits. Findings The authors model a point of differentiation in facilitating existing ageing well policies in the community, through a focus on an integrated and multi-dimensional collaborative framework that can deliver user value and contributes to community and economic benefits. Research limitations/implications Generalising results without a commercial business case from this single strategic viewpoint requires caution. The positive outcomes from this innovation collaborative concept can be used to guide further policy development and business investment in ageing well needs. Practical implications Such an integrated innovation collaborative structure provides the capacity to identify ageing well opportunities, to contract enterprises, both SMEs? and larger companies, for development of the opportunities into user-valued outcomes, to network venture resources and deliver these outcomes to a sustainable market of ageing well citizens. Social implications The Ageing Well Innovation collaborative framework identifies practical ways to integrate new concepts of ageing participation to be realised by the increasing number of ?Boomers?. It provides a self-managing process for linking individuals, public and private parties to maximise information and ideas flow, and engagement of the skilled resources in the Boomer group. Originality/value The innovation collaborative structure proposed is not simply novel but is a targeted focus on entrepreneurship and innovation applied strategically to the needs of ageing boomers and community needs. The added-value is in the demonstrated enhancement to effective innovation outcomes in community ageing and the economy.; Purpose Within the ?wicked? concept of ageing, this paper aims to primarily model an integrated approach to identifying and evaluating opportunities that deliver innovative outcomes in Ageing Well Practice, Health and Economic Policy and Research Actions using a collaborative and entrepreneurial mindset. The strategic focus is on a ?Boomer? (user)-driven and facilitated Network ? that brings together health professionals, research specialists, technologists, ageing well providers, ?encore? career specialists, life-style providers, community groups, wealth creation specialists and industry innovators to streamline the progression of identified concepts to valued users and markets and enhance the economy. Design/methodology/approach Using the unit of analysis for innovation, i.e. the ?added-value? as perceived by the user and not simply a product or a technology, the identified ?opportunity-outcome? will embed a new service concept or intervention, which embraces and promotes ageing well, independent living or resident-centred care in the community and delivers direct and indirect economic benefits. Findings The authors model a point of differentiation in facilitating existing ageing well policies in the community, through a focus on an integrated and multi-dimensional collaborative framework that can deliver user value and contributes to community and economic benefits. Research limitations/implications Generalising results without a commercial business case from this single strategic viewpoint requires caution. The positive outcomes from this innovation collaborative concept can be used to guide further policy development and business investment in ageing well needs. Practical implications Such an integrated innovation collaborative structure provides the capacity to identify ageing well opportunities, to contract enterprises, both SMEs? and larger companies, for development of the opportunities into user-valued outcomes, to network venture resources and deliver these outcomes to a sustainable market of ageing well citizens. Social implications The Ageing Well Innovation collaborative framework identifies practical ways to integrate new concepts of ageing participation to be realised by the increasing number of ?Boomers?. It provides a self-managing process for linking individuals, public and private parties to maximise information and ideas flow, and engagement of the skilled resources in the Boomer group. Originality/value The innovation collaborative structure proposed is not simply novel but is a targeted focus on entrepreneurship and innovation applied strategically to the needs of ageing boomers and community needs. The added-value is in the demonstrated enhancement to effective innovation outcomes in community ageing and the economy.

This special issue will help to disseminate new research in the self-care field to inform the work of nurses and other health professionals. We invite submissions that report research using all research designs. We welcome reviews and studies that have the potential to change nursing care practice or policy, irrespective of methods. We particularly encourage submission of reports of rigorous and generalizable randomised controlled trials and systematic review of trials that advance the evidence base for promoting self-care in long term conditions.

The 2019 KT Canada Annual Scientific Meeting is being held on May 30th and 31st in Winnipeg, Manitoba at the Delta Hotel. The theme is ‘Advancing the science of integrated knowledge translation’

The purpose of the awards is to recognize the work of graduate students regarding knowledge translation in public health in Canada. Defined by the Canadian Institutes of Health Research, knowledge translation is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system.

The CIHR Institute of Aging (IA) has partnered with The Quebec Network for Research on Aging to host an innovative five-day training program. The Summer Program in Aging (SPA) 2019 will provide graduate students and post-doctoral fellows interested in the area of Geroscience, an advanced training program that crosses disciplines, institutions and geographical boundaries. The Geroscience approach seeks to understand the molecular and cellular mechanisms responsible for aging that are considered as major risk factors and drivers of the development of common chronic conditions and diseases in the trajectory of life. While aging itself is not a disease, the aging process represents a major risk factor for the development of a number of chronic diseases and conditions, including cardiovascular disease, diabetes, many cancers, arthritis, and frailty, among others. The knowledge that will be acquired using the Geroscience approach will inspire novel and innovative public health interventions for the prevention of chronic diseases.

The importance of knowledge as a strategic asset for organizations has been recognized by both researchers and practitioners. To gain a competitive advantage, firms are required to effectively manage their knowledge resources. The most central activity in managing knowledge is to ensure its transfer within and between organizations. Knowledge transfer (KT) has thus been recognized as a key component of the knowledge management processes. The purpose of this research is to provide a holistic view of the KT barriers and enablers within an organization, from a multilevel and process-based perspectives. We first review the extant literature to identify the key enablers and barriers to KT. Second, we develop a multilevel conceptualization of enablers and barriers that can influence KT at different levels ? individual, team/exchange and organization. The proposed model improves current understanding of KT by offering a holistic and integrated view of enablers and barriers.

