May 5, 2020

COVID-19 is only revealing fault lines that already existed in long-term care. Now we must do everything we can to make sure we don’t put either our vulnerable seniors or our care aides at unnecessary risk.

Tragic death toll among seniors in nursing homes was half a century in the making, says elder care expert.

Multi-sectoral, interdisciplinary health research is increasingly recognizing integrated knowledge translation (iKT) as essential. It is characterized by diverse research partnerships, and iterative knowledge engagement, translation processes and democratized knowledge production. This paper reviews the methodological complexity and decision-making of a large iKT project called Seniors – Adding Life to Years (SALTY), designed to generate evidence to improve late life in long-term care (LTC) settings across Canada. We discuss our approach to iKT by reviewing iterative processes of team development and knowledge engagement within the LTC sector. We conclude with a brief discussion of the important opportunities, challenges, and implications these processes have for LTC research, and the sector more broadly.

This policy brief sets forth the American Geriatrics Society’s (AGS’s) recommendations to guide federal, state, and local governments when making decisions about care for older adults in assisted living facilities (ALFs) during the COVID-19 pandemic. It focuses on the need for personal protective equipment (PPE), access to testing, public health support for infection control, and workforce training. The AGS continues to review guidance set forth in peer-reviewed articles, as well as ongoing and updated guidance from the U.S. Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and other key agencies. This brief is based on the situation and any federal guidance or actions as of April 15, 2020. Joining a separate AGS policy brief on COVID-19 in nursing homes (DOI: 10.1111/jgs.16477), this brief is focused on ALFs, given that varied structure and staffing can impact their response to COVID-19. This article is protected by copyright. All rights reserved.

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

i4 is a virtual conference happening on October 6 and 7, 2020. I4 (formerly known as Quality Summit) is a flagship conference led by Alberta Health Services and numerous partners that aims to explore the future of health and care through ideation, incubation, invigoration and implementation. In its 5th year, this event is striving to be Canada’s most forward-thinking health and care conference that has experiential sessions and inspirational thought leaders from across the globe.

While at first glance cruise ships, prisons, and nursing homes are very different institutions, in fact they share many commonalities. Each is a densely-population congregate setting with cramped housing units that do not lend themselves well to sheltering in place. Each prepares meals in a central kitchen and serves them to large gatherings. Each sponsors activities that bring large groups together on a regular basis. Each has relatively large numbers of staff who have extensive contact with the residents and work under demanding conditions for modest pay. Each has medical resources that compete with other, non-medical priorities. Each has health care regulations that, while extensive, could not possibly have fully prepared them for COVID-19; instead, in the face of an impending outbreak, rapid, nimble responses were needed, and these have proven hard to initiate and coordinate in all three settings. Thus, each setting can be considered high risk for amplifying infectious diseases such as COVID-19, because the conditions that prevent disease dissemination are nearly impossible to achieve.

The decision of the Centers for Medicare & Medicaid Services to suspend routine surveys in favor of focused inspections targeted at infection control is the first signal that long-term care will be at the epicenter of federal oversight.

While many infectious disorders are unknown to most neurologists, COVID-19 is very different. It has impacted neurologists and other health care workers, not only in our professional lives but also through the fear and panic within our own families, colleagues, patients and their families, and even in the wider public. COVID-19 affects all sorts of individuals, but the elderly with underlying chronic conditions are particularly at risk of severe disease, or even death. Parkinson’s disease (PD) shares a common profile as an age-dependent degenerative disorder, frequently associated with comorbidities, particularly cardiovascular diseases, so PD patients will almost certainly fall into the high-risk group. Therefore, the aim of this review is to explore the risk of COVID-19 in PD based on the susceptibility to severe disease, its impact on PD disease severity, potential long-term sequelae, and difficulties of PD management during this outbreak, where neurologists face various challenges on how we can maintain effective care for PD patients without exposing them, or ourselves, to the risk of infection. It is less than six months since the identification of the original COVID-19 case on New Year’s Eve 2019, so it is still too early to fully understand the natural history of COVID-19 and the evidence on COVID-19-related PD is scant. Though the possibilities presented are speculative, they are theory-based, and supported by prior evidence from other neurotrophic viruses closely related to SARS-CoV-2. Neurologists should be on high alert and vigilant for potential acute and chronic complications when encountering PD patients who are suspected of having COVID-19.

Most older adults with physical or cognitive disabilities require physically close caregiving to perform activities of daily living (ADLs). This presents a unique challenge in this time of physical and social distancing necessitated by the COVID‐19 pandemic. Where is the balance between physically close caregiving and physical distancing at home and in care settings? We survey scenarios by setting and provide preliminary thoughts on caregiving at a physical distance, drawing from public health and telehealth.

Motivated by the potential devastating effect of a COVID-19 outbreak in retirement homes and long-term facilities for dependent elderly, we present the impact of worst-case scenarios in French institutions using a specific age structure and case-age fatality ratios. The death toll could equal the yearly death toll caused by seasonal influenza in those older than 65 years or could largely exceed that, depending on the final attack rate and proportion of infected institutions.

Older age and the presence of comorbidities are associated with increased risk of mortality in the current pandemic. The high prevalence of functional and cognitive impairment and behavioural symptoms add to the risk posed to nursing home residents, The synergy of these factors is reflected in the first major study of COVID-19 in a nursing home. Nearly two-thirds of residents were infected over a three week period, with a death rate of 33%: fifty staff members and 16 visitors were also infected . In Spain, it has been reported that a significant proportion of COVID-19 associated deaths have been nursing home residents. There is also a concern that many jurisdictions are not including nursing home deaths in the COVID-19 death toll.

At this most challenging time, there is no place for blaming. We need to ask what did we learn and how can we do things better. Several lessons are apparent. First, the emptying of nursing homes displacing large numbers of long‐term care residents is the worst possible option for creating post‐acute care capacity to decompress hospitals. Second, nursing homes have become an epicenter for the shifting pandemic.

This letter briefly reviews the current state of remote cognitive assessment, with the goal of outlining appropriate clinical measures for older adults.

Geriatrics in Canada differs in significant ways from American practice. This letter summarizes the response of Canadian internist-geriatricians to the COVID-19 pandemic. In normal times they function as consultants, typically working within academic health care centres. They do not provide primary medical care or play a major role in long-term care (LTC) facilities.

