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Purpose: The aim of this study was to explore and clarify the role of nursing staff in geriatric rehabilitation on supporting patients in goal setting and achieving, through reflecting on rehabilitation interventions. Design: A descriptive qualitative study was conducted. Methods: We conducted four online focus group interviews with 23 members of the nursing staff working in geriatric rehabilitation. They reflected on six interventions, preclassified into three types: setting goals in the admission phase, increasing patient participation in order to personalize the rehabilitation trajectory, and supporting patients in working on short-term goals. Data were analyzed using thematic content analysis. Results: Setting goals in the admission phase is primarily the task of the multidisciplinary team rather than the nursing staff. Interventions to increase patient participation align with the coordinating role of nursing staff in the rehabilitation team. Working on short-term goals is of great value to patients. Clinical Relevance to the Practice of Rehabilitation Nursing: The connection between the patient’s personal goals and professional treatment aimed at functional recovery can be enhanced by strengthening the position of nursing staff working in geriatric rehabilitation. Conclusion: Members of nursing staff in geriatric rehabilitation see themselves playing a coordinating role in the multidisciplinary team, supporting the patient in goal work. Interventions aimed at advancing patient participation and providing support for short-term goals reinforce this role.

Background Nurses are consistently present throughout the rehabilitation of older patients but are apprehensive about performing goal-centred care in the multidisciplinary team. Objectives The aim of this review was to explore working interventions on setting goals and working with goals designed for nurses in geriatric rehabilitation, and to describe their distinctive features. Methods We performed a scoping review. We searched MEDLINE and CINAHL through August 4, 2021. Search terms related to the following themes: nurses, rehabilitation, geriatric, goal and method. We used snowballing to find additional. From the selected studies, we systematically extracted data on means, materials and the nursing role and summarized them in a narrative synthesis, using intervention component analysis. Results The study includes 13 articles, describing 11 interventions which were developed for six different aims: improving multidisciplinary team care; increasing patient centredness; improving disease management by patients; improving the psychological, and emotional rehabilitation; increasing the nursing involvement in rehabilitation; or helping patients to achieve goals. The interventions appeal to four aspects of the nursing profession: assessing self-care skills incorporating patient's preferences; setting goals with patients, taking into account personal needs and what is medically advisable; linking the needs of the patient with multidisciplinary professional treatment and vice versa; and thus, playing an intermediate role and supporting goal achievement. Conclusions The interventions show that in goal-centred care, the nurse might play an important unifying role between patients and the multidisciplinary team. With the support of nurses, the patient may become more aware of the rehabilitation process and transfer of ownership of treatment goals from the multidisciplinary team to the patient might be achieved. Not many

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Background: In the care of people with intellectual disability, support staff apply restrictions to people with moderate intellectual disabilities (ID) in several domains of daily life, such as restrictions on bedtimes or on the amount of food intake. Support staff may experience moral dilemmas applying these restrictions. In this respect, moral case deliberation (MCD) is used as an instrument for support staff to jointly reflect on dilemmas in care and is considered a form of ethical support. MCD also seems to broaden the perspective of their participants. Specific Aims: This study examined to what extent MCD led to changes in support staff's perspectives with regard to daily life restrictions placed upon people with moderate ID. Consequently, this study examined to what extent support staff's perspectives on these restrictions were broadened as a result of their participation in the study. Method: Prior to and following a series of three MCD sessions on moral dilemmas commonly encountered in daily life care, interviews were held with 12 support staff across two teams. Participants were asked what they considered to be good care in the given dilemmas. To systematically compare all of the answers given in the interviews prior to and following the MCDs, the same interview-guide was used in both instances. Interviews were analyzed inductively. Findings: Following the MCD sessions, the respondents tended to hold onto their perspective to restrict clients to provide them with structure, clarity and rest, as expressed prior to the MCD. However, some respondents adapted their perspective on restrictions and were willing to provide people with moderate ID more freedom after the MCD. Discussion: This study contributed to the evidence underlying MCD in healthcare and in providing insights into MCD with regard to daily life restrictions in the care of people with moderate ID. Partly, MCD leads to a broadening of perspect