Dementia is a widely recognized public health priority due to the increasing number of people living with the condition and its attendant health, social, and economic costs. Delivering appropriate care is a challenge in many countries in Europe contributing to unmet needs of people living with dementia. Acute hospital settings are often the default route in pursuit for dementia care due to the lack of or limited knowledge of local service provisions. The care environment and the skillsets in acute hospitals do not fully embrace the personhood necessary in dementia care. Predictions of an exponential increase in people living with dementia in the coming 30 years require evidence-based strategies for advancing dementia care and maximizing independent living. However, the evidence required to inform priorities for enabling improvements in dementia care is rarely presented in a way that stimulates and sustains political interests. This scoping review of the literature drew on principles of meta-ethnography to clarify the gaps and priorities in dementia care in Europe. The review constituted eight papers (n = 8) and a stakeholder consultation involving three organizations implementing dementia care programs in Europe comprising Emmaus Elderly Care in Belgium, Residential Care Holy Heart in Belgium, and ZorgSaam in the Netherlands. Overarching concepts of gaps identified include fragmented non-person-centered care pathways, the culture of dementia care, limited knowledge and skills, poor communication and information sharing, and ineffective healthcare policies. Key areas distinguished from the literature for narrowing the gaps to improve care experiences and the support for people living with dementia care encompass person-centered care, integrated care pathways, and healthcare workforce development. Action for advancing care and maximizing independent living needs to go beyond mere inclusions on political agendas to incorporate a shift in health and social care policies to address the needs of people living with dementia.

While improved mealtime practices can reduce agitation, improve quality of life, and increase food intake for people in aged care, the degree of implementation of these strategies is unknown. This study describes food service practices in residential aged care facilities, focusing on units caring for people with dementia. An online survey was distributed to residential aged care facilities for completion by the food service manager (n = 2057). Of the 204 responses to the survey, 63 (31%) contained a dementia-specific unit. Most facilities used adaptive equipment (90.2%) and commercial oral nutritional supplements (87.3%). A higher proportion of facilities with a dementia-specific service used high-contrast plates (39.7%) than those without (18.4%). The majority of facilities had residents make their choice for the meal more than 24 h prior to the meal (30.9%). Use of high contrast plates (n = 51, 25%) and molds to reform texture-modified meals (n = 41, 20.1%) were used by one-quarter or less of surveyed facilities. There is a relatively low use of environmental and social strategies to promote food intake and wellbeing in residents, with a focus instead on clinical interventions. Research should focus on strategies to support implementation of interventions to improve the mealtime experience for residents.

The quality of a care relationship between a client and a care professional is seen as fundamental if high-quality care is to be delivered. This study reviews studies about the determinants of the quality of the client-professional relationship in long-term care. METHODS: A systematic review was performed using the electronic databases of Medline, Psycinfo, CINAHL and Embase. The review focused on three client groups receiving long-term care: physically or mentally frail elderly, people with mental health problems and people with physical or intellectual disabilities. Included studies concern clients receiving inpatient or outpatient care and care professionals who provided recurring physical and supporting care for a long period of time. The studies we included contained primary empirical data, were written in English and were published in peer-reviewed journals. Data extraction was carried out by two researchers independently. RESULTS: Thirty-two studies out of 11,339 initial hits met the inclusion criteria. In total, 27 determinants were revealed, six at the client level, twelve at the professional level, six between the client and care professional levels and three at the contextual level. The data analysis showed that most determinants were relevant in more than one client group. CONCLUSIONS: This is the first review that looked at determinants of the quality of the care relationship for three large client groups receiving long-term care. It suggests that the current client group-specific focus in research and quality improvement initiatives for care relationships might not be needed. Care organisations can use the findings of this review as guidance on determinants to look for when mapping the quality of a care relationship in order to get a picture of specific points of attention for quality improvement.

We used latent transition analysis to explore common long-term care (LTC) service trajectories and their predictors for older adults with dementia. METHOD: Using linked administrative data collected over a 4-year interval (2008-2011), the study sample included 3,541 older persons with dementia who were clients of publicly funded LTC in British Columbia, Canada. RESULTS: Our results revealed relatively equal reliance on home care (HC) and facility-based residential care (RC) as starting points. HC service users were further differentiated into “intermittent HC” and “continuous HC” groups. Mortality was highest for the RC group. Age, changes in cognitive performance, and activities of daily living were important predictors of transitions into HC or RC. DISCUSSION: Reliance on HC and RC by persons with dementia raises critical questions about ensuring that an adequate range of services is available in local communities to support aging in place and to ensure appropriate timing for entry into institutions.

Culture change (CC) initiatives, focused on improving life quality for older adults and supporting empowerment for direct care staff, have become increasingly normative in long-term care, and include key components of providing a home environment: individualized, person directed care; consistent staffing; and meaningful relationships.1 Although some nursing homes undertake individual CC components, there are comprehensive models that can be adopted. For example, the small house (SH) model in a skilled nursing home is a small intentional community of older adults who need nursing care and help with daily activities.