This review is one of a series of rapid reviews that Cochrane contributors have prepared to inform the 2020 COVID-19 pandemic. When new respiratory infectious diseases become widespread, such as during the COVID-19 pandemic, healthcare workers’ adherence to infection prevention and control (IPC) guidelines becomes even more important. Strategies in these guidelines include the use of personal protective equipment (PPE) such as masks, face shields, gloves and gowns; the separation of patients with respiratory infections from others; and stricter cleaning routines. These strategies can be difficult and time-consuming to adhere to in practice. Authorities and healthcare facilities therefore need to consider how best to support healthcare workers to implement them. OBJECTIVES: To identify barriers and facilitators to healthcare workers’ adherence to IPC guidelines for respiratory infectious diseases. SEARCH METHODS: We searched OVID MEDLINE on 26 March 2020. As we searched only one database due to time constraints, we also undertook a rigorous and comprehensive scoping exercise and search of the reference lists of key papers. We did not apply any date limit or language limits. SELECTION CRITERIA: We included qualitative and mixed-methods studies (with a distinct qualitative component) that focused on the experiences and perceptions of healthcare workers towards factors that impact on their ability to adhere to IPC guidelines for respiratory infectious diseases. We included studies of any type of healthcare worker with responsibility for patient care. We included studies that focused on IPC guidelines (local, national or international) for respiratory infectious diseases in any healthcare setting. These selection criteria were framed by an understanding of the needs of health workers during the COVID-19 pandemic. DATA COLLECTION AND ANALYSIS: Four review authors independently assessed the titles, abstracts and full texts identified by our search. We used a prespecified sampling frame to sample from the eligible studies, aiming to capture a range of respiratory infectious disease types, geographical spread and data-rich studies. We extracted data using a data extraction form designed for this synthesis. We assessed methodological limitations using an adapted version of the Critical Skills Appraisal Programme (CASP) tool. We used a ‘best fit framework approach’ to analyse and synthesise the evidence. This provided upfront analytical categories, with scope for further thematic analysis. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and developed implications for practice. MAIN RESULTS: We found 36 relevant studies and sampled 20 of these studies for our analysis. Ten of these studies were from Asia, four from Africa, four from Central and North America and two from Australia. The studies explored the views and experiences of nurses, doctors and other healthcare workers when dealing with severe acute respiratory syndrome (SARS), H1N1, MERS (Middle East respiratory syndrome), tuberculosis (TB), or seasonal influenza. Most of these healthcare workers worked in hospitals; others worked in primary and community care settings. Our review points to several barriers and facilitators that influenced healthcare workers’ ability to adhere to IPC guidelines. The following factors are based on findings assessed as of moderate to high confidence. Healthcare workers felt unsure as to how to adhere to local guidelines when they were long and ambiguous or did not reflect national or international guidelines. They could feel overwhelmed because local guidelines were constantly changing. They also described how IPC strategies led to increased workloads and fatigue, for instance because they had to use PPE and take on additional cleaning. Healthcare workers described how their responses to IPC guidelines were influenced by the level of support they felt that they received from their management team. Clear communication about IPC guidelines was seen as vital. But healthcare workers pointed to a lack of training about the infection itself and about how to use PPE. They also thought it was a problem when training was not mandatory. Sufficient space to isolate patients was also seen as vital. A lack of isolation rooms, anterooms and shower facilities was a problem. Other important practical measures described by healthcare workers included minimising overcrowding, fast-tracking infected patients, restricting visitors, and providing easy access to handwashing facilities. A lack of PPE, and equipment that was of poor quality, was a serious concern for healthcare workers and managers. They also pointed to the need to adjust the volume of supplies as infection outbreaks continued. Healthcare workers believed that they followed IPC guidance more closely when they saw the value of it. Some healthcare workers felt motivated to follow the guidance because of fear of infecting themselves or their families, or because they felt responsible for their patients. Some healthcare workers found it difficult to use masks and other equipment when it made patients feel isolated, frightened or stigmatised. Healthcare workers also found masks and other equipment uncomfortable to use. The workplace culture could also influence whether healthcare workers followed IPC guidelines or not. Across many of the findings, healthcare workers pointed to the importance of including all staff, including cleaning staff, porters, kitchen staff and other support staff when implementing IPC guidelines. AUTHORS’ CONCLUSIONS: Healthcare workers point to several factors that influence their ability and willingness to follow IPC guidelines when managing respiratory infectious diseases. These include factors tied to the guideline itself and how it is communicated, support from managers, workplace culture, training, physical space, access to and trust in personal protective equipment, and a desire to deliver good patient care. The review also highlights the importance of including all facility staff, including support staff, when implementing IPC guidelines.

The Seattle, Washington area was ground zero for coronavirus disease 2019 (COVID-19). Its initial emergence in a skilled nursing facility (SNF) not only highlighted the vulnerability of its patients and residents, but also the limited clinical support that led to national headlines. Furthermore, the coronavirus pandemic heightened the need for improved collaboration among healthcare organizations and local and state public health. The University of Washington Medicine’s Post-Acute Care Network developed a three phase approach, Initial, Delayed and Surge Phases, to help slow the spread of the disease, support local area SNFs from becoming overwhelmed when inundated with COVID-19 cases or persons under investigation, and help decrease the burden on area hospitals, clinics, and emergency medical services. This article is protected by copyright. All rights reserved.

Nursing homes (NH) are considered hotspots for COVID-191,2 given their residential environments and patient vulnerabilities. We describe the COVID-19 preparedness of NHs across the nation.

In Spain, the country with the most coronavirus cases in Europe, the impact of the outbreak in nursing homes is having a dramatic and tragic effect, reports Aser García Rada

More than 10 000 older people in Spain have died in the covid-19 pandemic, while thousands of others remain isolated—and this is a best estimate, as experts suspect that the true figure is worse. As official statistics on cases and deaths continue to climb at an alarming rate, nursing homes have been a blind spot for a country that ranks third in the world for covid-19 deaths.

«We are at war», said President Emmanuel Macron on 16th March 2020, about the health crisis against COVID-19, then in full epidemic expansion in France. Nearly 600,000 people (6% of people aged 85 or older) live in the 7,200 French nursing homes. In addition to the now well-known risk factors of age, dependence and associated co-morbidities, community life exposes NH residents to specific increased risks of this easily inter human transmissible virus.

Because those most affected are the frail older adults, I propose to add geroscience as a new tool to our strategy against COVID‐19. There is no doubt that a long‐term approach to this crisis involves the rapid development of vaccines and other prophylactics. But unfortunately, this takes time, and in the meantime the frail are dying. Geroscience posits that all diseases affecting primarily older adults, even diseases as disparate as cancer and heart disease, have as a common (and major) cause the declining function and resilience that often accompanies the aging process.

