Nursing Homes Research Papers - Academia.edu (original) (raw)

, the number of elderly Hispanics and Asians living in US nursing homes grew by 54.9 percent and 54.1 percent, respectively, while the number of elderly black residents increased 10.8 percent. During the same period, the number of white nursing home residents declined 10.2 percent. These shifts have been driven in part by changing demographics, especially the fast growth of older minority populations. However, the numbers of minority residents in nursing homes increased more rapidly than the minority population overall, even in areas with high concentrations of minority populations. Thus, these results may indicate unequal minority access to home and communitybased alternatives, which are generally preferred for long-term care. When designing initiatives to balance institutional and noninstitutional long-term care, policy makers should take steps to reduce racial and ethnic disparities.

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- Demography, Long Term Care, Aging, Risk assessment
- by Kristin Heggen
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- Psychology, Nursing, Communication, Symbolism

Purpose: To examine the scientific evidence for the effect of comprehensive culture change model implementation on resident health outcomes in longterm care. Design: In this integrated review, an electronic literature search was conducted for studies that examined the effect of comprehensive culture change models on long-term care residents' physical and psychosocial health. Methods: Eleven articles were thoroughly reviewed for outcomes related to resident health, and findings were integrated across models. Each study was assigned a level of evidence rating using the Scottish Intercollegiate Guidelines Network guidelines and an overall recommendation grade was determined. Findings: Evaluation of the literature indicates that results are conflicting, although potential resident benefits as a result of model implementation may exist, particularly in regard to psychosocial health outcomes. Conclusions: Evidence regarding long-term care residents' health outcomes after comprehensive culture change model implementation is inconsistent, and the grade of the evidence makes practice recommendations difficult at this time. However, integrated findings across studies demonstrate potential psychosocial benefits to long-term care residents. Clinical Relevance: Nurses working in long-term care play a crucial role in the success of culture change initiatives as well as the health outcomes of residents. Empirical evidence for the effect of comprehensive culture change models on resident health outcomes supports reasonable expectations of their implementation and indicates areas for future research and translation into practice.

- by A. Kolanowski
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- Nursing, Organizational Culture, Quality of Mental Health Care, Nursing Homes

Objective. To examine racial differences in the risk of hospitalization for nursing home (NH) residents. Data Sources. National NH Minimum Data Set, Medicare claims, and Online Survey Certification and Reporting data from 2000 were merged with independently collected Medicaid policy data. Study Design. One hundred and fifty day follow-up of 516,082 long-stay residents. Principle Findings. 18.5 percent of white and 24.1 percent of black residents were hospitalized. Residents in NHs with high concentrations of blacks had 20 percent higher odds (95 percent confidence interval [CI] 5 1.15-1.25) of hospitalization than residents in NHs with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent (95 percent CI 5 0.93-1.00) for white residents and 22 percent (95 percent CI 5 0.69-0.87) for black residents. Conclusions. Our findings illustrate the effect of contextual forces on racial disparities in NH care.

- by Orna Intrator and +1
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- Risk assessment, Policy making, Health Services, Nursing Homes

A quality of care debate centers on whether pressure ulcers result from factors largely dependent on caregivers, or whether pressure ulcers result from factors associated with patient morbidity. A reduction in incidence, defined as the development of a new pressure ulcer, is the focus of prevention strategies. Yet epidemiological data demonstrates a stability in the incidence of pressure ulcers despite drastic improvements in understanding of pressure ulcers, increased regulatory oversight, and improvements in technologies available for prevention of pressure ulcers. The explanation for this stable incidence of pressure ulcers includes a failure of known effective preventive treat-ment to be applied or the failure of prevention strategies to be effective in spite of being applied. No intervention strategy has been reported that consistently and reproducibly reduces the incidence of pressure ulcers to zero. The published data on prevention of pressure ulcers do not support an assumption that all pressure ulcers are preventable. An effective prevention strategy demonstrated to eliminate pressure ulcers across healthcare settings is lacking. (J Am Med Dir Assoc 2003; 4: S44-S48)

- by Jacob Dimant
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- Nutrition, Quality of Mental Health Care, Quality Improvement, Nursing Homes

Given the preferential tax treatment afforded nonprofit firms, policymakers and researchers have been interested in whether the nonprofit sector provides higher nursing home quality relative to its for-profit counterpart. However, differential selection into for-profits and nonprofits can lead to biased estimates of the effect of ownership form. By using "differential distance" to the nearest nonprofit nursing home relative to the nearest for-profit nursing home, we mimic randomization of residents into more or less "exposure" to nonprofit homes when estimating the effects of ownership on quality of care. Using national Minimum Data Set assessments linked with Medicare claims, we use a national cohort of post-acute patients who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for profit status, we found that post-acute patients in nonprofit facilities had fewer 30-day hospitalizations and greater improvement in pain and ADL functioning.

