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Objectives: Innovative care environments are developed for people with dementia to encourage person-centered care. This study aims to investigate whether residents of green care farms that provide 24-hour nursing care participate more in (physical) activities and social interaction compared with residents of other nursing homes., Design: Longitudinal observation study., Setting: Nursing homes in the Netherlands (green care farms, traditional nursing homes, and regular small-scale living facilities)., Participants: A total of 115 nursing home residents at baseline, 100 at follow-up., Measurements: Ecological momentary assessments (n = 16,860) were conducted using the Maastricht Electronic Daily Life Observation Tool. Residents living at green care farms were compared with residents living in traditional nursing homes and regular small-scale living facilities. The following aspects were collected for this study: the activity performed by the participant or occurring in his or her vicinity, the engagement in the activity, the level of physical activity during the activity, the physical environment (location where the activity occurred), and the level of social interaction during the activity., Results: In total, 9660 baseline observations and 7200 follow-up observations were conducted. Analyses showed that residents of green care farms significantly more often participated in domestic activities (P = .004, SE = 1.6) and outdoor/nature-related activities (P = .003, SE = 0.9), and significantly less often engaged in passive/purposeless activities (P < .001, SE = 1.7) compared with residents of traditional nursing homes. Furthermore, residents of green care farms had significantly more active engagement (P = .014, SE = 0.9), more social interaction (P = .006, SE = 1.1), and came outside significantly more (P = .010, SE = 1.1) than residents of traditional nursing homes. Residents of green care farms were significantly more physically active (P = .013, SE = 0.8) than were residents of regular small-scale living facilities. No other significant differences were found., Conclusion: Green care farms can be a valuable alternative to traditional nursing homes. They provide an attractive, homelike environment and activities that positively influence engagement and social interaction. Research is needed to study how successful elements of green care farms can be implemented in existing nursing homes., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Research shows that nursing home residents are largely inactive. This inactivity negatively influences physical fitness, and participation in daily activities is known to have a positive influence on physical function and quality of life. Existing research does not provide sufficient insight into the daily activities in which nursing home residents participate. This insight is needed to develop future interventions so as to encourage nursing home residents to participate in daily activities and, thereby, decrease inactivity. The purpose of this study was to obtain insight into daily (in)activities of psychogeriatric and somatic nursing home residents during the day and their body positions during these (in)activities., Design: Cross-sectional observation study., Setting: Nursing homes in the Netherlands (19 psychogeriatric and 11 somatic wards)., Participants: Participants were 723 home residents in 7 nursing homes., Measurements: Observations were conducted using a self-developed observation list. Residents were observed in their wards during 5 random observation times between 7:00 am and 11:00 pm, in which the daily activity and position of the resident during this activity were scored. Percentages of activities and positions were calculated for each observation time., Results: In total, 3282 observations (91% of the intended 3615 observations) were conducted. Nursing home residents of both psychogeriatric and somatic wards were mainly observed partaking in in activities, such as sleeping, doing nothing, and watching TV (range: 45%-77% of the 5 observation times). Furthermore, residents were engaged in activities of daily living (ADLs) (range: 15%-38%) that mainly comprised activities related to mobility (range: 10%-19%) and eating and drinking (range: 2%-17%). Engagement of residents in instrumental ADLs (IADLs) was rarely observed (up to 3%). Residents were largely observed in a lying or sitting position (range: 89%-92%)., Conclusion: Most of the psychogeriatric and somatic nursing home residents spend their day inactive in a lying or sitting position in the ward. To encourage nursing home residents in daily activities in the wards, interventions are needed that (1) focus on increasing ADLs and IADLs, and (2) encourage standing and walking., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe care worker-reported quality of care and to examine its relationship with staffing variables, work environment, work stressors, and implicit rationing of nursing care., Design: Cross-sectional study., Setting: National, randomly selected sample of Swiss nursing homes, stratified according to language region and size., Participants: A total of 4311 care workers of all educational backgrounds (registered nurses, licensed practical nurses, nurse aides) from 402 units in 155 nursing homes completed a survey between May 2012 and April 2013., Measurements: Care worker-reported quality of care was measured with a single item; predictors were assessed with established instruments (eg, Practice Environment Scale-Nurse Working Index) adapted for nursing home use. A multilevel logistic regression model was applied to assess predictors for quality of care., Results: Overall, 7% of care workers rated the quality of care provided as rather low or very low. Important factors related to better quality of care were higher teamwork and safety climate (odds ratio [OR] 6.19, 95% confidence interval [CI] 4.36-8.79); better staffing and resources adequacy (OR 2.94, 95% CI 2.08-4.15); less stress due to workload (OR 0.71, 95% CI 0.55-0.93); less implicit rationing of caring, rehabilitation, and monitoring (OR 0.34, 95% CI 0.24-0.49); and less rationing of social care (OR 0.80, 95% CI 0.69-0.92). Neither leadership nor staffing levels, staff mix, or turnover was significantly related to quality of care., Conclusions: Work environment