The tragic events in Italy, with more than 10 000 deaths due to novel coronavirus 2019 (COVID-19), are causing pain and demoralisation to a still incredulous and shocked general population. It is particularly distressing that outbreaks of infection have developed rapidly in many nursing homes, where staff have been completely neglected by health authorities and can offer only little protection to many frail and needy older people.

Globally, more than 50 million people have dementia, and one new case occurs every 3 seconds. Dementia has emerged as a pandemic in an ageing society. The double hit of dementia and COVID-19 pandemics has raised great concerns for people living with dementia.

The Handbook on Implementation Science provides an overview of the field’s multidisciplinary history, theoretical approaches, key concepts, perspectives, and methods. By drawing on knowledge concerning learning, habits, organizational theory, improvement science, and policy research, the Handbook offers novel perspectives from a broad group of international experts in the field representing diverse disciplines. The editors seek to advance implementation science through careful consideration of current thinking and recommendations for future directions.

Patients in long-term care (LTC) homes face barriers to accessing specialist advice. Electronic consultation (eConsult) has the potential to improve access for these patients. We used a multi-method approach to evaluate adoption of the Champlain BASE eConsult service in LTC homes across Eastern Ontario, Canada. We conducted a cross-sectional study of all eConsults submitted by primary care providers (PCPs) working at LTC homes between January 1, 2018 and December 31, 2018. Service use data were collected and descriptive statistics were calculated. We completed a thematic analysis of 4 focus groups with PCPs, senior leadership, and a nurse champion working in LTC homes where eConsult is used. Sixty-four cases were submitted to 23 specialty and subspecialty groups by LTC PCPs, most frequently dermatology (19%), geriatric medicine (11%), and infectious disease (9%). Specialists responded in a median of 0.6Â days, and 70% of cases were resolved without the resident needing a face-to-face specialist visit. In 60% of cases, PCPs received advice for a new or additional course of action. Participants described complexities in the LTC context, the value of eConsult in LTC, and considerations for implementation. PCPs with experience using the service described increased access to specialist advice, ease of use, and benefits to themselves, residents, and families. eConsult is feasible in LTC and should continue to be used in this region and beyond to improve equity of access to specialist advice. Resolving the identified limitations in LTC, which hinder access to specialists and adoption of eConsult and similar innovations, should be of high priority to researchers and policy makers.; Patients in long-term care (LTC) homes face barriers to accessing specialist advice. Electronic consultation (eConsult) has the potential to improve access for these patients. We used a multi-method approach to evaluate adoption of the Champlain BASE eConsult service in LTC homes across Eastern Ontario, Canada. We conducted a cross-sectional study of all eConsults submitted by primary care providers (PCPs) working at LTC homes between January 1, 2018 and December 31, 2018. Service use data were collected and descriptive statistics were calculated. We completed a thematic analysis of 4 focus groups with PCPs, senior leadership, and a nurse champion working in LTC homes where eConsult is used. Sixty-four cases were submitted to 23 specialty and subspecialty groups by LTC PCPs, most frequently dermatology (19%), geriatric medicine (11%), and infectious disease (9%). Specialists responded in a median of 0.6Â days, and 70% of cases were resolved without the resident needing a face-to-face specialist visit. In 60% of cases, PCPs received advice for a new or additional course of action. Participants described complexities in the LTC context, the value of eConsult in LTC, and considerations for implementation. PCPs with experience using the service described increased access to specialist advice, ease of use, and benefits to themselves, residents, and families. eConsult is feasible in LTC and should continue to be used in this region and beyond to improve equity of access to specialist advice. Resolving the identified limitations in LTC, which hinder access to specialists and adoption of eConsult and similar innovations, should be of high priority to researchers and policy makers.

In Switzerland as in many countries, steady trend is observed in nursing homes to promote writing of advanced directives (ADs). Implementation of ADs reflects the rise in public concern for the persons’ right to self-determination and informed decision. The issue of end-of-life conditions is particularly acute in situations with dementia. This article investigates how ADs interventions in nursing homes strive simultaneously to behave in line with the principles of care ethics and with the intention to respond to legally binding instructions. Healthcare to dying residents with dementia in nursing homes is interpreted in light of the Regulation theory. METHODS: Nursing home palliative care reference nurses were contacted through questionnaire. One hundred twenty-one addresses were reached, 69 responses were collected, giving a response rate of 57%. In order to deepen the understanding, 10 semi-directive interviews were conducted in 10 different nursing facilities with 12 palliative nurses. RESULTS: Presently, Swiss nursing homes are lacking a model of AD suitable to people with dementia. The study sheds light on dissimilarities in the purpose assigned to ADs’ procedure in the different facilities. Discrepancies in end-of-life care practices reveal more the influence of structural and organisational devices specific to each setting than conflicting views on end-of-life care principles. We analyse the interpretation of the Law and its implementation in the participating NHs as compromises that could be accounted for as a form of social regulation. CONCLUSION: Dementia accentuates the uncertainty inherent to end-of-life trajectories. The implementation of standardised procedures aimed at collecting the wishes of the person deprived of his or her discernment is source of dissonances with regard to the multiple interests involved in these care situations. In this context, the drafting of ADs during end-of-life care in NH correspond to new normative constraints requiring new collective regulation actions.

With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident’s wishes for care at the end-of-life and organise the care plan accordingly. AIM: To explore nurses’ perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents. DESIGN: A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted. RESULTS: Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses’ perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers’ preferences, knowledge of residents’ preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences. CONCLUSION: This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares’ and resident’s preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.

There are studies on the normative ethical frameworks used by long-term care staff and studies proposing how staff should reason, but few studies explore how staff actually reason. This study reports on the ethical reasoning process and experiences of moral distress of long-term care staff in the provision of social care. Seven interdisciplinary focus groups were conducted with twenty front-line staff. Staff typically did not have difficulty determining the ethical decision and/or action; however, they frequently experience moral distress. To manage these experiences of moral distress in making ethical decisions, staff 1) comply with being told what to do out of fear of consequences, 2) defer decisions to family, 3) “have a meeting,” 4) socialization into and acceptance of workplace culture. Findings suggest that to better understand how and why staff make ethical decisions and improve quality and ethical care, we must explore the interaction between front-line practice and organizational and public policy.