- by Richard Hirth and +2
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- Health Economics, Quality of Mental Health Care, Applied Economics, Ownership

La contenzione fisica è una misura frequentemente utilizzata, nonostante presenti un rischio piuttosto elevato di conseguenze negative, e per questo suscita ampio dibattito tra i professionisti in tutti i luoghi di cura. L’obiettivo che ci si pone attraverso questo elaborato è delineare le evidenze scientifiche, attraverso una revisione della letteratura, delle complicanze legate all’uso della contenzione fisica praticata negli ospedali e nelle strutture residenziali per anziani, evidenziandone la tipologia e le eventuali differenze dei due ambiti.

- by Ivan Rubbi
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- Psychiatry, Prevention, Nursing Homes, Hospital

RNs make measurable contributions to the health and wellness of individuals living in nursing homes. However, most nursing homes do not employ adequate numbers of professional nurses with specialized training in the nursing care of older adults to positively affect resident outcomes. As a result, many people never receive excellent geriatric nursing while living in a long-term care facility. Nurses have introduced various professional practice models into health care institutions as tools for leading nursing practice, improving client outcomes, and achieving organizational goals. Problematically, few professional practice models have been implemented in nursing homes. This article introduces an evidence-based framework for professional nursing practice in long-term care. The Everyday Excellence framework is based on eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence. Future research will evaluate the usefulness...

- by Stacie Salsbury
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- Nursing, Leadership, Long Term Care, Evidence Based Nursing

Objective: To determine the interrater reliability of the United States Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Number 16 for rehabilitative placement of poststroke patients. Design: Pairs of rehabilitation professionals, highly trained in the Guideline, rated the appropriateness of rehabilitative placements. Setting: Acute care hospitals in three regions of the country. Patients: Sixty patients with moderate-to-severe stroke. Measures: Numerous factors affecting appropriate placement according to the Guideline were abstracted from medical records or obtained by direct evaluation of patients. Results: Good reliability was attained for home and nursing facility placement with rehabilitation services but with no multidisciplinary rehabilitation program (intraclass correlation coefficient = .73 and .60, respectively). Serious reliability problems were found for placements in low-intensity outpatient rehabilitation and high-intensity inpatient rehabilitation programs. Chief sources of unreliability were ambiguous or missing data in hospital medical records, complexities in the Guideline, and raters' tendencies to follow their own clinical judgments. More than one type of placement was appropriate for 65% of patients. Conclusions: Reliable placement guidelines are possible, but aspects of the Guideline require additional development. Evidence of demonstrated reliability and validity will be required to resolve disputes between rehabilitation professionals and payers regarding appropriate levels and types of rehabilitation and to guide patients and their families.

- by Mark Johnston
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- Medicine, Nursing Homes, Missing Data, Patient Admission
- by Adeline Cooney
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- Nursing, Quality of life, Grounded Theory, Ireland
- by Thomas Konrad
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- Long Term Care, Nursing Homes, North Carolina, Aged

Absiract. The compliance of practice to national guidelines on urethral catheter care has been examined. Questionnaires on the practices used with patients under their care were sent to 1350 nursing staff. Replies were received from 1153 individuals, 692 from hospitals, 345 from nursing homes and 116 from home care. While national guidelines stress the importance of maintaining a closed urine drainage system, the results revealed that 25.4% of respondents opened the drainage system to collect samples of urine for analysis, 57.9% to perform bladder washouts and 76% to change urine bags. 26% of respondents reported that they collected urine samples for routine bacteriological surveillance, a procedure considered unnecessary in the guidelines. 83% of staff reported that they washed their hands after emptying urine bags. Staff awareness of written guidelines for various aspects of catheter care ranged from 2 5 4 8 % in hospitals, 27-45% in nursing homes and 7-17% in home care. A marginal costs analysis was performed to estimate the economic consequences of non-compliance to the national guidelines.

- by Kjeld Poulsen
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- Treatment, Public Health, Prevention, Home Care

We developed a staff management system for maintaining treatment gains achieved on a specialized continence unit located in a geriatric nursing home. Geriatric assistants learned to use a prompted voiding procedure to maintain improved dryness for 4 elderly residents. The staff management system induded self-monitoring and recording of prompted voiding activities and supervisory monitoring and feedback based on group performance of these activities. Results show that the system was effective in maintaining prompted voiding activities with corresponding maintenance of improved patient continence. However, a gradual decline in staff performance was noted 4 to 5 months after the initiation of the system. During a subsequent phase of the study, provision of individual feedback restored staff performance to previous levels. Results are discussed in relation to the practicality of prompted voiding interventions in nursing home environments and the applicability of staff management systems in this setting.