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Background Due to incompatibilities in communication, it is key that family members and support staff can take the perspective of people with moderate to profound intellectual disabilities (ID) whilst putting aside their own perspectives. Method Ten vignettes describing types of restraint interventions (RIs) were presented to 20 unique pairs of support staff and family members related to individuals with moderate to profound ID. Results In taking their own perspective, more than half of the support staff and family members perceived all RIs as involuntary and severe. In contrast, when asked to put themselves in the position of the client/family member, only three RIs were considered involuntary by a majority of support staff and family members. Conclusions These results indicate that support staff and family members can take into account the perspective of people with moderate to profound ID in the evaluation and consideration of involuntary care.

Objectives: Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population. Design(s): A Delphi consensus procedure. Setting and Participants: An international panel of practitioners recognized as experts in the field of UTI in frail older patients. Measures: In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool. Result(s): Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter. Conclusion(s): A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.Copyright © 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine

Item does not contain fulltext, OBJECTIVES: We explored how pneumonia and intake problems affect survival in nursing home residents in variable stages of dementia. METHODS: In a longitudinal observational study (372 residents) with up to 3.5 years of follow-up, we examined relationships between dementia severity, the development of pneumonia, intake problems, and mortality using joint modeling, Cox models, and mediation analyses. Dementia severity was measured semiannually with the Bedford Alzheimer Nursing Severity-Scale (BANS-S). RESULTS: The median BANS-S score at baseline was 13 (range, 7 to 28). Pneumonia occurred in 103 (28%) and intake problems in 126 (34%) of 367 residents with complete registration of pneumonia and intake problems. Compared with dementia severity, incident pneumonia and, even more so, incident intake problems were more strongly associated with mortality risk. Pneumonia and intake problems both mediated the relationship between more severe dementia and mortality. DISCUSSION: Developing pneumonia and intake problems affects survival, and this is not limited to advanced dementia. The occurrence of pneumonia and intake problems are important signals to consider a palliative care approach in nursing home residents with dementia, and an active focus on advance care planning is needed. Future studies should investigate whether this is also relevant for patients in primary care.

Item does not contain fulltext, OBJECTIVES: To explore changes in care goals and treatment orders around the occurrence of pneumonia and intake problems, and whether hospitalization is in line with earlier agreed-upon do-not-hospitalize orders. DESIGN: Data were collected as part of the Dutch End of Life in Dementia study (2007-2011), a longitudinal observational study with up to 3.5 years of follow-up. SETTING: Long-term care facilities (N = 28) in the Netherlands. PARTICIPANTS: Newly admitted nursing home patients (N = 372) in various stages of dementia. MEASUREMENTS: Semiannually, physicians completed questionnaires about care goals and treatment orders, and they continuously registered episodes of pneumonia, intake problems and hospitalization. We report on changes in care goals and treatment orders during follow-up in relation to the developing of pneumonia and intake problems and on hospitalization and reasons for hospitalization. RESULTS: The proportion of patients with palliative care goals and do-not-treat orders rose during follow-up, especially before death. Treatment orders most frequently referred to resuscitation and hospitalization (do-not order increased from 73% to 92%, and from 28% to 76%, respectively). The proportions of patients with a palliative care goal and do-not-treat orders were similar after developing pneumonia, but increased after intake problems. During follow-up, 46 patients were hospitalized one or more times. Hospitalization occurred despite a do-not-hospitalize order in 21% of decisions. The most frequently reported reason for hospitalization was a fracture, especially in patients with a do-not-hospitalize order. CONCLUSION: Care plans, including global care goals (predominantly palliative care goals), are made soon after admission, and specific treatment orders are agreed upon in more detail when the condition of the patient worsens. Establishing care plans shortly after nursing home admission may help to prevent burdensome treatment.