To examine whether nursing homes (NHs) provide better quality when unemployment rates rise (countercyclical) and explore mechanisms contributing to the relationship between quality and unemployment rates. Research Design and Methods: The study uses the data on privately owned, freestanding NHs in the continental United States that span a period from 2001 through 2015. The empirical analysis relies on panel fixed-effect regressions with the key independent variable being the county-level unemployment rate. NH quality is measured using deficiencies, outcomes, and care process measures. We also examine nursing staff levels, as well as employee turnover and retention. Results: NHs have better quality when unemployment rates increase. Higher unemployment rates are associated with fewer deficiencies and lower deficiency scores. This countercyclical relationship is also found among other quality measures. In terms of mechanisms, we find higher nursing staff levels, lower employee turnover, and better workforce retention when unemployment rates rise. Improvement in staffing is likely contributing to better quality during recessions. Interestingly, these effects predominately occur in for-profit NHs for deficiencies and staffing levels. Discussions and Implications: NH quality is countercyclical. With near record-low unemployment rates in 2018, regulatory agencies should pay close attention to NH quality when and where the local economy registers strong growth. On the other hand, the finding of the unemployment rate-staffing/turnover relationship also suggests that policies increasing staffing and reducing employee turnover may not only improve NH quality but also have the potential to smooth quality fluctuations between business cycles.

Despite cumulative and integrative evidence of registered nurse (RN) staffing on nursing home residents’ outcomes worldwide, few studies integrate the effects of residents’ case mix, healthcare markets, and nurse staffing on psychotropic-medication use and weight loss in Korea. This article examined the relationship between nurse staffing and residents’ quality-of-care outcomes, controlling for long-term healthcare market characteristics in Korea. Using a multilevel cross-sectional design, a disproportionate stratified random sampling was used. Of 87 nursing homes contacted, 60 agreed to participate. Weighted linear regression was used to test the hypotheses. RN hours per resident day (HPRD) had a statistically significant positive impact on reducing the number of residents with psychotropic medication (ss=-.331, p=.008). Greater RN HPRD positively marginally related to fewer residents with cognitive impairment (ss=-0.201, p=.139). Higher turnover of RN staff related to decreased proportions of residents with weight loss (ss=-.331 p=.008). Policymakers should cautiously consider requiring mandatory nurse staffing in nursing homes in Korea, where it is still acceptable to have certified nurse aids as substitutes for RNs.

There is no common definition for the Dementia Care Network (DCN). They are heterogeneous and there is no general, longitudinal evidence for the effects of DCN. OBJECTIVE: We describe changes in utilization of health services by people served by dementia care networks in Germany and factors associated with those changes over time. METHODS: Primary data was assessed in 560 people with dementia (PwD) and their caregivers supported by DCN in Germany; sociodemographic and clinical variables, utilization of services; DCN were characterized according to governance. The design: observational study with face-to-face interviews at two time points over a period of one year. Data was assessed via semi-structured interviews at the participants’ homes. RESULTS: Utilization of health services in this study is consistently higher than reported for the general population and does not significantly change over time. The strongest predictor of utilization of any service after one year was the use of this service at baseline (OR from 3.23 to 44.16). Higher activities of daily functioning increased the chances to utilize specialist physicians (OR = 1.32; 95% -CI: 1.08-1.63) or occupational therapy (OR = 1.24; 95% -CI: 1.02-1.50) significantly. Being a female decreased chances to utilize specialist physicians (OR = 0.57; 95% -CI: 0.37-0.87) and increased the chances to utilize no services (OR = 2.08; 95% -CI: 1.29-3.33). CONCLUSION: While health care acknowledges the importance and benefits of dementia care networks (i.e., in Germany, the results were considered in new German legislation (SGB XI)), further research is needed to define this kind of service delivery to facilitate comparison as well as promote evidence-based implementation.

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes’ implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.

For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement. Research Design and Methods: We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success. Results: Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff. Discussion and Implications: The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.

This research explored residential aged care (RAC) workplace design features that influence how RAC staff feel valued, productive, safe, like they belong and connected. A secondary aim was to validate emerging themes about RAC design features with stakeholders. METHODS: A multistage qualitative study was conducted in one RAC facility with 100 residents in outer metropolitan Melbourne: (i) photo-elicitation – photographs were used to prompt discussions with RAC staff; (ii) individual interviews with RAC directors; and (iii) validity testing with the advisory committee occurred. RESULTS: Key workplace design features that influenced how RAC staff feel valued, productive, safe, like they belong and connected included the following: (i) home-like environment; (ii) access to outdoor spaces; (iii) quality indoor environment; and (iv) access to safe, open and comfortable workplaces. CONCLUSIONS: Key workplace design features that matter to RAC staff in a ‘shared workspace’ exist. Increasing demands upon RAC requires evidence-based workplace design policy and evaluation approaches that support RAC staff to work in RAC shared workspaces.

To identify the success attributions of high-performing Australian general practices and the enablers and barriers they envisage for practices wishing to emulate them. DESIGN: Qualitative study using semi-structured interviews and content analysis of the data. Responses were recorded, transcribed verbatim and coded according to success characteristics of high-performing clinical microsystems. SETTING: Primary healthcare with the participating general practices representing all Australian states and territories, and representing metropolitan and rural locations. PARTICIPANTS: Twenty-two general practices identified as high performing via a number of success criteria. The 52 participants were 19 general practitioners, 18 practice managers and 15 practice nurses. RESULTS: Participants most frequently attributed success to the interdependence of the team members, patient-focused care and leadership of the practice. They most often signalled practice leadership, team interdependence and staff focus as enablers that other organisations would need to emulate their success. They most frequently identified barriers that might be encountered in the form of potential deficits or limitations in practice leadership, staff focus and mesosystem support. CONCLUSIONS: Practice leaders need to empower their teams to take action through providing inclusive leadership that facilitates team interdependence. Mesosystem support for quality improvement in general practice should focus on enabling this leadership and team building, thereby ensuring improvement efforts are converted into effective healthcare provision.