- by Louis Burgio
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- Psychology, Cognitive Science, Dementia, Applied Behavior Analysis

BACKGROUND There is little information about Chilean elderly residents of long term care facilities, regarding their characteristics and need for resources. AIM To describe main characteristics and resource utilization of residents of one of the largest nursing homes in Chile, Fundación Las Rosas de Ayuda Fraterna. MATERIAL AND METHODS In a cross sectional and descriptive study, all residents were evaluated using the RUG T-18 method, that assess activities of daily living and the complexity of their clinical situation. RESULTS We assessed 1497 subjects 60 years old and over (73% women), with an age range of 60-106 years. Thirty six percent had urinary incontinence, 19% required assistance for feeding, and 38% needed help for walking or moving. Fifty seven percent were in the lowest category of complexity, "Institutionalization". Very few residents were in the most demanding categories, no one classified as "Rehabilitation", and only 0.7% were in "Special Car...

- by Marcela Carrasco
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- Poverty, Chile, Medicine, Activities of Daily Living

Objective: To identify nursing home standards related to items brought in from the community for residents through a nationwide survey of directors of nursing. Specifically we examined the policies with regard to food, cigarettes,... more

- by richard stefanacci
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- Food, Tobacco, Food Allergy, Nursing Homes

Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our... more

- by Funda Dogruman-Al
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- Microbiology, Epidemiology, Medical Microbiology, Turkey

New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided in...

- by michael cary
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- Communication, Evidence Based Practice, Quality Improvement, Medicine

Carriage of meningococci in contacts of patients with meningococcal disease "Kissing contacts" need to be defined Editor-In their study Kristiansen et al show high carriage rates of pathogenic strains of Neisseria menigitidis in household and kissing contacts of patients with invasive meningococcal disease. 1 While it is easy to define a household contact it may be more difficult to define a kissing contact. There are many types of kiss, ranging from a "peck on the cheek" to much more! In some cultures kissing is as common as shaking hands. In such situations widespread chemoprophylaxis to "kissing contacts" may not be appropriate. It would be valuable to know whether Kristiansen et al placed any restrictions on who was defined as a kissing contact.

- by Shane Kavanagh
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- Family Practice, Nursing Homes, Aged, Public health systems and services research
- by Mary Happ
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- Philosophy, Ethics, Medical Law, Philosophy of Medicine

Scientific evidence on the impact of small-scale living facilities (SSLFs) on quality of life of nursing home clients remains scarce. In this study a simulation model is developed to examine the performance of SSLFs, in terms of meeting the time preferences of their residents. We model scheduled care using historical data and unscheduled care using a Poisson-Gamma mixture model. The model is used to explore the impact of a change in demand characteristics, duration of care delivery, travel time, allocation flexibility, shifts, number of clients and allocation policy. The results show that to further improve the performance, the focus should lie on: (1) increasing the allocation flexibility of care workers and the number of clients per SSLF, and (2) time dependent staffing. Furthermore, this study shows that simulation is a useful tool for assessing and improving daily nursing home operations. The presented simulation model provides a basis for building a decision support tool for nursing home managers.

- by Dennis Moeke
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- Long Term Care, Modeling and Simulation, Health Care Management, Quality of Care

Objective To examine the practice of concealing drugs in patients' foodstuff in nursing homes. Design Cross sectional study with data collected by structured interview. Setting All five health regions in Norway. Participants Professional carers of 1362 patients in 160 regular nursing home units and 564 patients in 90 special care units for people with dementia. Main outcome measures Frequency of concealment of drugs; who decided to conceal the drugs; how this practice was documented in the patients' records; and what types of drugs were given this way. Results 11% of the patients in regular nursing home units and 17% of the patients in special care units for people with dementia received drugs mixed in their food or beverages at least once during seven days. In 95% of cases, drugs were routinely mixed in the food or beverages. The practice was documented in patients' records in 40% (96/241) of cases. The covert administration of drugs was more often documented when the physician took the decision to hide the drugs in the patient's foodstuff (57%; 27/47) than when the person who made the decision was unknown or not recorded (23%; 7/30). Patients who got drugs covertly more often received antiepileptics, antipsychotics, and anxiolytics compared with patients who were given their drugs openly. Conclusions The covert administration of drugs is common in Norwegian nursing homes. Routines for such practice are arbitrary, and the practice is poorly documented in the patients' records.

