Health Care Administration and Organization

Collection of articles on Health Care Administration and Organization is available here.

Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review.
Access if not affiliated with University of Alberta

K. Anantapong, N. Davies, J. Chan, D. McInnerney and E. L. Sampson.
BMC Geriatr 2020 Dec 2;20(1):520-020-01931-y
BACKGROUND: This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved. METHODS: We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497. RESULTS: Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation. CONCLUSIONS: The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner.

Diagnostic Testing in Long-Term Care and Resident Emergency Department Visits: A Retrospective Cohort Study.
Access if not affiliated with University of Alberta

E. Kunkel, P. Tanuseputro, A. Hsu, et al.
J Am Med Dir Assoc 2020 Nov 17
To investigate the association between rapid access to radiographs, blood tests, urine cultures, and intravenous (IV) therapy in a long-term care (LTC) home with resident transfers to the emergency department (ED). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 21,811 residents living in 162 LTC homes in Ontario, Canada. METHODS: We administered a survey to LTC homes to collect wait times for radiographs, basic blood tests, urine culture, and IV therapy. Rapid availability was defined as typically receiving test results within 1 or 2 days, or same-day IV therapy. We linked the survey results to administrative data and defined a cohort of residents living in survey-respondent homes between January and May 2017. We followed residents in the linked administrative databases for 6 months, until discharge, or death. Two physicians identified diagnostic codes for ED visits that were potentially preventable with rapid availability of each of the 4 resources. Multilevel logistic regression models estimated associations between potentially preventable ED visits and rapid diagnostic tests and intravenous access while controlling for demographic characteristics, illness severity, LTC home size, chain status, and physician availability. RESULTS: Rapid blood tests, radiographs, urine culture, and IV therapy were available in 55%, 47%, 34%, and 45% of LTC homes, respectively. LTC homes that were part of multihome chains were less likely to have rapid access to the 4 resources. Of the 4736 residents (27%) who visited an ED during follow-up, individuals from homes with rapid access to radiographs (odds ratio 0.79, 95% confidence interval 0.66-0.97), urine culture (0.88, 0.72-1.08), blood tests (0.83, 0.69-1.00), and IV therapy (0.93, 0.70-1.23) tended to have fewer potentially preventable ED visits. CONCLUSIONS AND IMPLICATIONS: Rapid access to diagnostic testing and IV therapy in LTC reduced ED visits. Improving access to these resources may prevent ED visits and allow residents to stay home.

Knowing the person of the resident–a theoretical framework for Person-centred Practice in Long-term Care (PeoPLe).

Hanna Mayer, Brendan McCormack, Christiane Hildebrandt, Sabine K\ock-H\’odi, Eva Zojer and Martin Wallner.
International Practice Development Journal 2020;10(2).
Demographic change and a shift of values in society bring new challenges for the longterm care of older people, suggesting the institutional model of care should give way to one that places the person at the centre of decision making. Aim: To describe the development of a theoretical framework for person-centred practice with older people in long-term care. Development process: The framework was developed by synthesising original empirical research, existing evidence and existing theory, using an iterative and integrated approach to theory development based on a dialogical understanding of knowledge construction. The project formed part of a fiveyear research and practice development programme on person-centred practice in long-term care in Austria. Results: The Person-centred Practice Framework for Long-Term Care (PeoPLe) is a theoretical framework of person-centred practice, consisting of five constructs: prerequisites, practice environment, personcentred processes, fundamental principles of care, and outcome. It is dependent on the macro-context of healthcare delivery. Conclusion: PeoPLe provides a comprehensive theoretical framework for the development of personcentred practice in long-term care. The framework can be used to guide empirical inquiry, education and practice development. Implications for practice:
• The Person-centred Practice Framework for Long-term Care (PeoPLe) is a comprehensive theoretical framework that sets out principles for the operationalisation of person-centred practice with older people in long-term care
• The Fundamental Principles of Care component of the PeoPLe framework is reported to appeal to many practitioners and may serve also as a low-threshold starting point for practice development
• The Fundamental Principles of Care component may steer the development of person-centred processes and individual care plans with persons in care. It can, for example, be used to guide assessment, case conferences and documentation