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Item does not contain fulltext, OBJECTIVE: To investigate the appropriateness of decisions to prescribe or withhold antibiotics for nursing home (NH) residents with infections of the urinary tract (UTI), respiratory tract (RTI), and skin (SI). DESIGN: Prospective study. SETTING: Ten NHs in the central-west region of the Netherlands. PARTICIPANTS: Physicians providing medical care to NH residents. MEASUREMENTS: Physicians completed a registration form for any suspected infection over an 8-month period, including patient characteristics, signs and symptoms, and treatment decisions. An algorithm, developed by an expert panel and based on national and international guidelines, was used to evaluate treatment decisions for appropriateness of initiating or withholding antibiotics. Results : Appropriateness of 598 treatment decisions was assessed. Overall, 76% were appropriate, with cases that were prescribed antibiotics judged less frequently "appropriate" (74%) compared with cases in which antibiotics were withheld (90%) (P = .003). Decisions around UTI were least often appropriate (68%, compared with 87% for RTI and 94% for SI [P < .001]). The most common situations in which antibiotic prescribing was considered inappropriate were those indicative of asymptomatic bacteriuria or viral RTI. CONCLUSION: Although the rate of appropriate antibiotic prescribing in Dutch NHs is relatively high compared with previous studies in other countries, our results suggest that antibiotic consumption can be reduced by improving appropriateness of treatment decisions, especially for UTI. Given the current antibiotic resistance developments in long-term care facilities, interventions reducing antibiotic use for asymptomatic bacteriuria and viral RTI are warranted.

Contains fulltext : 138130.pdf (publisher's version ) (Open Access), BACKGROUND: The Grip on Challenging Behavior care program for managing challenging behavior was implemented in the dementia special care units of 17 Dutch nursing homes. A process evaluation of the implementation of the care program was performed to determine the quality of the implementation and the lessons to be learned for future implementation. METHODS: The care program was implemented according to a stepped wedge design. First-order data (data on recruitment, reach, relevance and feasibility) were used to determine the validity of the study, and second-order data (intervention quality and the barriers and facilitators for implementing the care program) were used to describe the implementation process. Two structured questionnaires were administered to care staff and key stakeholders and semi-structured interviews were held in the units. RESULTS: University affiliated and non-affiliated nursing homes from different parts of the Netherlands participated. The resident participation rate was over 95% and the participation rate for the training sessions was 82%. Respondents considered the care program relevant and feasible. The degree of implementation was not optimal. The barriers and facilitators in implementing the care program could be divided into three categories: organizational aspects, culture on the unit and aspects of the care program itself. CONCLUSIONS: The recruitment, reach, relevance and feasibility are sufficient to allow for analysis and generalization of the effects of the care program, but the degree of implementation should be taken into account in further analysis. Future projects that involve implementation should consider the specific features of the organization and the cultural orientation of the unit to better adapt to specific needs. TRIAL REGISTRATION: The Netherlands National Trial register under number NTR2141 registered on 11 December 2009. Randomization took place in November 2010, and the first intervention group started using the in

Item does not contain fulltext, OBJECTIVES: The Grip on Challenging Behavior care program was developed using the current guidelines and models on managing challenging behavior in dementia in nursing homes. It was hypothesized that the use of the care program would lead to a decrease in challenging behavior and in the prescription of psychoactive drugs without increase in use of restraints. DESIGN: A randomized controlled trial was undertaken using a stepped-wedge design to implement the care program and to evaluate the effects. An assessment of challenging behavior and psychoactive medication was undertaken every 4 months on all participating units followed by the introduction of the care program in a group of 3 to 4 units. A total of 6 time assessments took place over 20 months. SETTING: Seventeen dementia special care units of different nursing homes. PARTICIPANTS: A total of 659 residents of dementia special care units. All residents with dementia on the unit were included. Units were assigned by random allocation software to 1 of 5 groups with different starting points for the implementation of the care program. INTERVENTION: A care program consisting of various assessment procedures and tools, which ensure a multidisciplinary approach and which structure the process of managing challenging behavior in dementia. MEASUREMENTS: Challenging behavior was measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory. Research assistants (blinded for intervention status of the unit) interviewed nurses on the units about challenging behavior. Data on psychoactive drugs and restraints were retrieved from resident charts. RESULTS: A total of 2292 assessments took place involving 659 residents (1126 control measurements, 1166 intervention measurements). The group of residents who remained in the intervention condition compared with the group in the control condition differed significantly in the CMAI change scores between successive assessments [-2.4 CMAI points, 95%