- by O. Kirkevold
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- Dementia, Food, British medical history, Norway

Objectives To study the relationship between the prevalence of depressive symptoms in newly admitted nursing home residents and their previous place of residence. Methods In 65 nursing homes in the Netherlands trained physicians assessed 562 residents (mean age 78.5, range 28-101, 64.6% female) within 10 days after admission. Depressive symptoms were assessed with the Minimum Data Set (MDS) Depression Rating Scale (DRS), and the MDS items: 'diagnosis of major or minor depression', 'change in depression' and 'indicators of persistent depressed, sad or anxious mood disorder present'. Previous place of residence was categorized as 'own home', 'hospital' or 'sheltered living facility'. Adjustments were performed for demographic and health related factors measured with the MDS. Results The prevalence of depressive symptoms (DRS ! 3) for all 562 residents was 26.9%; it was higher in residents admitted from their own home (34.3%) than in residents admitted from the hospital (19.7%) (p ¼ 0.002). Residents who were admitted from the hospital have an adjusted Odds Ratio for having many depressive symptoms of 0.54 (95% CI 0.31-0.94) compared to residents admitted from their own home. There is, after adjustment, no statistical significant difference between residents admitted from their own home, or residents admitted from a sheltered living facility. Conclusions Depressive symptoms are very prevalent in nursing homes. Residents who are admitted from their own home, or from a residential facility, have more depressive symptoms than residents admitted from the hospital. This may reflect different conceptualizations or different adjustment patterns for those groups. For a better understanding of the factors associated with nursing home depression, future studies in detection, prevention and management of depressive symptoms should start prior to or directly after admission, especially for those who have no prior institutional history.

- by Wilco P Achterberg
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- Psychology, Cognitive Science, Depression, Hospitals

Objective To investigate the prescribing patterns and the prevalence of polypharmacy in community-dwelling elderly people, and to analyze the association of chronic medications and number of drug prescriptions with age and sex. Methods All prescriptions for people aged 65 years or older reimbursed by the Italian National Health Service (NHS) and dispensed by retail pharmacies of the 15 local health units (LHU) in the Lombardy Region during 2005 were analyzed. Logistic regression analysis was used to assess the association between drug prescription (overall, chronic drugs, and polypharmacy) and age, sex, and LHU of residence. Results Eighty-eight percent of the 1 767 239 analyzed elderly received at least one drug prescription. The overall prescription rate was slightly higher for women than men (odds ratio [OR] 1.20; 95%CI 1.19-1.21). Seventy-six percent of the elderly received at least one chronic drug, 46% were exposed to polypharmacy, and 20% to chronic polypharmacy. At multivariate analysis, age and LHU residence of the elderly were the main determinants of drug exposure. A significant correlation was found between the overall prescription prevalence rate and exposure to chronic drugs and to chronic polypharmacy (r s ¼ 0.79, p < 0.0005 and r s ¼ 0.84, p < 0.0001, respectively). Conclusions Our findings indicate that age and LHU residence of the elderly are the main determinants of drug prescribing, and there is evidence of a significant correlation between the overall prescription prevalence rate and exposure to chronic drugs and to chronic polypharmacy.

- by Lara Monesi
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- Primary Health Care, Italy, Nursing Homes, Aged

Aim. This study sought to uncover what nurses perceived to have learned, during their participation in video supported counselling, based on Marte Meo principles, in four dementia specific care units.

- by Rigmor Alnes
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- Nursing, Dementia, Focus Groups, Counseling

Thyroid disorders occur at any age, but hypothyroidism is more common in older than in younger adults. In fact, the prevalence of thyroid disorders increases with age, and it is higher in old-old frail residents in nursing homes. Since thyroid diseases in older age, both overt reduced and increased function, may manifest as disorders of other organs, physicians need a high index of suspicion to detect thyroid dysfunction in an older person with multiple comorbidities and chronic polypharmacy. This is particularly true for residents of longterm facilities, where multiple chronic diseases may make it less attractive to direct attention to thyroid function. Subclinical hyperthyroidism and hypothyroidism, more frequently seen in older populations, have been linked to increased total and cardiovascular mortality. Since chronic diseases are more prevalent in old age, nonthyroidal illness is also seen frequently in this age group. Although, there is still debate on the decision to treat or not to treat subclinical thyroid disorders, current recommendations state the necessity of considering treatment on an individual basis according to symptomatology and to the possible benefit that the older person may obtain with treatment, discouraging extended screening and treatment in the community population of subjects older than 65. However, in the long-term setting, the possibility of thyroid dysfunction can be more often investigated, and the consideration of treatment and follow-up is needed to improve quality of life of affected older people.