factors and organizational processes are vital to provide high quality of care. The improvement of work environment, support in handling work stressors, and reduction of rationing of nursing care might be intervention points to promote high quality of care in nursing homes., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Increasing demands in long-term care for older people and a decrease in workforce availability can be expected in the future. These developments challenge the sustainability and quality of long-term care for older people. To address these challenges, long-term care organizations are forced to innovate. The aim of this study is to provide an overview of potential labor-saving and quality-improving innovations long-term care organizations are working on and to assess the self-reported extent of effectiveness., Design: This is a descriptive cross-sectional study., Methods: In total, 32 long-term care organizations in the region of Limburg in The Netherlands were invited to participate in the study. The inventory was performed by means of semistructured interviews with chief executive officers, managers, and staff members of the long-term care organizations. Based on the interview data, all innovations were described in a standardized form and subsequently checked by the participants. All innovations were clustered into product, process, organizational, and marketing innovations., Results: In total, 26 long-term care organizations delivering home and/or institutional long-term care for older people participated in the study. Overall, 228 innovations were identified; some innovations were described in a similar way by different organizations. The majority of innovations were product innovations (n = 96), followed by organizational innovations (n = 75), and process innovations (n = 42). In addition to the main types, 15 other innovations incorporating characteristics of different types of innovations were detected. Little evidence about the effectiveness of the innovations was reported by the organizations., Conclusions: This study shows that a large number and a broad variety of innovations have been implemented or are currently being developed in long-term care organizations for older people. However, according to the organizations, there is relatively little (scientific) evidence confirming the effectiveness of these innovations. More research is needed to evaluate the effects of the innovations and to indicate whether they provide real solutions to future challenges., (Copyright © 2015 AMDA - The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The relationship between nurse staffing and quality of care (QoC) in nursing homes continues to receive major attention. The evidence supporting this relationship, however, is weak because most studies employ a cross-sectional design. This review summarizes the findings from recent longitudinal studies., Methods: In April 2013, the databases PubMed, CINAHL, EMBASE, and PsycINFO were systematically searched. Studies were eligible if they (1) examined the relationship between nurse staffing and QoC outcomes, (2) included only nursing home data, (3) were original research articles describing quantitative, longitudinal studies, and (4) were written in English, Dutch, or German. The methodological quality of 20 studies was assessed using the Newcastle-Ottawa scale, excluding 2 low-quality articles for the analysis., Results: No consistent relationship was found between nurse staffing and QoC. Higher staffing levels were associated with better as well as lower QoC indicators. For example, for restraint use both positive (ie, less restraint use) and negative outcomes (ie, more restraint use) were found. With regard to pressure ulcers, we found that more staff led to fewer pressure ulcers and, therefore, better results, no matter who (registered nurse, licensed practical nurse/ licensed vocational nurse, or nurse assistant) delivered care., Conclusions: No consistent evidence was found for a positive relationship between staffing and QoC. Although some positive indications were suggested, major methodological and theoretical weaknesses (eg, timing of data collection, assumed linear relationship between staffing and QoC) limit interpretation of results. Our findings demonstrate the necessity for well-designed longitudinal studies to gain a better insight into the relationship between nurse staffing and QoC in nursing homes., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore reasons for institutionalization of people with dementia according to informal caregivers as well as variation in reasons between countries., Design: An explorative cross-sectional study was conducted in 8 European countries., Setting: Per country, a minimum of 3 long term care facilities, offering care and accommodation as a package, participated in this study. Participating countries were selected to represent different geographic areas in Europe., Participants: Of the 791 informal caregivers involved in the RightTimePlaceCare project of people with dementia who were recently admitted to a long term care facility, 786 were included for this study., Measurements: As part of a semistructured interview, informal caregivers were asked the main reason for institutionalization in an open-ended question. Answers were categorized according to a conventional coding approach. All reasons were then quantified and tested., Results: Mainly patient-related reasons were stated, such as neuropsychiatric symptoms (25%), care dependency (24%), and cognition (19%). Neuropsychiatric symptoms were among the most often mentioned reasons in most countries. Besides patient-related reasons, caregiver burden and the inability of the informal caregiver to care for the patient were stated as reasons (both 15%). Further analyses showed countries differ significantly in reasons according to informal caregivers. Additionally, reasons were analyzed for spouses and child-caregivers, showing that spouses more often stated reasons related to themselves compared with child-caregivers., Conclusion: Multiple reasons contribute to the institutionalization for people with dementia, with several factors that may influence why there were country differences. Variation in the organization of dementia care and cultural aspects, or the relationship between the informal caregiver and person with