Examining the Impact of Fictional Life Story of Resident with Dementia on Staff Levels of Empathy, Self-confidence, Workload Burden, and Perception of Resident: A Cross-sectional Survey in Long-term Care Communities.
Access if not affiliated with University of Alberta

A. Muller, P. Missotten and S. Adam.
Clin Gerontol 2020 Dec 2:1-12
Determine the impact of fictional life story on staff members levels of empathy, self-confidence, workload burden, and perception of resident before the implementation of care for new resident with dementia in long-term care community. Methods: An online cross-sectional survey based on two fictive clinical vignettes was used: one vignette described a resident with typical medical information (e.g., level of autonomy, health status, medication …), while the other contained typical medical information and life story information. The two vignettes were visually similar. The order in which vignettes were read was counterbalanced. Staff members (n = 95) were asked to consider the care needed by these residents and to assess, with a visual analogue scale, the amount of useful information provided by vignettes, their self-confidence and level of empathy, their perception of the resident’s level of sympathy, his dependence, and the associated workload. Results: After reading the vignette containing life story information, staff members considered that they had more useful information and empathy for the resident. They also felt more confident about the care. They perceived the resident as more sympathetic and less dependent, and the workload seemed lighter to them compared to the case described in the vignette that did not contain life story information. Conclusions: This quantitative study shows, in clinical fictive situations, the positive impact of life story on staff members before care begins. Clinical implications: Results highlight the importance of considering life story early. Getting to know residents should be the first step of care.

React and act: a qualitative study of how nursing home leaders follow up on staff-to-resident abuse.
Access if not affiliated with University of Alberta

J. Myhre, S. Saga, W. Malmedal, J. Ostaszkiewicz and S. Nakrem.
BMC Health Serv Res 2020 Dec 1;20(1):1111-020-05969-x
Elder abuse in nursing homes is a complex multifactorial problem and entails various associations across personal, social, and organisational factors. One way leaders can prevent abuse and promote quality and safety for residents is to follow up on any problems that may arise in clinical practice in a way that facilitates learning. How nursing home leaders follow up and what they follow up on might reflect their perceptions of abuse, its causal factors, and the prevention strategies used in the nursing home. The aim of this study was to explore how nursing home leaders follow up on reports and information regarding staff-to-resident abuse. METHODS: A qualitative explorative design was used. The sample comprised 43 participants from two levels of nursing home leadership representing six municipalities and 21 nursing homes in Norway. Focus group interviews were conducted with 28 care managers, and individual interviews took place with 15 nursing home directors. The constant comparative method was used for the analyses. RESULTS: Nursing home leaders followed up incidents of staff-to-resident abuse on three different levels as follows: 1) on an individual level, leaders performed investigations and meetings, guidance, supervision, and occasionally relocated staff members; 2) on a group level, feedback, openness, and reflection for shared understanding were strategies leaders used; and 3) on an organisational level, the main solutions were to adjust to available resources, training, and education. We found that leaders had difficulties defining harm and a perceived lack of power to follow up on all levels. In addition, they did not have adequate tools for evaluating the effect of the measures that were taken. CONCLUSIONS: Nursing home leaders need to be clear about how they should follow up incidents of elder abuse on different levels in the organisation and about their role in preventing elder abuse. Evaluation tools that facilitate systematic organisational learning are needed. Nursing homes must operate as open, blame-free cultures that acknowledge that incidents of elder abuse in patient care arise not only from the actions of individuals but also from the complex everyday life of which they are a part and in which they operate.