- by ligia dominguez
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- Long Term Care, Aging, Medicine, Nursing Homes

This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self-report of pain but allows for observation of pain-related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients’ temporal pain trends.

- by Benny Katz
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- Documentation, Pain, Dementia, Pain Management

To investigate whether robots could reduce resident sleeping and stimulate activity in the lounges of an older persons' care facility. Non-randomised controlled trial over a 12-week period. The intervention involved situating robots in low-level and high-dependency ward lounges and a comparison with similar lounges without robots. A time sampling observation method was utilised to observe resident behaviour, including sleep and activities over periods of time, to compare interactions in robot and no robot lounges. The use of robots was modest; overall 13% of residents in robot lounges used the robot. Utilisation was higher in the low-level care lounges; on average, 23% used the robot, whereas in high-level care lounges, the television being on was the strongest predictor of sleep. This study found that having robots in lounges was mostly a positive experience. The amount of time residents slept during the day was significantly less in low-level care lounges that had a robot.

- by Chandimal Jayawardena
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- Robotics, Quality of life, Television, Activities of Daily Living

Purpose: This article focuses on why it is important for longterm care ombudsmen to collect resident demographics. Design and Methods: The authors analyzed a cross-sectional, 6-state database to show the importance of ombudsman programs' collecting demographic information about the residents of long-term care facilities whom they serve. To demonstrate the importance of collecting demographic data about residents, the authors examined the relationships between race, gender, and types of complaints lodged, verified, and fully resolved. Results: A higher percentage of complaints lodged on behalf of racial minorities was verified, yet a lower percentage was fully resolved. Implications: Ombudsman databases are a potential resource for identifying residents' characteristics that increase their vulnerability in long-term care settings.

- by Kevin Borders
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- Long Term Care, Quality of life, Research, Minority Groups

Objectives The primary purpose of this study was to compare the social health and quality of life of the
older people resident in nursing homes with non-resident elderlies in Tehran City, Iran, in 2015.
Methods & Materials In this descriptive-analytic study with a cross-sectional design, 434 older people,
both resident and non-resident in nursing homes took part. The cluster sampling method was used for
selecting nursing home resident elderlies and convenient sampling method for non-resident elderlies.
Three tools of Keyes Social Health Scale, Elderly Quality of Life Questionnaire (LIPAD), and a demographic
questionnaire were used to measure the variables. After sampling and gathering the questionnaires, the
collected data were analyzed with descriptive and inferential indexes of the Chi-squared test, Kolmogorov-
Smirnov test, and the Independent t-test in SPSS.
Results A total of 217 elderlies resident in nursing homes (144 female and 73 male) and 217 non-resident
elderlies (132 female and 85 male) took part in the study. Two groups were matched for gender, age, and
education (P>0.05) but marriage status (P<0.05). Findings showed that the Mean±SD social health scores
for resident and non-resident elderlies in nursing homes were respectively 45.92±7.87 and 47.25±8.91,
and there was no significant difference between two groups (P>0.05). The Mean±SD quality of life scores
for resident and non-resident elderlies in nursing homes were respectively 27.88±9.80 and 31.81±10.79,
and there was a significant difference between the two groups (P<0.05).
Conclusion According to study results, the resident and non-resident elderlies in nursing homes of Tehran
had low and medium social health and quality of life, respectively. In addition, residency at nursing
homes was not an effective factor for elderly social health; however, it was an effective factor for the
quality of life of older people.

- by Salmand: Iranian Journal of Ageing
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- Quality of life, Nursing Homes, Social Health, Elderlies

Background & aims: Disease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to V 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands. Methods: A cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing-and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands. Results: The total additional costs of managing adult patients with disease related malnutrition were estimated to be V 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study.

- by Karen Freijer
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- Nutrition and Dietetics, Malnutrition, Clinical Nutrition, Nursing Homes
- by Pravin Kamble
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- Decision Making, Depression, Dementia, Anxiety

This article highlights issues and presents strategies for conducting intervention research in highly unstable environments such as schools, critical care units, and long-term care facilities. The authors draw on their own experiences to discuss the challenges that may be encountered in highly unstable settings. The concept of validity provides a framework for understanding the value of addressing the many methodological issues that can emerge in settings characterized by instability. We explain unstable environments by elaborating on knowable elements that contribute to instability. Strategies are provided for improving success of intervention research in unstable settings by carrying out an environmental assessment prior to beginning a study.