In the future, elderly care workers need to have competence of various different conditions due to greater amount of multimorbid elderly. Further, knowledge of national level guidelines is important since they are closely linked to improving quality of care and implementing better practices at work places. The impact of national level guidelines on quality of care at care units is, however, not widely examined in the Finnish context. In this study, the aim was to find out if worker’s experience of his/her own competence is associated with quality of care. Secondly, we aimed to see how common is addressing national guidelines and policies at workplaces, and if they are associated with quality of care. Thirdly, we aimed to see whether there are differences between different occupational statuses in competence and addressing national guidelines and policies. METHODS: Total number of respondents was 1997 from 273 different units. Xtreg procedure was used for examining the associations of age, occupational status, unit type, professional competence and addressing the guidelines and policies with quality of care. RESULTS: Higher grade for QoC was associated with age, supervisor position, working in institutionalized care, better competence in supporting the self-determination of a person with memory disorders and falls prevention and addressing the act for elderly care and memory policy. CONCLUSION: This study demonstrated that national policies and guidelines are not widely addressed among Finnish elderly care workers. The study also showed that experienced competence of workers and discussion of policies and guidelines are related to quality of care. Especially competence related to memory disorders was associated with higher QoC. However, the relationship between quality of care and things influencing it seems complex and a major part of the variation in QoC remained unexplained. Although the relationships between guidelines, competences and quality of care are weak, national policies and competences seem to have impact on actual care provided. Therefore, sufficient time to address the guidelines should be provided at workplace and competences developed, which can be seen as a supervisor’s task. With knowledge about the guidelines, workers are able to change their practices at work places.

Frail seniors often receive ineffective care, which does not meet their needs. It is still unclear how healthcare systems should be redesigned to be more sensitive to the needs and values of frail seniors and their caregivers. We thus aimed to describe key stakeholders’ perspectives on the current healthcare and services available to frail seniors. METHODS: In this qualitative descriptive study, we conducted semi-structured interviews with a convenience sample of 42 frail seniors, caregivers, clinicians, or healthcare administrators/decision makers involved in frail senior care from five Canadian provinces. We explored participants’ perspectives on the quality of care and services for frail seniors. We used an inductive/deductive thematic data analysis approach based on the Square-of-Care model, including emerging themes using the constant comparison method. RESULTS: We grouped participants’ perspectives into strengths, weaknesses and opportunities for improvement, and then into nine themes: care processes, continuity of care, social frailty, access to healthcare and services, models of healthcare delivery, cost of care, healthcare staff management and professional development of healthcare providers, material resources and environmental design of healthcare facilities, and coordination of care. Our findings suggest redesigning assessment, communication with frail seniors and their caregivers, targeting care and services to the needs, and integrating care better across settings and in time. CONCLUSIONS: A systematic identification of frail older people is the first step to adapt healthcare systems to this population’s needs. Participation of frail older people and their caregivers to decision making would also allow choosing care plans meeting their care goals. The integration of care and services across settings, over time, and with various providers, is also needed to meet frail senior needs.

This article describes nursing home (NH) leaders’ involvement in quality improvement (QI) decisions, with an emphasis on the concept of alignment in QI decisions across leaders. Research Design and Methods: We used a qualitative approach and semistructured interviews to collect data from a convenience sample of 39 NH leaders, including corporate/executive-level leaders and facility-level leaders. Thematic analysis was used to inductively capture key patterns in data. Results: Variations in alignment emerged as a major theme to describe the interface and interaction among facility- and corporate/executive-level leaders around QI decision making and implementation of QI decisions. For this study, alignment refers to the extent of shared understanding, beliefs, motivations, and implied or explicit agreement among leaders in regards to: (a) goals, values, priorities, and expectations for quality or QI (and/or applicable resources); and (b) expectations for leaders to carry out QI decisions made by other leaders. Discussion and Implications: This study offers new insights into the complexities associated with leadership alignment toward improving NH quality. The findings provide a glimpse into leaders’ involvement in QI based on their position on the facility’s organizational chart and extend our understanding of the centrality of the concept of alignment in promoting QI. These findings may inform future research on facility- and corporate/executive-level leader interactions and how these interactions impact quality outcomes.

The purpose of this study was to use qualitative methods to explore nursing home staff perceptions of antipsychotic medication use and identify both benefits and barriers to reducing inappropriate use from their perspective. Research Design and Methods: Focus groups were conducted with a total of 29 staff in three community nursing homes that served both short and long-stay resident populations. Results: The majority (69%) of the staff participants were licensed nurses. Participants expressed many potential benefits of antipsychotic medication reduction with four primary themes: (a) Improvement in quality of life, (b) Improvement in family satisfaction, (c) Reduction in falls, and (d) Improvement in the facility Quality Indicator score (regulatory compliance). Participants also highlighted important barriers they face when attempting to reduce or withdraw antipsychotic medications including: (a) Family resistance, (b) Potential for worsening or return of symptoms or behaviors, (c) Lack of effectiveness and/or lack of staff resources to consistently implement nonpharmacological management strategies, and (d) Risk aversion of staff and environmental safety concerns. Discussion and Implications: Nursing home staff recognize the value of reducing antipsychotic medications; however, they also experience multiple barriers to reduction in routine clinical practice. Achievement of further reductions in antipsychotic medication use will require significant additional efforts and adequate clinical personnel to address these barriers.