The goal of this scoping review was to identify existing palliative models in long-term care (LTC) homes and differentiate between the key components of each in terms of training/capacity-building strategies; resident, family and staff support; and advance care planning (ACP) and goals-of-care discussions. METHODS: We conducted a scoping review based on established methods to summarize the international literature on palliative models and programs for LTC. We analyzed the data using tabular summaries and content analysis. RESULTS: We extracted data from 46 articles related to palliative programs, training/capacity building, family support, ACP and goals of care. Study results highlighted that three key components are needed in a palliative program in LTC: (1) training and capacity building; (2) support for residents, family and staff; and (3) ACP, goals-of-care discussion and informed consent. CONCLUSION: This scoping review provided important information about key components to be included in a palliative program in LTC. Future work is needed to develop a model that suits the unique characteristics in the Canadian context.

Nursing home (NH) nurses play a key role in hospital transfer decisions. In case of unavailability of physicians, they have to decide alone. In doing so, they consider potential threats to residents’ quality of life (QoL), but they also fear the consequences of wrong decisions. The present study examines the causal influence of these deliberations on nurses’ transfer decisions and emotional strain. In all, 241 NH nurses participated in the experiment. The vignette describing a resident with deteriorating health state elicited either thoughts on residents’ QoL, on legal consequences, or on QoL and legal consequences. In the QoL condition, the likelihood of a hospital transfer was lower compared with all other conditions. Emotional strain was stable across experimental conditions. When thoughts on QoL and legal consequences were induced at the same time, strain was positively correlated with the inclination to transfer the resident. Promoting QoL considerations can help to reduce avoidable transfers.

Improving communication during transitions from acute care hospitals into long-term post-acute care (LTPAC) settings is imperative for clinical staff to have the information they need to admit and care for the patient with accurate medical information provided in an efficient way. The research goals of this study are to examine the user experience of a new data sharing method, “Continued Access,” a supplement to the standard summary of care, and to evaluate staff attitudes of the model on LTPAC residents’ care. Clinical staff ( n = 20) from a U.S. Midwestern LTPAC setting were interviewed to give their evaluation of the new model of data access, their concerns, and ways to improve the effectiveness of the model. Respondents reported better opportunities for quality care based on improved insight and clarity around patients’ medical history, medications, and tests. Strategies for integrating Continued Access into the workflow and improving quality outcomes are discussed.

Australia’s aged care workforce is facing pressures due to increased demands from an ageing population. This paper reflects upon whether existing workspace environmental design evaluations are supporting the aged care workforce. METHODS: This brief report was informed by a 2018 Optimising Aged Care Workspace Environment Symposium with three streams: (a) Developing, (b) Implementing and (c) Evaluating Aged Care Workspace Environments. RESULTS: Symposium key messages included the following: ‘evidence (lived experiences and feedback) from both older people and the aged care workforce needs to inform both development and implementation of aged care environment design’. The Evaluating Aged Care Workspace Environments stream key messages included the following: ‘evaluation approaches are required that are responsive and appropriate to the complex dynamic aged care workspace contexts’. CONCLUSION: To better inform the design of future aged care settings and support the aged care workforce, principles-focused evaluations of existing aged care settings with input from the aged care workforce are required.

Long-term care (LTC) facilities are particularly dangerous places for the spread of Covid-19 given that they house vulnerable, high-risk populations. Transmission-based precautions to protect residents, employees, and families alike must account for potential risks posed by LTC workers’ second jobs and unpaid care work. This observational study describes the prevalence of their (1) second jobs and (2) unpaid care work for dependent children and/or adult relatives (double- and triple-duty caregiving) overall and by occupational group (registered nurses, licensed practical nurses, or certified nursing assistants). DESIGN: A descriptive, secondary analysis of data collected as part of the final wave of the Work, Family and Health Study. SETTING: Thirty nursing home facilities located throughout the northeastern United States. PARTICIPANTS: A subset of 958 essential, facility-based LTC workers involved in direct patient care. MEASUREMENTS: We present information on LTC workers’ demographic characteristics, health, features of their LTC occupation, additional paid work, wages, and double- or triple-duty caregiving roles. RESULTS: The majority of LTC workers were certified nursing assistants, followed by licensed practical nurses and registered nurses. Overall, over 70% of these workers agreed or strongly agreed with the following statement: “When you are sick, you still feel obligated to come into work.” One-sixth had a second job, where they worked an average of 20 hours per week, and over 60% held double- or triple-duty caregiving roles. Additional paid work and unpaid care work characteristics did not significantly differ by occupational group, although the prevalence of second jobs was highest and accompanying work hours were longest among certified nursing assistants. CONCLUSION: LTC workers commonly hold second jobs along with double- and triple-duty caregiving roles. To slow the spread of Covid-19, both the paid and unpaid activities of these employees warrant consideration in the identification of appropriate clinical, policy, and informal supports. This article is protected by copyright. All rights reserved.

Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach. METHODS: We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English. RESULTS: Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities. CONCLUSIONS: Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach. TRIAL REGISTRATION: Protocol registered on PROSPERO (CRD42018088309).

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.

The adoption of information and communication technology by elderly care organizations is an inevitable trend. Most empirical studies on e-Health service quality have focused predominantly on the general population rather than on the elderly. Thus, the generalizations are rather problematic. In addition, in the planning stage, pre-implementation analysis is considered critical but seldom performed. In this research, an instrument to evaluate the e-Health service quality in nursing homes was developed based on the SERVQUAL model. Furthermore, a pre-implementation analysis combining the SERVQUAL questionnaire and importance performance analysis was performed. Dissatisfactory factors were identified as follows. Regarding the physical environment quality, the residents expressed that the nursing homes did not provide well-maintained rooms and that the temperature in the rooms was unsuitable. Regarding the outcome quality, the elderly residents replied that the medical treatments and doctor visits were not well scheduled. Regarding the interaction quality, the residents indicated that the staff did not solve their problems sincerely or clearly understand their needs. Health care informatics (HCI) such as an electronic shift system (ESS) and electronic health records (EHR) are proposed to eliminate these problems. Given current resource limitations, our instrument and methodology proposed in this research could be extremely meaningful in practical application.