The Effects of Education About Urinary Incontinence on Nurses’ and Nursing Assistants’ Knowledge, Attitudes, Continence Care Practices, and Patient Outcomes: A Systematic Review.
Access if not affiliated with University of Alberta

J. Ostaszkiewicz, E. Tomlinson and K. Hunter.
J Wound Ostomy Continence Nurs 2020 Jul/Aug;47(4):365-380
The aims of this systematic review were to describe, critique, and summarize research about the effects of education about urinary incontinence on nurses’ and nursing assistants’ knowledge and attitudes toward urinary incontinence, their continence care practices, and patient outcomes. We searched key electronic databases (PsycINFO, MEDLINE, CINAHL, Web of Science, and Cochrane Library) for full-text primary research articles written in the English language and published between January 1990 and October 2018. Studies were included if they described a controlled or uncontrolled trial of an education program for nurses or nursing assistants about urinary incontinence and evaluated the effects of the program on either knowledge, attitudes, practice, or patient outcomes. Data were extracted about the aim, design, sample and setting, trial methods, intervention, outcomes of interest, and findings. Quality appraisal was conducted using a mixed-methods appraisal tool. Results are presented in tabular format and reported descriptively. Nineteen studies met inclusion criteria; most were set in the United States or the UK. All trials that evaluated the effects on knowledge reported improvements; however, the effects of education on attitudes were mixed as were the effects of education on continence care practices. Eleven of the 19 studies reported the statistical effect of education on patient outcomes. Uncontrolled trials reported improvements in nursing home residents’ and community-dwelling patients’ continence status, but this effect was not observed in a large controlled trial. Similarly, 2 studies set in inpatient rehabilitation found no significant differences in patient continence outcomes following an educational intervention targeted to nurses.

Variation in Provision of Collaborative Medication Reviews on Entry to Long-Term Care Facilities.
Access if not affiliated with University of Alberta

J. K. Sluggett, J. S. Bell, C. Lang, et al.
J Am Med Dir Assoc 2020 Nov 30
Residential medication management reviews (RMMRs) are comprehensive medication reviews conducted by clinical pharmacists and general medical practitioners. RMMRs are the primary government-funded service to optimize medication management in Australian residential aged care facilities (RACFs) and are recommended for all new residents. This study investigated resident characteristics associated with timely RMMR provision within 90 days of RACF entry and national intrafacility variation in timely RMMR provision. DESIGN: National retrospective cohort study. SETTING AND PARTICIPANTS: Individuals aged ≥65 years who first entered permanent residential aged care in Australia between January 1, 2012, and December 31, 2015, received at least 1 medication in the previous year, and were alive at 90 days post-RACF entry. METHODS: Resident characteristics associated with timely RMMR provision were determined using multivariate logistic regression. Crude and risk-adjusted funnel plots were used to examine intrafacility variation in timely RMMR provision. RESULTS: Of the 143,676 residents from 2799 RACFs included, 30,883 (21.5%) received an RMMR within 90 days. Resident characteristics associated with timely provision included dementia (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.02-1.08), primary language other than English (aOR 1.04, 95% CI 1.01-1.09), number of unique prescriptions dispensed in the previous year (aOR [per additional 5 prescriptions] 1.02, 95% CI 1.01-1.03), need for medication administration assistance (aORs ranged from 1.35 to 1.42, compared with residents self-managing) and facility remoteness (aORs ranged from 0.67 to 0.75 for residents outside major cities). The proportion of new residents receiving a timely RMMR ranged from 0% (n = 303 RACFs) to 100% (n = 4 RACFs). There were 174 RACFs (6.2%) in which ≥50% of new residents received a timely RMMR. CONCLUSIONS AND IMPLICATIONS: Although there was some evidence that RMMRs are targeted to individuals with a greater burden of medication use and those living with dementia, considerable variation in provision exists nationally. This flagship medication review service is generally underutilized among residents of Australian RACFs.

Staffing policy in aged care must look beyond the numbers.
Access if not affiliated with University of Alberta

S. Wise.
Aust Health Rev 2020 Dec;44(6):829-830
The COVID-19 pandemic has highlighted an aged care system struggling to meet the needs of vulnerable Australians. Staffing levels and skill mix in aged care have declined, whereas the health and social needs of an older and more clinically complex population have risen. Increasing staff and improving personal care workers’ skills and education are essential steps to quality aged care in Australia, but it will not be possible without funding models that foster secure employment, development opportunities and long-term career pathways.