Cognitively impaired individuals are at increased risk for functional and behavioral difficulties at mealtimes, leading to compromised eating performance, low food and fluid intake, and negative functional and nutritional outcomes. Nursing assistants are the most critical front-line care staff and best positioned to manage the personal and environmental factors that influence resident eating performance. Identifying nursing assistants’ perceptions of barriers and facilitators to engaging residents in eating will provide important experientially based foundation for developing and testing evidence-driven interventions to promote mealtime care. METHODS: A qualitative descriptive study was conducted in three sites: two nursing homes and one hospital gero-psychiatric inpatient unit. Six focus groups were conducted with a purposive sample of 23 nursing assistants who regularly provided mealtime care to residents with cognitive impairment. Interview questions addressed barriers and facilitators at resident, caregiver, environmental (facility), and policy levels in optimizing mealtime care. Audio recordings of focus groups were transcribed and analyzed using qualitative descriptive content analysis. Both barriers and facilitators were organized into a hierarchical taxonomy based on similarities and differences framed by the Social Ecological Model. RESULTS: The majority of barriers and facilitators were at the caregiver level. Caregiver-level barriers included lack of preparation and training, competing work demands, time pressure, and frustration. Caregiver-level facilitators included caregiver preparation and motivational, technical, informational, and instrumental assistance. Environmental-level barriers and facilitators related to the physical, social, and cultural environment and facility practices. Only barriers to optimizing mealtime care were identified at resident and policy levels. CONCLUSIONS: Nursing assistants identified multilevel barriers as well as a wide range of caregiver and environmental facilitators to optimizing dementia mealtime care. Findings can inform the development and implementation of multifaceted innovative mealtime assistance and staff training programs to promote resident eating performance while fostering person-centered individualized mealtime care practice.

Although the concept of subjective quality of life in the nursing home setting is seen as a promising approach to discovering opportunities for improvement from the resident’s perspective, it appears problematic in classical surveys that self-reported quality ratings on the basis of satisfaction questions tend to turn out overly positive. The aim of this article is to analyze how people in residential care facilities interpret and process response stimuli received from a questionnaire on subjective quality of life. In this analysis, we aim to gain methodological insights into the way a survey instrument on subjective quality of life can adequately represent individual ratings, as well as expectations regarding different aspects of quality of life. To test the feasibility of the proposed approach, we employed a range of probing techniques from the cognitive interviewing approach. The result is a promising design principle for constructing survey instruments to measure subjective quality of life.

Acknowledging and navigating “mess” are clear priorities in the mixed methods literature. Mess enters the mixed methods process in two interrelated ways. The first is empirically, where quantitative and qualitative findings diverge or contrast rather than cohere; the second is through design, where research contexts demand unplanned adaptation. This article outlines three practices that help mixed methods researchers recognize and navigate both kinds of mess, collectively called the ?craft attitude.? The craft attitude consists of comfort with uncertainty, a nonlinear/recursive approach to research, and understanding research as storytelling. I further argue these components can orient researchers to mess in both structured and flexible ways by fostering three intellectual activities: science, craft/art, and ethical value judgment. This article contributes to the field of mixed methods by offering a practice-oriented concept facilitating the collective acknowledgement and engagement of mess, rather than concealing it in our research.

Despite 32 years of research and 13 reviews published in the field, no intervention can be considered a gold standard for maintaining eating performance among residents with dementia. The study aim was to highlight the interventions derived from tacit knowledge and offered daily in assisting eating by healthcare professionals (HCPs) in nursing homes (NHs). METHOD: A multicentre descriptive qualitative study was performed in 2017. Thirteen NHs admitting residents with moderate/severe functional dependence in eating mainly due to dementia, were approached. A purposeful sample of 54 HCPs involved on a daily basis in assisting residents during mealtime were interviewed in 13 focus groups. Data analysis was conducted via qualitative content analysis. RESULTS: The promotion and maintenance of eating performance for as long as possible is ensured by a set of interventions targeting three levels: (a) environmental, by ‘Ritualising the mealtime experience by creating a controlled stimulated environment’; (b) social, by ‘Structuring effective mealtime social interactions’; and (c) individual, by ‘Individualising eating care’ for each resident. CONCLUSIONS: In NHs, the eating decline is juxtaposed with complex interventions regulated on a daily basis and targeting the environment, the social interactions, and the residents’ needs. Several interventions that emerged as effective, according to the experience of participants, have never been documented before; while others are in contrast to the evidence documented. This suggests the need for further studies in the field; as no conclusions regarding the best interventions have been established to date.

People with advanced dementia often experience suboptimal end of life care (EoLC) with inadequate pain control, increased hospitalisation, and fewer palliative care interventions compared to those with cancer. Existing policy, guidance and recommendations are based largely on expert opinion because of a shortage of high quality, empirical research. Previous studies have tended to consider the views and experience of particular groups. Whilst providing important evidence, they do not take into account the diversity of perspectives of different stakeholders. The Supporting Excellence in End of life care in Dementia (SEED) programme involved multiple stakeholder groups and an integrative analysis to identify key components of good EoLC for people with dementia and to inform a new intervention. METHODS: The views of national experts, service managers, frontline staff, people with dementia and family carers were explored using a range of qualitative methods (semi-structured interviews, focus groups, discussions and observations of routine care). The large dataset comprises 116 interviews, 12 focus groups and 256 h of observation. Each dataset was initially analysed thematically prior to an integrative analysis, which drew out key themes across stakeholder groups. RESULTS: Through the integrative analysis seven key factors required for the delivery of good EoLC for people with dementia were identified: timely planning discussions; recognition of end of life and provision of supportive care; co-ordination of care; effective working relationships with primary care; managing hospitalisation; continuing care after death; and valuing staff and ongoing learning. These factors span the entire illness trajectory from planning at a relatively early stage in the illness to continuing care after death. CONCLUSIONS: This unique study has confirmed the relevance of much of the content of existing end of life frameworks to dementia. It has highlighted seven key areas that are particularly important in dementia care. The data are being used to develop an evidence-based intervention to support professionals to deliver better EoLC in dementia.