Over 25% of nursing home residents have diabetes. Nurses (registered nurses and registered practical nurses), registered dietitians and personal support workers (PSWs) provide the bulk of diabetes care in long-term care (LTC) homes, but their self-rated diabetes knowledge is poor. In this study, we evaluated the impact of an educational intervention on comfort with, and knowledge of, diabetes management among frontline LTC staff. METHODS: We implemented an educational intervention in 2 LTC homes in Ontario that targeted nurses and dietitians, PSWs and physicians. A self-assessment questionnaire and a knowledge test were administered to nurses and dietitians and PSWs before and after the intervention. We also measured pre- and postintervention glycated hemoglobin levels, use of sliding scale insulin and type and dose of diabetes medications prescribed. RESULTS: After the intervention, both the nurses and dietitians and PSWs groups demonstrated increased comfort with diabetes management and improved self-appraised knowledge. Among PSWs, knowledge of foot care improved the most, and the nurses and dietitians group had the greatest improvement in knowledge of blood glucose monitoring. In addition, there was reduced use of sliding scale insulin, and in the number of residents requiring renal-based dose reductions of glucose-lowering medications. This intervention was innovative as it targeted different LTC health-care providers; it demonstrated the potential to increase LTC health-care providers’ confidence in diabetes management. Future studies could assess the clinical benefits of an educational intervention on rates of hypoglycemia and improving A1C targets. CONCLUSIONS: An educational intervention can improve knowledge and comfort of diabetes management of frontline LTC staff.

This pilot study aimed to assess whether an on-site pharmacist could influence indicators of quality use of medicines in residential aged care. Methods: A pharmacist was embedded in a residential aged care home for six months. A similar control site received usual care. Polypharmacy, drug burden index, antipsychotic and benzodiazepine use, hospital admission rates and length of stay, and emergency department presentation rates were outcomes used to indicate medication use quality. Data were extracted from participating resident health records. Results: Fifty-eight residents at the study site and 39 residents at the control site were included in the analysis. There was a reduction in the proportion of residents at the study site who had at least one hospital admission at follow-up (28% to 12%, p < 0.01), but no significant difference in other outcomes. Conclusions: This pilot study suggests that a residential care pharmacist may positively influence indicators of medication use quality in aged care; however, further research is needed to expand on these findings.

The current project assessed the oral health of residents in a long-term care (LTC) facility, implemented a new evidence-based oral care protocol, and trained nursing staff about oral hygiene for older adults. A pre-/post-intervention design was used to measure knowledge, skills, and attitudes among 29 staff members. The oral health outcomes of 10 LTC residents without dysphagia were assessed after 14 days of protocol use. Knowledge improved from a mean total pre-test score of 88.8 to a mean total post-test score of 97.7 (Z = -2.308, p = 0.021). The Oral Health Assessment Tool measured oral health outcomes at three time points in 10 older adults, and statistically significant improvement in oral health was identified (p = 0.001). Nursing home staff play an important role in improving oral hygiene of older adults in LTC facilities by routinely using an easy to follow oral health protocol twice daily.

There are an increasing number of people living with dementia in care home settings. Recent reports suggest that people who deliver care to residents living with dementia in care homes require specialist support to provide optimum care. To address this need Four Seasons Health Care, the largest provider of care homes within the UK today, sought to design a dementia care framework that enhanced the quality of life for people living with dementia in their care homes. The framework was designed using a robust evidence base, engagement with people living with dementia, their care partners, policy-writers, multidisciplinary professionals and people within the organisation. This paper describes the methodology behind the dementia care framework and outcomes data from the first phase (of 20 care homes that included the care of 451 people living with dementia). The main outcome was a significant improvement in the quality of the lives of residents across biological, psychological, social and spiritual needs.

Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare? METHODS: A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework. RESULTS: Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings. CONCLUSIONS: This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017062135.

Long term care facilities (LTCFs) are increasingly a place of care at end of life in Europe. Longer residence in an LTCF prior to death has been associated with higher indicators of end of life care; however, the relationship has not been fully explored. The purpose of this analysis is to explore associations between length of stay and end of life care. The analysis used data collected in the Palliative Care for Older People in care and nursing homes in Europe (PACE) study, a cross-sectional mortality follow-back survey of LTCF residents who died within a retrospective 3-month period, conducted in Belgium, England, Finland, Italy, the Netherlands and Poland. Primary outcomes were quality of care in the last month of life, comfort in the last week of life, contact with health services in the last month of life, presence of advance directives and consensus in care. Longer lengths of stay were associated with higher scores of quality of care in the last month of life and comfort in the last week of life. Longer stay residents were more likely to have advance directives in place and have a lasting power of attorney for personal welfare. Further research is needed to explore the underlying reasons for this trend, and how good quality end of life care can be provided to all LTCF residents.

International collaboration in science has received increasing attention given emphases on relevance, generalizability, and impact of research. Implementation science (IS) is a growing discipline that aims to translate clinical research findings into health services. Research is needed to identify efficient and effective ways to foster international collaboration in IS. Concept-mapping (CM) was utilized with a targeted sample for preliminary exploration of fostering international collaboration. Concept-mapping is a mixed-method approach (qualitative/quantitative) particularly suited for identifying essential themes and action items to facilitate planning among diverse stakeholders. We sought to identify key factors likely to facilitate productive and rewarding international collaborations in implementation research. RESULTS: We identified eleven dimensions: Strategic Planning; Practicality; Define Common Principles; Technological Tools for Collaboration; Funding; Disseminate Importance of Fostering International Collaboration in IS; Knowledge Sharing; Innovative & Adaptive Research; Training IS Researchers; Networking & Shared Identity; Facilitate Meetings. Strategic Planning and Funding were highest rated for importance and Strategic Planning and Networking and Shared Identity were rated most feasible to institute. Fostering international collaboration in IS can accelerate the efficiency, relevance, and generalizability of implementation research. Strategies should be developed and tested to improve international collaborations and engage junior and experienced investigators in collaborations advancing implementation science and practice.

This paper explores some of the ethical considerations of working collaboratively with people with dementia within research based upon the experiences, challenges and learning from three doctoral research studies. Focus is on the research relationship with participants and gatekeepers, the importance of setting and access, the power relations within the research and ways in which people with dementia can be supported to be active and have a voice in research. This sits within an ethical framework of principalist ethics and ethics of care to guide not only how research is planned ethically and with consideration of participants, but also how this can support decisions made in situ. The aim is to share, based upon these three studies, ways of managing and working through some of the ethical consideration to support researchers in their decisions in planning and conducting research with people with dementia as active collaborators.