- by Margaret Grey and +3
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- Nursing, Research Design, Schools, Nursing Research

Insight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors. Semi-structured qualitative interviews were conducted with physicians (n = 13) and nursing staff (n = 13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff. The analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians' perce...

- by Wilco P Achterberg
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- Decision Making, Long Term Care, Qualitative Research, Nursing Homes

Aims: to investigate the prevalence of and interrelationship between cognitive impairment and behavioural problems in older people in residential care. Subjects: all those aged 65 years and over resident on one night in any type of residential care within the Leicestershire District Health Authority. Methods: an assessment form for each resident was completed by care staff. The assessment included demographic information and functioning (both mental and physical) during the previous week. Cognitive impairment was measured by the confusion sub-scale of the Crichton Royal Behavioural Rating Scale. Results: 6079 people were enumerated in 241 establishments, including hospitals, homes and hostels provided by the National Health Service (NHS), local authority social services and private and voluntary agencies. Thirty-eight percent (2219) were moderately or severely cognitively impaired and behavioural problems were present in 11.5%, most being associated with the presence of cognitive impairment. Compared •with elderly people in private residential homes, residents in local authority (part HI) homes had significantly higher odds of demonstrating offensive behaviour of 1.40 (95% confidence interval 1.11-1.78) after adjustment for age, sex and cognitive impairment. No significant association between number of patients in the home and the proportion exhibiting offensive behaviour was found in any of the non-NHS facilities. Conclusions: this survey of old people in institutional care found that most of those with behavioural problems were cognitively impaired. This has implications for staff training in the management of behavioural problems in demented people

- by Carol Jagger
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- Psychology, Dementia, Hospitals, Residential care

Background: resource use by different types of patients is of increasing interest to health care services all over the world. Case-mix systems that group together individuals with similar patterns of resource use have been developed to address these questions. Resource Utilization Groups version III (RUG-III) was developed in the USA to address the issue in the care of elderly people and has been validated in a number of countries. Method: this paper synthesizes the results of RUG-III validation studies performed in the USA, Japan, Spain, Sweden and England and Wales, showing the consistency of the system in spite of different skill-mix and total time spent with patients. Data from the validation studies of five countries were compared. Percentage of time given by trained nurses and mean nursing time per patient was compared overall and between selected RUG-III groups. Results: mean time per patient ranged from 84.4 min per day in Japan, to 155.6 min in England and Wales. Trained nurse time ranged from 7.5% of total time in the USA to 53.2% of total time in England and Wales. The inter-group relationship was very similar in all countries. The RUG-III system appears robust in a wide variety of settings and countries. Future research should address the relationship between skill-mix and total time spent with patients with respect to outcome and quality of care.

- by G. Ljunggren and +1
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- Psychology, Long Term Care, Japan, Activities of Daily Living

Objective: To provide a systematic review of selected experimental studies of psychosocial treatments of behavioral disturbances in dementia. Psychosocial treatments are defined here as strategies derived from one of three psychologically... more

- by D. Ames
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- Depression, Treatment, Evidence, Music Therapy

The purpose of this article was to investigate nursing homes' (NHs') readiness to implement a quality assurance and performance improvement (QAPI) program as required by Section 6102 of the Affordable Care Act. Nursing home administrators (NHAs) in 3000 NHs (response rate, 67%) were surveyed using a 70-item questionnaire to assess: (1) current facility approaches to quality, (2) NHA's self-assessed knowledge of QAPI techniques; and (3) the use of QAPI techniques. The Online Survey, System for Certification and Administrative Reporting data and the Area Resource File were also used to examine and compare facility and market characteristics. As rated on a scale of 1 to 10, NHs are more likely to use quality assurance (rating, 7.2) and least likely to use total quality management (rating, 4.1). Few NHAs use tools for QAPI such as flow charts (23%), Plan-Do-Check-Act cycles (13%), or run charts (9%). A gap in knowledge of quality improvement tools has been identified signifying that the new QAPI regulations may pose an issue for NHAs who possibly lack the knowledge and technical expertise to implement a comprehensive QAPI program. (K.M. Smith). JAMDA j o u r n a l h o m e p a g e : w w w . j a m d a . c o m

- by Kathryn Hyer and +1
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- Nursing Homes, United States, Patient Protection and Affordable Care Act, Clinical Sciences

Respect for autonomy is well known as a core element of normative views on good care. Most often it is interpreted in a liberal way, with a focus on independence and self-determination. In this article we argue that this interpretation is too narrow in the context of care in nursing homes. With the aim of developing an alternative view on respect for autonomy in this setting we described four interpretations and investigated the moral intuitions (i.e. moral judgements) of caregivers regarding these approaches. We found that these caregivers seemed to value different notions relating to respect for autonomy under different circumstances. There was no significant difference in moral judgements between men and women or between doctors and nurses. We conclude that a multidimensional understanding of this principle would best fit this context. We end this article with a description of a modest theory of respect for autonomy in nursing homes.