dementia may be factors influencing the reasons. Because of a wide variation in reasons between countries, no one-size-fits-all approach can be offered to guide informal caregivers when facing the possibility of institutionalization of the person with dementia., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore how quality of life (QoL) and quality of care (QoC) for people with dementia (PwD) vary across 8 European countries; to explore how QoL and QoC for PwD vary across living arrangements; and to assess the association between QoL and QoC., Design: Cross-sectional survey., Setting: Institutional long term care and home care in 8 European countries (England, Estonia, Finland, France, Germany, the Netherlands, Spain, and Sweden)., Participants: PwD receiving formal home care but at risk for admission to an institutional setting, and PwD who were recently admitted., Measurements: QoL was assessed by the PwD and by their best informed proxies using the Quality of Life-Alzheimer's Disease scale (QoL-AD) (range 13-52). QoC was measured using quality of care indicators (eg, the presence of depressive symptoms, the presence of pressure ulcers)., Results: A total of 1123 PwD living at home (mean age 82.2, 63%women) and 791 PwD living in institutional care (mean age 84.1, 74% women) participated. QoL of PwD was most often rated highest in Sweden and England and lowest in Estonia and Spain. No differences in QoL were detected among the settings. For the QoC indicators, no consistent patterns were visible in such a way that certain countries or settings scored "higher" or "lower." The presence of depressive symptoms was most consistently associated with lower QoL (P ≤ .001)., Conclusion: There is great variation in QoL and QoC scores among European countries and settings. To gain insight into the underlying causes of these differences, more knowledge is needed about the effect of different national health care systems and dementia strategies on QoL and QoC indicators. Depressive symptoms were associated with QoL, and executing longitudinal studies investigating which factors are associated with change in QoL is highly recommended., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: The current study describes the process evaluation of a multicomponent intervention program (Expelling Belts [EXBELT]) to reduce the use of belt restraints in psychogeriatric nursing homes. The aim was to assess the feasibility and ascertain suggestions for optimization of the EXBELT program., Design: A descriptive study comprising longitudinal elements., Setting: Fifteen psychogeriatric nursing home wards in 6 Dutch nursing homes., Participants: The study population consisted of 4 different groups of participants who took part in the intervention arm of the quasi-experimental study examining the effectiveness of EXBELT: nursing home staff who attended the final session of the educational program; 2 nurse specialists who delivered the educational program and did the consultations; 4 groups of delegates representing the nursing home associations where the EXBELT program was implemented; and the relatives of those residents in the intervention group who were restrained with a belt at the start of the study., Measurements: Both quantitative and qualitative data were collected from the study population. Data were assessed by means of self-administered questionnaires, recording forms, group interviews, telephone interviews, and monthly meetings., Results: The EXBELT study was largely performed according to protocol and very well received by nursing home staff as well as resident's relatives. Suggestions to improve the EXBELT program include the addition of examples of how to communicate about the policy change, improving the reach of the intended target population, adding more case-based learning strategies, and embedding the available consultants more proactively., Conclusions: The implementation of EXBELT was highly successful in the current research population and is likely to be feasible in psychogeriatric nursing homes in general., (Copyright © 2013 American Medical Directors Association, Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the effects of small-scale living facilities in dementia care on residents, family caregivers, and staff., Design: This was a quasi-experimental study including 2 types of institutional nursing care: small-scale living facilities (experimental group), and regular psychogeriatric nursing home wards (control group). Three measures were conducted: at baseline and follow-ups after 6 and 12 months., Setting: Twenty-eight houses in small-scale living facilities and 21 regular psychogeriatric nursing home wards., Participants: In total, 259 residents were included in the study: 124 in small-scale living facilities and 135 controls, matched on cognitive and functional status. Furthermore, 229 family caregivers were included and 305 staff members., Measurements: For residents, main outcome measures were quality of life, neuropsychiatric symptoms, and agitation. Main outcome measures for family caregivers included perceived burden, satisfaction, and involvement with care. Main outcome measures for staff were job satisfaction and motivation., Results: No effects were found for residents' total quality of life, neuropsychiatric symptoms, and agitation. Family caregivers in small-scale living reported significantly less burden (adjusted mean difference 0.8, 95% CI 0.1-1.5) and were more satisfied with nursing staff (0.3, 0.2-0.5) than family caregivers in regular wards. No differences were found in their involvement with care. Overall, no significant differences were found for staff's job satisfaction and motivation, although subgroup analyses using contrast groups (regarding typical small-scale living and regular wards) revealed more job satisfaction (2.0, 0.5-3.5) and motivation (0.6, 0.0-1.3) in small-scale living compared with regular wards., Conclusion: This study was unable to demonstrate convincing overall effects of small-scale living facilities. Because governmental policies and, in some countries, financial support, are increasingly aimed at providing small-scale, homelike care, it is suggested that this may not be a final solution to accomplish high-quality dementia care and that other options should be considered., (Copyright © 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)