Special care units are a well-utilized approach in the long-term care for persons with dementia. A therapeutic goal of such settings is to provide meaningful engagement and a sense of community that is crucial for the overall quality of life. In recent years, several studies followed this notion by investigating residents’ social interactions and the influence of the environment on these interactions. Aims This review aims to synthesize the literature on the social interactions of persons with dementia living in special care units. Design A mixed-methods systematic review was conducted. Methods Literature was searched in PubMed, CINAHL, PsycINFO, the Cochrane Library and Web of Science databases. Additionally, reference lists of relevant articles were searched. Studies were screened, data were extracted and the quality was appraised. Separate syntheses were conducted for qualitative and quantitative studies, which were subsequently merged in the final mixed-methods synthesis. Results In total, 18 articles were included, investigating large-scale, small-scale and homelike special care units and green care farms. Residents in special care units experience few social interactions but more than those in the comparative groups. Opportunities to interact are only marginally seized. Interactions typically occur in small groups and are facilitated by familiarity and the organizational environment. Residents mainly rely on staff members to create social interaction, for example initiating or facilitating resident-to-resident interaction. Conclusion Although the evidence base is increasing, it is still fragmented and built on different concepts, interventions, control groups and measurements. Nevertheless, the first conclusions suggest a positive impact of special care units on residents’ social interactions. Although the review yielded a more comprehensive picture of residents’ social life, further high-quality research built on a sound theoretical background is needed.

The oral hygiene of nursing home residents is poor. We aimed to investigate the efficacy of professional brushing using a specialized brush every three weeks, and its impact on geriatric outcomes. METHODS: Nursing home residents received professional brushing with a three-headed brush by a dental nurse every three weeks for three months. Controls comprised subjects from an earlier investigation. Their general clinical, geriatric, and oral health (number of teeth, periodontitis, Gingivitis Index, Plaque Index, Root Caries Index, Volpe-Manhold Index (VMI)) were investigated, and Geriatric Oral Health Assessment Index (GOHAI) was obtained before and after three months. RESULTS: Forty nursing home residents were included. 76% of participants suffered from periodontitis, while 48% had partial and 20% total dentures. After three months, VMI had decreased versus baseline (p<0.001). An improvement in nutritional status (p=0.012) was found in residents with dementia after the intervention, as well as an improvement in the GOHAI (p=0.031) in all participants. Gingivitis and plaque indices did not improve. CONCLUSIONS: The oral health of nursing home residents is poor for various reasons, and nursing home staff cannot fully address the increased oral hygiene risk with increasing multimorbidity. Professional brushing performed regularly by a dental nurse is an efficient method to improve oral hygiene in nursing home residents, and may contribute to better nutritional status and quality of life. However, brushing every three weeks with a three-headed brush was not effective at improving gingivitis or plaque and was inferior to the two-week brushing interval with a manual toothbrush.

For people with dementia living in residential care facilities, maintaining autonomy and receiving informal care are important. The objective of this review is to understand how caregiving approaches and physical environment, including technologies contribute to the maintenance of autonomy and informal care provision for this population. RESEARCH DESIGN AND METHODS: A literature review of peer-reviewed articles published between January 1995 and July 2017 was performed. Realist logic of analysis was used, involving context, mechanism and outcome configurations. RESULTS: Forty-nine articles were included. The improvement of the relationship between residents and formal/informal caregivers is important. This increases the knowledge (sharing) about the resident and contributes to their autonomy. A social, flexible, and welcoming attitude of the formal caregiver improves the provision of informal care. Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy. Use of technologies reduces caregiver’s time for primary tasks and therefore enables secondary tasks such as interaction with the residents. DISCUSSION AND IMPLICATIONS: The results revealed how residential care facilities could maintain autonomy of their residents and improve informal care delivery using caregiving approaches and the physical environment including technologies. The results are supporting toward each other in maintaining autonomy and also helped in enhancing informal care provision. For residential care facilities that want to maintain the autonomy of their residents and improve informal care delivery, it is important to pay attention to all aspects of living in a residential care facility.

Depression is a pernicious, growing problem in the aged care population. Knowledge about the risk factors for depression focuses on unchangeable, medical factors; therefore, a deeper, systematic understanding of modifiable psychological risk indicators is needed. METHODS: This secondary analysis used data from an observational cohort study (T1, n = 147; T2, n = 81) of adults aged >/=65 years recruited from 15 aged care facilities in Melbourne, Australia. Meaningful existence, mastery, social support and person-environment fit were investigated as risk indicators. RESULTS: Generalised estimating equation analysis identified that changes in meaningful existence (b = -0.06, P < .05), mastery (b = -0.05, P < .05) and person-environment fit (b = -0.02, P < .05) were significantly associated with change in depression score. These remained significant controlling for socio-demographic variables, cognitive impairment and functional impairment. CONCLUSION: Because these psychological risk factors-meaningful existence, mastery and person-environment fit-are suitable therapeutic targets, they are well positioned to inform prevention and intervention programs.

To assess the impact of dementia on the use of health and community services in the last 2 years of life by women who also had other major chronic conditions. DESIGN: Matched groups of women with a chronic condition who did or did not also have dementia, and who died or did not die for at least another 2 years. SETTING AND PARTICIPANTS: Participants in the Australian Longitudinal Study on Women’s Health who were born from 1921-1926. These women were from a random, nationally representative sample of 12,432 recruited in 1996 with follow-up until 2014. METHODS: Repeated survey data and linked administrative records were used to identify women with heart disease, chronic lower respiratory tract disease, and dementia. Use of aged care services, medical visits, and hospital admissions were compared among the matched groups. RESULTS: Women with dementia were more likely to move into residential aged care, especially in the months and years before death. Consequently, they made less use of community-based services. Numbers of general practitioner visits were similar for women with or without dementia, increasing substantially in the last 4 months of life. In contrast, women with dementia were less likely to see medical specialists and slightly less likely to be admitted to hospital, even in the last 4-6 months of life when hospitalization was more common. The findings were similar whether the comorbid condition was heart disease or chronic lower respiratory tract disease. CONCLUSIONS AND IMPLICATIONS: Use of other services is affected by use of residential aged care, so the comprehensive care of people with dementia requires understanding connections between sectors.