- by Johannes Van Delden
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- Nursing, Applied Ethics, Medicine, Nursing Homes

Aim. This paper is a report of a study assessing pressure ulcer incidence and factors affecting pressure ulcer development among older nursing home residents. Background. Previous researchers have shown that demographic, clinical, health... more

- by Gloria Aboo
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- Nursing, Hong Kong, Prospective studies, Advanced Nursing Practice

Objectives-To have healthcare professionals in nursing homes identify organizational-level and individual-level modifiable barriers to medication error reporting. Design-Nominal group technique sessions to identify potential barriers, followed by development and administration of a 20-item cross-sectional mailed survey. Participants and Setting-Representatives of 4 professions (physicians, pharmacists, advanced practitioners, and nurses) from 4 independently owned, nonprofit nursing homes that had an average bed size of 150, were affiliated with an academic medical center, and were located in urban and suburban areas. Measurements-Barriers identified in the nominal group technique sessions were used to design a 20-item survey. Survey respondents used 5-point Likert scales to score factors in terms of their likelihood of posing a barrier ("very unlikely" to "very likely") and their modifiability ("not modifiable" to "very modifiable"). Immediate action factors were identified as factors with mean scores of <3.0 on the likelihood and modifiability scales, and represent barriers that should be addressed to increase medication error reporting frequency. Results-In 4 nominal group technique sessions, 28 professionals identified factors to include in the survey. The survey was mailed to all 154 professionals in the 4 nursing homes, and 104 (67.5%) responded. Response rates by facility ranged from 55.8% to 92.9%, and rates by profession ranged from 52.0% for physicians to 100% for pharmacists. Most respondents (75.0%) were women.

- by Ellen Olshansky
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- Documentation, Risk Management, Nursing Homes, Feedback

Objective: To test the hypothesis that individual and institutional-level factors influence the effects of a humor therapy intervention on aged care residents. Methods: Data were from the humor therapy group of the Sydney Multisite Intervention of LaughterBosses and ElderClowns, or SMILE, study, a single-blind cluster randomized controlled trial of humor therapy conducted over 12 weeks; assessments were performed at baseline, week 13, and week 26. One hundred eighty-nine individuals from 17 Sydney residential aged care facilities were randomly allocated to the humor therapy intervention. Professional performers called "ElderClowns" provided 9e12 weekly humor therapy 2-hour sessions, augmented by trained staff, called "LaughterBosses." Outcome measures were as follows: Cornell Scale for Depression in Dementia, Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and proxy-rated quality of life in dementia population scale. Facility-level measures were as follows: support of the management for the intervention, commitment levels of LaughterBosses, Environmental Audit Tool scores, and facility level of care provided (high/low). Resident-level measures were engagement, functional ability, disease severity, and time-in-care. Multilevel path analyses simultaneously modeled resident engagement at the individual level (repeated measures) and the effects of management support and staff commitment to humor therapy at the cluster level. Results: Models indicated flow-on effects, whereby management support had positive effects on LaughterBoss commitment, and LaughterBoss commitment increased resident engagement. Higher resident engagement was associated with reduced depression, agitation, and neuropsychiatric scores. Conclusion: Effectiveness of psychosocial programs in residential aged care can be enhanced by management support, staff

- by B. Goodenough and +1
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- Depression, Dementia, Treatment Outcome, Nursing Homes

Consultants are an integral part of the medical care team in long-term care facilities. Attending physicians rely on consultants to obtain needed knowledge or provide specialty care to residents. Communications between attending physicians, consultants, and other members of the care team is crucial to quality care, error prevention, and risk management. The importance of a well-structured and defined system to ensure availability of consultations, timeliness of consultants' visits and care, and communications between consultants and attending physicians is underscored by negative patient outcomes and legal liability resulting from lack of such systems.

- by Jacob Dimant
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- Documentation, Long Term Care, Consultants, Nursing Homes
- by Lois Miller and +1
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- Nursing, Leadership, Long Term Care, Quality of Mental Health Care

Background: This paper was written as a result of the International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care. The appraisal presented here aims to (1) identify the best available evidence that underpins best practice for geriatric mental health education and training of staff working in long-term care, and (2) summarize the appraisal of the literature to provide recommendations for practice.