Seventy percent of people with advanced dementia live and die in care homes. Multisensory approaches, such as Namaste Care, have been developed to improve the quality of life and dying for people with advanced dementia but little is known about effectiveness or optimum delivery. The aim of this review was to develop an explanatory account of how the Namaste Care intervention might work, on what outcomes, and in what circumstances. METHODS: This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories, and their validation with a purposive sample of stakeholders. Twenty stakeholders – user/patient representatives, dementia care providers, care home staff, researchers -took part in interviews and/or workshops. RESULTS: We included 85 papers. Eight focused on Namaste Care and the remainder on other types of sensory interventions such as music therapy or massage. We identified three context-mechanism-outcome configurations which together provide an explanatory account of what needs to be in place for Namaste Care to work for people living with advanced dementia. This includes: providing structured access to social and physical stimulation, equipping care home staff to cope effectively with complex behaviours and variable responses, and providing a framework for person-centred care. A key overarching theme concerned the importance of activities that enabled the development of moments of connection for people with advanced dementia. CONCLUSIONS: This realist review provides a coherent account of how Namaste Care, and other multisensory interventions might work. It provides practitioners and researchers with a framework to judge the feasibility and likely success of Namaste Care in long term settings. Key for staff and residents is that the intervention triggers feelings of familiarity, reassurance, engagement and connection. STUDY REGISTRATION: This study is registered as PROSPERO CRD42016047512.

Aged care services increasingly respond to the needs of people with dementia. Non-pharmacological approaches are preferable to reduce responsive behaviours, improve/maintain functional capacity and reduce emotional disorders. This rapid review of systematic reviews aimed to consolidate the evidence for non-pharmacological interventions and determine outcome effectiveness. METHODS: Systematic review literature was comprehensively searched for non-pharmacological interventions for dementia in residential care. Quality ratings used adapted GRADE methodology, and ease of implementation assessed. RESULTS: Of 629 abstracts screened, 81 full-text articles were retrieved, 38 articles included. The strongest evidence for reducing responsive behaviours was music, sensory stimulation, simulated presence and validation therapies. Exercise and light therapy improved/maintained activities of daily living, while cognitive stimulation and reminiscence improved cognition. Strongest evidence for reducing emotional disorders was music, psychological interventions and reminiscence. CONCLUSION: Much evidence of varying quality exists, with resource-constrained residential care providers now able to make evidence-based decisions about non-pharmacological interventions.

Long-term care (LTC) homes expressed concern that patients had experienced medication incidents after hospital discharge as a result of poor coordination of care. OBJECTIVE: The London Transfer Project aimed to reduce LTC medication incidents by 50% within 48 hours of discharge from general medicine units at the London Health Sciences Centre. DESIGN: This quality improvement study involved 2 hospitals and 5 LTC homes in London, Ontario, Canada. The baseline prevalence of medication incidents was measured and explored for root causes. Two change ideas were tested on general medicine units to improve transfer communication: (1) expediting medication reconciliation and (2) faxing medication plans before discharge. MEASURES: Evaluation involved time-series measurement and a comparison of baseline and intervention periods. The primary outcome was medication incidents by omission or commission within 48 hours of discharge, which was determined by dual chart reviews in hospital and LTC homes. Process measures included medication reconciliation and fax completion times. Hospital discharge times were included as a balance measure of the new communication process. RESULTS: Four hundred seventy-seven LTC transfers were reviewed between 2016 and 2017; 92 transfers were reviewed for medication incidents in participating homes at baseline (January-April 2016) and implementation (January-April 2017). Medication incidents decreased significantly by 56%, from 44% (22/50) at baseline to 19% (8/42) during implementation (P = .006). Medication reconciliation completion by noon increased from 56% (28/50) to 74% (31/42) but not significantly (P = .076). Faxes sent before discharge increased significantly from 4% (2/50) to 67% (28/42, P = .015). There was no significant change in hospital discharge time. CONCLUSIONS/IMPLICATIONS: Medication incidents can be significantly reduced during care transitions by taking a systems perspective to explore quality gaps and redesign communication processes. This solution will be scaled to other inpatient services with a high proportion of LTC residents.