Dementia is a chronic condition which progressively affects memory and other cognitive functions, social behaviour, and ability to carry out daily activities. To date, no treatment is clearly effective in preventing progression of the disease, and most treatments are symptomatic, often aiming to improve people’s psychological symptoms or behaviours which are challenging for carers. A range of new therapeutic strategies has been evaluated in research, and the use of trained animals in therapy sessions, termed animal-assisted therapy (AAT), is receiving increasing attention. OBJECTIVES: To evaluate the efficacy and safety of animal-assisted therapy for people with dementia. SEARCH METHODS: We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group’s Specialised Register on 5 September 2019. ALOIS contains records of clinical trials identified from monthly searches of major healthcare databases, trial registries, and grey literature sources. We also searched MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), ISI Web of Science, ClinicalTrials.gov, and the WHO’s trial registry portal. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-randomised trials, and randomised cross-over trials that compared AAT versus no AAT, AAT using live animals versus alternatives such as robots or toys, or AAT versus any other active intervention. DATA COLLECTION AND ANALYSIS: We extracted data using the standard methods of Cochrane Dementia. Two review authors independently assessed the eligibility and risk of bias of the retrieved records. We expressed our results using mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with their 95% confidence intervals (CIs) where appropriate. MAIN RESULTS: We included nine RCTs from 10 reports. All nine studies were conducted in Europe and the US. Six studies were parallel-group, individually randomised RCTs; one was a randomised cross-over trial; and two were cluster-RCTs that were possibly related where randomisation took place at the level of the day care and nursing home. We identified two ongoing trials from trial registries. There were three comparisons: AAT versus no AAT (standard care or various non-animal-related activities), AAT using live animals versus robotic animals, and AAT using live animals versus the use of a soft animal toy. The studies evaluated 305 participants with dementia. One study used horses and the remainder used dogs as the therapy animal. The duration of the intervention ranged from six weeks to six months, and the therapy sessions lasted between 10 and 90 minutes each, with a frequency ranging from one session every two weeks to two sessions per week. There was a wide variety of instruments used to measure the outcomes. All studies were at high risk of performance bias and unclear risk of selection bias. Our certainty about the results for all major outcomes was very low to moderate. Comparing AAT versus no AAT, participants who received AAT may be slightly less depressed after the intervention (MD -2.87, 95% CI -5.24 to -0.50; 2 studies, 83 participants; low-certainty evidence), but they did not appear to have improved quality of life (MD 0.45, 95% CI -1.28 to 2.18; 3 studies, 164 participants; moderate-certainty evidence). There were no clear differences in all other major outcomes, including social functioning (MD -0.40, 95% CI -3.41 to 2.61; 1 study, 58 participants; low-certainty evidence), problematic behaviour (SMD -0.34, 95% CI -0.98 to 0.30; 3 studies, 142 participants; very-low-certainty evidence), agitation (SMD -0.39, 95% CI -0.89 to 0.10; 3 studies, 143 participants; very-low-certainty evidence), activities of daily living (MD 4.65, 95% CI -16.05 to 25.35; 1 study, 37 participants; low-certainty evidence), and self-care ability (MD 2.20, 95% CI -1.23 to 5.63; 1 study, 58 participants; low-certainty evidence). There were no data on adverse events. Comparing AAT using live animals versus robotic animals, one study (68 participants) found mixed effects on social function, with longer duration of physical contact but shorter duration of talking in participants who received AAT using live animals versus robotic animals (median: 93 seconds with live versus 28 seconds with robotic for physical contact; 164 seconds with live versus 206 seconds with robotic for talk directed at a person; 263 seconds with live versus 307 seconds with robotic for talk in total). Another study showed no clear differences between groups in behaviour measured using the Neuropsychiatric Inventory (MD -6.96, 95% CI -14.58 to 0.66; 78 participants; low-certainty evidence) or quality of life (MD -2.42, 95% CI -5.71 to 0.87; 78 participants; low-certainty evidence). There were no data on the other outcomes. Comparing AAT using live animals versus a soft toy cat, one study (64 participants) evaluated only social functioning, in the form of duration of contact and talking. The data were expressed as median and interquartile ranges. Duration of contact was slightly longer in participants in the AAT group and duration of talking slightly longer in those exposed to the toy cat. This was low-certainty evidence. AUTHORS’ CONCLUSIONS: We found low-certainty evidence that AAT may slightly reduce depressive symptoms in people with dementia. We found no clear evidence that AAT affects other outcomes in this population, with our certainty in the evidence ranging from very-low to moderate depending on the outcome. We found no evidence on safety or effects on the animals. Therefore, clear conclusions cannot yet be drawn about the overall benefits and risks of AAT in people with dementia. Further well-conducted RCTs are needed to improve the certainty of the evidence. In view of the difficulty in achieving blinding of participants and personnel in such trials, future RCTs should work on blinding outcome assessors, document allocation methods clearly, and include major patient-important outcomes such as affect, emotional and social functioning, quality of life, adverse events, and outcomes for animals.

Quality of life is important especially in incurable illness. In dementia, we often need proxy reports of quality of life, but we know little about how individuals make their judgements. In care homes, proxies may be staff providing care or relatives, but staff rate quality of life differently to family. To our knowledge, no one has explored this qualitatively, so we used qualitative interviews to explore why staff and family think differently about quality of life. METHODS: We interviewed 12 staff and 12 relatives who had provided proxy ratings of quality of life for people living with dementia in care homes in the Managing Agitation and Raising Quality of life (MARQUE) study. We asked why they had rated the resident’s quality of life as “Very Good, Good, Fair, or Poor.” Using thematic analysis, we compared staff and relatives’ proxy responses. RESULTS: For staff, the concept of quality of life was often viewed synonymously with quality of care, influenced by their sense of responsibility and informed by their professional understanding. For relatives, quality of life was often judged in relation to how the person with dementia lived before diagnosis and was influenced by their perception of loss for the person with dementia and their own adjustment. CONCLUSIONS: Proxy reports were influenced by rater’s own contexts and experiences. This can enhance our understanding of widely used research tools, aid the evaluation of intervention outcomes, and indicate possible targets for improving perceived and actual quality of life of people with dementia.

The worries of next of kin about their older loved ones in nursing homes can be extensive and can adversely affect their subjective experiences of their own physical, mental and social well-being. It is thus of utmost importance to measure the quality of life of next of kin in a valid and reliable way. METHODS: The design is a cross-sectional study with psychometric evaluation based on classical test theory in preparation for a planned educational intervention study on palliative care. An abbreviated version of the World Health Organization’s quality-of-life self-assessment instrument WHOQOL, the Swedish WHOQOL-BREF, was completed by 254 next of kin of older persons in 30 nursing homes. Data quality was assessed via the mean, median, item response, missing values, and floor and ceiling effects. Reliability was estimated using Cronbach’s alpha and corrected item-total correlations. Construct validity was estimated by Spearman’s rank correlation, and model fit was assessed using confirmatory factor analysis. RESULTS: The rate of missing data was low (less than 2%). Ceiling effects ranged from 11 to 43% and were above 20% for 21 of 24 items. The corrected item-total correlations varied between 0.35 and 0.68 and were thus well above the lower limit of 0.30. Cronbach’s alpha was 0.83, indicating satisfactory internal consistency. The confirmatory factor analysis indicated a fair to close model fit (comparative fit index 0.93, root mean squared error of approximation 0.06). CONCLUSIONS: The findings suggest that the WHOQOL-BREF may constitute a reliable and valid measure of quality of life for use among next of kin to older persons in nursing homes. When interpreting the results, it is important to assess the ceiling effect, as it may restrict the ability of the WHOQOL-BREF to detect true positive changes in quality of life over time. TRIAL REGISTRATION: NCT02708498.