- by Susan Lieff
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- Long Term Care, Evidence Based Medicine, Nursing Homes, Mental Disorders

Background & aims: Malnutrition is a common problem in the elderly living in nursing homes. A clear understanding of associated factors is missing. The aim of this study was to evaluate prevalence of malnutrition and to determine factors independently associated with malnutrition in this setting. Methods: A cross-sectional, multi-centre study was conducted in 23 nursing homes in Flanders, Belgium. The nutritional status was assessed using the Mini Nutritional Assessment (MNA). Data on possible associated factors were collected using validated scales. Results: The study included 1188 elderly residents; 38.7% were at risk for malnutrition and 19.4% were malnourished. The presence of a wound/pressure ulcer, a recent hospitalization (<3 months ago), being involved in a tailored nutritional intervention, and suffering from a lower cognitive state were significantly associated with malnutrition. Receiving additional meals provided by family members was negatively associated with malnutrition. Conclusion: Malnutrition is a prevalent problem in nursing homes in Flanders. Systematic screening and well-defined tailored interventions should be further developed and evaluated in this population at risk.

- by Koen Van Herck and +1
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- Nutrition and Dietetics, Belgium, Malnutrition, Clinical Nutrition

To determine the interobserver reliability of radiologists&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; interpretations of mobile chest radiographs for nursing home-acquired pneumonia. A cross-sectional reliability study. Nursing homes and an acute care hospital. Four radiologists reviewed 40 mobile chest radiographs obtained from residents of nursing homes who met a clinical definition of lower respiratory tract infections. Radiologists were asked to interpret radiographs with respect to the film quality; presence, pattern, and extent of an infiltrate; and the presence of a pleural effusion or adenopathy. Interrater reliability was evaluated using the intraclass correlation coefficient derived from a 2-way random effects model. On average the radiologists reported that 6 of the 40 films were of very good or excellent quality and 16 of the 40 were of fair or poor quality. When the finding of an infiltrate was dichotomized (0 = no; 1 = possible, probable, or definite) all 4 radiologists agreed on 21 of the 37 chest radiographs. The intraclass correlation coefficient for the presence or absence of infiltrates was 0.54 (95% confidence intervals [CI] 0.38 to 0.69). For the 14 radiographs where infiltrates were observed by all radiologists, intraclass correlation coefficients for the presence of pleural effusions was 0.08 (95% CI -0.10 to 0.41), hilar adenopathy 0.54 (95% CI 0.29 to 0.79), and mediastinal adenopathy 0.49 (95% CI 0.21 to 0.76). In conclusion, the interrater agreement among radiologists for mobile chest radiographs in establishing the presence or absence of an infiltrate can be judged to be &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;fair.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; Treatment decisions need to include clinical findings and should not be made based on radiographic findings alone.

- by Soo Chan Carusone
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- Geriatrics, Radiology, X Rays, Nursing Homes
- by Susan Kennerly
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- Nursing, Leadership, Nursing Homes, Patient Care Team

The aims and objectives of this paper are to illuminate and discuss the experiences and perceptions of nursing students and supervising nurses regarding the students' learning of person-centred care of patients with Alzheimer's disease in a teaching nursing home. This information is then used to develop recommendations as to how student learning could be improved.

- by Mari Skaalvik and +1
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- Psychology, Nursing, Learning, Student Experience

Nosocomial infections are a major problem in health care facilities, involving at least 2 million patients annually and resulting in extended durations of care and substantial morbidity. 1 Such infections are estimated to cause or contribute to 88,000 deaths annually in the United States and contribute to greater costs of hospitalization and overall costs of care. 1 The incidence of infections in acute-care facilities is approximately 9.8 infections per 1000 patient caredays and is approximately 7.2 infections per 1000 resident care-days in long-term care facilities. 2,3 Because infections are a major cause of morbidity and mortality in acute, extended, and long-term care settings, attempts to control infections have demanded increasing attention. Since good hand hygiene is acknowledged as a simple but powerful technique for preventing nosocomial infections, one focus of these infection control measures is hand hygiene practices. Handwashing is still considered the most important and effective infection control measure to prevent transmission of nosocomial infections. 4 However, compliance with handwashing procedures by health care workers has been, and continues to be, unacceptably low at 20% to 50%. 2,5-8 Recent studies have shown that deterrents to handwashing compliance include the amount of time required for soap-andwater handwashing with heavy workloads, skin irritation and dryness caused by frequent handwashing with soap and water, and poor access to sinks. 2,9-13 Use of waterless, alcohol-based hand sanitizers (gels) and rubs (rinses) instead of soap-and-water hand

- by Yasir Ali
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- Nursing, Health Care, Medicine, Infection Control