The number of individuals living with dementia is increasing, negatively affecting families, communities, and health-care systems around the world. A successful response to these challenges requires an accurate understanding of the dementia disease burden. We aimed to present the first detailed analysis of the global prevalence, mortality, and overall burden of dementia as captured by the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, and highlight the most important messages for clinicians and neurologists. METHODS: GBD 2016 obtained data on dementia from vital registration systems, published scientific literature and surveys, and data from health-service encounters on deaths, excess mortality, prevalence, and incidence from 195 countries and territories from 1990 to 2016, through systematic review and additional data-seeking efforts. To correct for differences in cause of death coding across time and locations, we modelled mortality due to dementia using prevalence data and estimates of excess mortality derived from countries that were most likely to code deaths to dementia relative to prevalence. Data were analysed by standardised methods to estimate deaths, prevalence, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs; computed as the sum of YLLs and YLDs), and the fractions of these metrics that were attributable to four risk factors that met GBD criteria for assessment (high body-mass index [BMI], high fasting plasma glucose, smoking, and a diet high in sugar-sweetened beverages). FINDINGS: In 2016, the global number of individuals who lived with dementia was 43.8 million (95% uncertainty interval [UI] 37.8-51.0), increased from 20.2 million (17.4-23.5) in 1990. This increase of 117% (95% UI 114-121) contrasted with a minor increase in age-standardised prevalence of 1.7% (1.0-2.4), from 701 cases (95% UI 602-815) per 100 000 population in 1990 to 712 cases (614-828) per 100 000 population in 2016. More women than men had dementia in 2016 (27.0 million, 95% UI 23.3-31.4, vs 16.8 million, 14.4-19.6), and dementia was the fifth leading cause of death globally, accounting for 2.4 million (95% UI 2.1-2.8) deaths. Overall, 28.8 million (95% UI 24.5-34.0) DALYs were attributed to dementia; 6.4 million (95% UI 3.4-10.5) of these could be attributed to the modifiable GBD risk factors of high BMI, high fasting plasma glucose, smoking, and a high intake of sugar-sweetened beverages. INTERPRETATION: The global number of people living with dementia more than doubled from 1990 to 2016, mainly due to increases in population ageing and growth. Although differences in coding for causes of death and the heterogeneity in case-ascertainment methods constitute major challenges to the estimation of the burden of dementia, future analyses should improve on the methods for the correction of these biases. Until breakthroughs are made in prevention or curative treatment, dementia will constitute an increasing challenge to health-care systems worldwide. FUNDING: Bill & Melinda Gates Foundation.

We aimed to develop a graphical procedure for benchmarking quality of life care results using the Long-Term Care Quality of Life (LTC-QoL) scale. While clinical care quality benchmarking is now well established, similar research for quality of life (QOL) aged care benchmarking has received scant attention. Data from 10 facilities utilizing the LTC-QoL scale were analysed to establish baseline statistics for developing a graphical procedure for QOL benchmarking. Client LTC-QoL records were tested with varimax rotation factor analysis revealing three viable benchmarking themes: B1 (Self-efficacy), B2 (supporting relationships), and B3 (outlook on life) were selected for benchmark development utilizing Analysis of Means to generate graphical outputs using Minitab version 17.3.1. In this way, in the absence of verified industry standards, it is possible to compare organizations providing similar services using the same indicators, against group averages. In conclusion, the benchmarking protocol produced comparative information on three benchmarks for 10 facilities. Similar analysis is feasible for a single facility over time. The results of these analyses provide evidence for on-site discussion of quality of life care quality performance.

Sleep problems are much more prevalent in nursing home residents than in their community-dwelling counterparts. Cognitive behavioural therapy is likely to improve sleep quality in older adults. However, these interventions have a narrow scope to generalise to nursing home practice, and there are minimal data on the effectiveness of the integration of cognitive behavioural therapy and motivational interviewing in nursing home settings. AIM: The purpose of this study was to investigate the impact of a nurse-led sleep programme on the sleep quality and depressive symptomatology in cognitively intact nursing home residents. METHODS: A non-randomised controlled study design was applied to 52 older adults living in three different nursing homes in the same locality. Then, we categorised our study cohort into the following two groups: intervention group in which the older adults received the nurse-led sleep programme and control group in which the older adults received regular nursing home services. One nursing home was assigned to the intervention, and two were assigned to control. The intervention group participated in four weekly 1-hr sessions performed by the first author. RESULTS: Follow-up assessments conducted at 8 and 12 weeks after the intervention ended revealed that participants in the intervention group experienced a significant improvement in some objective sleep parameters, including awakenings, total wake time, wake after sleep onset and sleep efficiency, as well as a significant decrease in depressive symptomatology. CONCLUSION: To summarise, the results of this study showed that the nurse-led sleep programme improved the sleep quality and reduced depressive symptomatology in cognitively intact nursing home residents. In this context, we can assert that interventions for sleep problems should be individualised by addressing sleep experience and sleep management strategies of older adults living in nursing homes and should be integrated with motivational interviewing techniques.

Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment. OBJECTIVES: To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers. SEARCH METHODS: In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-RCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence. MAIN RESULTS: The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both.One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-the-home care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision).In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low. AUTHORS’ CONCLUSIONS: Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.

Psychotropic medications have a high risk of serious adverse events and small effect size for changed behaviours for people with dementia. Non-pharmacological approaches are recommended as first-line treatment for changed behaviours, yet psychotropic medications remain highly prevalent in long-term aged care settings. This narrative review describes the current evidence regarding deprescribing psychotropic medications for people with dementia in long-term care. Deprescribing psychotropic medications can be achieved without harm to the person with dementia, and most people experience no withdrawal symptoms. Interventions to deprescribe psychotropic medications should be multifactorial, including lowering the dose of the medication over time, educational interventions and psychological support. However, implementing this is a significant challenge due to the overreliance on psychotropic medications for behavioural management in long-term aged care. Facilitators to deprescribing psychotropic medications in long-term care include multidisciplinary teams with adequate training, education and managerial support, engaging residents and families and change ‘champions’. Deprescribing practices should be person-centred, and an individualised deprescribing protocol should be in place, followed by careful monitoring of the individual. The person with dementia and their family, general practitioner, pharmacist, and allied health and direct care staff should all be involved throughout the deprescribing process. Direct care staff need adequate support, education and training, so they can effectively help the individual and implement person-centred approaches in the absence of psychotropic medications. Effective communication between residents and staff and amongst staff is consistently shown to be an important factor for deciding whether deprescribing of a medication should occur and the successful implementation of deprescribing psychotropic medications.