Item does not contain fulltext, OBJECTIVES: To optimize care and interventions to improve care, and to reduce staff burden, it is important to have knowledge of the relation between individual neuropsychiatric symptoms and distress of care staff. We therefore explored the relation between frequency and severity of individual neuropsychiatric symptoms and distress of care staff. DESIGN: This is an explorative study with a cross-sectional design. PARTICIPANTS AND SETTING: Care staff was interviewed regarding 432 residents of 17 nursing homes for people with dementia. MEASUREMENTS: Behavioural problems were assessed using the Nursing Home version of the Neuropsychiatric Inventory (NPI-NH) questionnaire. The distress scale of the NPI-NH was used to determine the distress of care staff. RESULTS: Agitation/aggression had the highest mean distress score and was also the most prevalent symptom. Disinhibition and irritability/lability also had high mean distress scores, whereas euphoria/elation, hallucinations and apathy had the lowest mean distress score. The symptom severity of each symptom strongly predicted the distress score, whereas the frequency of the symptoms was a less important factor. CONCLUSIONS: Although some of these findings are in accordance with studies among informal caregivers, there are also notable differences. Apathy caused little distress among care staff. Therefore, care staff might not feel the urgency to explore the causes of this symptom. The findings of this study emphasize the importance of supporting care staff in the management of behavioural problems, especially aggression and apathy. Copyright (c) 2013 John Wiley & Sons, Ltd.

Item does not contain fulltext, BACKGROUND: Current guidelines and theories on the origin of challenging behaviour in dementia indicate that a structured multidisciplinary approach to its management is necessary. In the Grip on Challenging Behaviour study, a care programme was developed to improve the management of challenging behaviour. METHOD: In developing the care programme, the overlapping parts of dementia care guidelines were supplemented with discipline-specific parts. Three meetings with experts were arranged to further develop the structure of the care programme and to ensure a good fit with practice. RESULTS: The care programme consists of four steps: detection, analysis, treatment, and evaluation. For each step, forms were developed to guide and structure the process and assign responsibilities for each discipline. As well as a description of the development and the content of the care programme, this paper presents two case studies in which the programme was used. CONCLUSION: The Grip on Challenging Behaviour care programme provides a way for dementia special care units to manage challenging behaviour in a structured way and with a multidisciplinary approach making use of their own resources.

Contains fulltext : 137210.pdf (publisher's version ) (Open Access), Background: Dementia is a life-limiting disease without curative treatments. Patients and families may need palliative care specific to dementia. Aim: To define optimal palliative care in dementia. Methods: Five-round Delphi study. Based on literature, a core group of 12 experts from 6 countries drafted a set of core domains with salient recommendations for each domain. We invited 89 experts from 27 countries to evaluate these in a two-round online survey with feedback. Consensus was determined according to predefined criteria. The fourth round involved decisions by the core team, and the fifth involved input from the European Association for Palliative Care. Results: A total of 64 (72%) experts from 23 countries evaluated a set of 11 domains and 57 recommendations. There was immediate and full consensus on the following eight domains, including the recommendations: person-centred care, communication and shared decision-making; optimal treatment of symptoms and providing comfort (these two identified as central to care and research); setting care goals and advance planning; continuity of care; psychosocial and spiritual support; family care and involvement; education of the health care team; and societal and ethical issues. After revision, full consensus was additionally reached for prognostication and timely recognition of dying. Recommendations on nutrition and dehydration (avoiding overly aggressive, burdensome or futile treatment) and on dementia stages in relation to care goals (applicability of palliative care) achieved moderate consensus. Conclusion: We have provided the first definition of palliative care in dementia based on evidence and consensus, a framework to provide guidance for clinical practice, policy and research.

Item does not contain fulltext, INTRODUCTION: The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance. METHODS: Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations. RESULTS: A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship. CONCLUSION: The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.

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