Elderly nursing home residents are often malnourished or at risk of malnutrition. Family members often visit residents during mealtimes, which might be an ideal opportunity for interventions targeted at improving the nutritional status of older residents. Therefore, this study aimed to explore motivations behind family member visits with nursing home residents during mealtime in Taiwan. METHODS: This phenomenological study was conducted with family members of residents from four nursing homes in Taiwan. Participants were purposively sampled. Data were collected with individual face-to-face interviews from 18 family members. Data from transcribed audio-recorded interviews were analyzed using the approach of van Manen. RESULTS: Analysis of the interview data identified the essence of motivations underlying family members’ visits to nursing home residents during mealtimes, which we termed “tailoring homely meals.” This referred to providing food tailored to residents’ needs, providing a comforting family atmosphere, assisting residents during mealtime, and monitoring food consumption. CONCLUSIONS: The motivations of family members to visit during mealtime could guide healthcare professionals working with East Asian populations in developing interventions to reduce the possibility of malnutrition, while also improving their quality of life. We recommend providing the following for nursing home residents: a nutritious and balanced diet, supporting their independence and ability to feed themselves, and encouraging involvement of family members during mealtimes.

Measuring the perceived mental and physical health status of older adults living in long-term residential care (LTRC) is central to patient-centered care. This study examined the qualitative content validity of the Veterans RAND 12 Item Health Survey (VR-12) for LTRC and, based on the findings, the authors developed an adapted version of the generic patient-reported outcome measure for this population.Methods: Content validity was evaluated in two steps: (1) initial resident feedback (n = 9) and research team consensus discussions and (2) cognitive interviews with residents (n = 18) and a research team consensus discussion. The cognitive interviews examined comprehension, acceptability, and relevance of the VR-12 items.Results: Two VR-12 items had limited acceptability in the LTRC setting, the reference to “work” in items was irrelevant to residents, and the lack of a frame of reference (“During the past week … “) impacted comprehension of several items.Conclusions: Study findings informed the development of an adapted version of the VR-12 for older adults living in Canadian LTRC homes and provided content validity evidence regarding its relevance and appropriateness for this population.Clinical implications: Measuring the health status of older adults living in LTRC can help to monitor changes in health status over time and support person-centered care.

Pain is often underassessed and undertreated among long-term care (LTC) residents living with dementia. When used regularly, the Pain Assessment Checklist for Seniors With Limited Ability to Communicate (PACSLAC) scales have been shown to have beneficial effects on pain assessment and management practices and stress and burnout levels in frontline staff in LTC facilities. Such scales, however, are not utilized as often as recommended, which is likely to be related to additional record-keeping and tracking over time involved with their paper-and-pencil administration. OBJECTIVE: Using implementation science principles, we assessed the introduction of the PACSLAC-II scale by comparing two methods of administration-a newly developed tablet app version and the original paper-and-pencil version-with respect to the frequency of pain assessment and facility staff feedback. METHODS: Using a case series approach, we tracked pain-related quality indicators at baseline, implementation, and follow-up periods. A quasi-experimental design was used to evaluate the effect of the method of administration (ie, paper-and-pencil only [n=18], tablet only [n=12], paper-and-pencil followed by tablet app [n=31], and tablet app followed by paper-and-pencil [n=31]) on pain assessment frequency and frontline staff stress and burnout levels. Finally, semistructured interviews were conducted with frontline staff to obtain perspectives on each method of administration. RESULTS: The implementation effort resulted in a great increase in pain assessment frequency across 7 independent LTC units, although these increases were not maintained during the follow-up period. Frontline staff reported lower levels of workload in the paper-and-pencil followed by tablet app condition than those in the paper-and-pencil only (P<.001) and tablet app followed by paper-and-pencil (P<.001) conditions. Frontline staff also reported lower levels of workload in the tablet-only condition than those in the paper-and-pencil only condition (P=.05). Similarly, lower levels of emotional exhaustion were reported by frontline staff in the paper-and-pencil followed by tablet app condition than those in the paper-and-pencil only (P=.002) and tablet app followed by paper-and-pencil (P=.002) conditions. Finally, frontline staff reported higher levels of depersonalization in the paper-and-pencil only condition than those in the tablet app only (P=.008), paper-and-pencil followed by tablet app (P<.001), and tablet app followed by paper-and-pencil (P<.001) conditions. Furthermore, narrative data from individual interviews with frontline staff revealed a preference for the tablet app over the paper-and-pencil method of administration. CONCLUSIONS: This study provides support for the use of either the tablet app or the paper-and-pencil version of the PACSLAC-II to improve pain-related quality indicators, but a reported preference for and lower levels of stress and burnout with the use of the tablet app method of administration suggests that the use of the tablet app may have more advantages compared with the paper-and-pencil method of administration.

Qualitative Evidence Synthesis (QES) is becoming increasingly utilized to bring together qualitative evidence to explore the complexities of human experience. There are multiple approaches to QES including meta-ethnography, framework synthesis, and thematic synthesis. Thomas and Harden (2008) provide guidance on conducting thematic synthesis that moves beyond description to develop analytical themes. The purpose of this webinar is to walk through a worked example of thematic synthesis on a recently completed review exploring the factors that impact on recruitment to trials. I will provide examples of the stages of synthesis and illustrate how Computer Assisted Qualitative Data Analysis Software (CAQDAS) can facilitate synthesis and sensitivity analysis. Webinar attendees will hopefully learn more about navigating the complexity of bringing together the worlds of qualitative research and systematic review.

This webinar is available in French only; it is not offered in English.

Email Meghan.Storey@unityhealth.to to register.

What does patient engagement look like in a time of COVID-19 from a patient, family or caregiver perspective and from an organizational and healthcare leader perspective? Participants on this webinar will discuss ways organizations have maintained their engagement and partnership activities and, in many cases, strengthened and accelerated their efforts. Participants will also share expectations and priorities for patients, families and caregivers.