The aim of the study was to scope and explore hydration practices in care homes. BACKGROUND: Older residents do not regularly consume adequate fluids to support health. Achieving this is difficult with residents who have coexisting health, sensory and functional problems, as well as challenging hydration habits. DESIGN: This project used a sequential exploratory mixed method design to scope and explore existing hydration practices. METHODS: Data were collected via two stages. First was a survey of hydration practices. Twenty-nine responses were received from 81 care homes (response rate: 35.8%). Second was the exploration of practitioners’ experiences and perceptions of hydration practice via semi-structured interviews (54 staff: 43 interviews). Descriptive statistics summarised the survey findings. Open coding and thematic analysis were applied to the qualitative data and details of the methods are reported in adherence to COREQ criteria. RESULTS: It is important to provide hydration support in addition to regularly offering drinks to residents. Hydration practices include: use of social interaction to encourage drinking; verbal and non-verbal prompts to drink; giving fluids with routine practices and social activities; providing drinks-related activity, use of aids and equipment to support drinking, and creating a drink-friendly environment. Practices are implemented in care homes, however no one care home implements all these hydration strategies at any one time. CONCLUSIONS: Older care home residents need support and encouragement to drink adequate fluids which can be difficult to achieve with residents who have complex needs and challenging drinking habits. In addition to the routine offer of drinks, hydration support should be used to facilitate residents to drink sufficient amounts of fluid. RELEVANCE TO CLINICAL PRACTICE: Staff working in care homes have an important role in assessing the hydration needs of residents and using multiple hydration practices to support residents to achieve their hydration requirements.

The perspectives of nursing professionals might differ from those of older adults when it comes to care for older people. This cross-sectional study compares the views of older adults with the views of nursing professionals on the quality of care after a nationwide improvement program for care for older people was implemented (2008-2016) in the Netherlands. METHODS: Questionnaire data were used from 385 nursing professionals (response rate 51%) that were part of the Nursing Staff Panel, a nationwide representative group of nursing staff, and working in home care, hospitals or general practices. Additionally, questionnaire data were used from 73 older adults (response rate 81%) who were involved in regional networks to discuss project proposals and to represent the voice of older adults in the nationwide improvement program. Participants were asked to evaluate care for older people with regard to collaboration between healthcare organizations and with regard to the tailored service, accessibility, and quality of care within their organizations and in the region in which they lived. RESULTS: A majority of older adults (54%) and nursing professionals (61%) felt that collaboration with others had improved over the last few years. Approximately one third of the older adults stated that care for older people was tailored to fit individual needs and was accessible most of the time or always, as opposed to approximately two thirds of the professionals. Moreover, 17% older adults thought that the quality of care was good, compared with 54% of the nursing professionals. 77% of the nursing professionals and 94% of the older adults thought that improvements were still needed in care for older people, for example better integration of the different aspects of care and a more patient-centered approach. CONCLUSION: Older adults who were involved in networks of the improvement program generally gave a less positive evaluation of aspects of care for older people and its development than nursing professionals. Considering differences in the perspectives of key stakeholders is relevant for the development and evaluation of nationwide improvement programs, for a correct interpretation of findings, and for making appropriate recommendations.

The Nursing Home Physical Performance Test (NHPPT) was developed to measure function among nursing home residents using sit-to-stand, scooping applesauce, face washing, dialing phone, putting on sweater, and ambulating tasks. Using item response theory, we explore its measurement characteristics at item level and opportunities for improvements. Research Design and Methods: We used data from long-term care women. We fitted a graded response model, estimated parameters, and constructed probability and information curves. We identified items to be targeted toward lower and higher functioning persons to increase the range of abilities to which the instrument is applicable. We revised the scoring by making sit-to-stand and sweater items harder and dialing phone easier. We examined changes to concurrent validity with activities of daily living (ADL), frailty, and cognitive function. Results: Participants were 86 years old, had more than three comorbidities, and a NHPPT of 19.4. All items had high discrimination and were targeted toward the lower middle range of performance continuum. After revision, sit-to-stand and sweater items demonstrated greater discrimination among the higher functioning and/or greater spread of thresholds for response categories. The overall test showed discrimination over a wider range of individuals. Concurrent validity correlation improved from 0.60 to 0.68 for instrumental ADL and explained variability (R2) from 22% to 36% for frailty. Discussion and Implications: NHPPT has good measurement characteristics at the item level. NHPPT can be improved, implemented in computerized adaptive testing, and combined with self-report for greater utility, but a definitive study is needed.

The Dementia Project was started by Guinness as part of its strategy and accompanying research report, published in 2015, to become a dementia-friendly organisation in order to better meet the needs of its customers living with dementia. This was a pioneering document for the sector, predating the Alzheimer’s Society charter, and helped put Guinness on the Dementia-friendly map. Knowledge and understanding of dementia and its impact is constantly evolving. Becoming more dementiafriendly means making changes across all aspects of policy and practice, and taking account of emerging learning within and outside the organisation. In this sense, the process of becoming dementia-friendly never stops. The findings in this report are therefore a snapshot of the situation at the end of the two year project.