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Objectives: People with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff-resident interactions.Design: An exploratory, cross-sectional study.Setting and Participants: In total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.Methods: Structured observations were carried out to assess the support of resident autonomy within staff-resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents' responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.Results: In total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents' needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.Conclusions and Implications: The findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents' individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy. (C) 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

BackgroundFamily inclusion in nursing homes is central to the provision of individualized care for people with dementia. Although positive effects can be recognized, barriers have been identified that hamper family inclusion in nursing homes. Specifically for people with dementia, insight into the content of interventions to foster family inclusion is lacking.MethodsA systematic review was performed by systematically searching the databases PubMed, Cinahl, PsycInfo and Embase. Studies were eligible if they examined (1) nursing home settings, (2) interventions to foster the inclusion of family members from people with dementia, (3) were original research articles in which effects/experiences of/with these interventions were evaluated, and (4) were written in English, Dutch or German. Findings were summarized systematically.ResultsTwenty-nine studies were included. Two interventions were targeted at creating family-staff partnerships from a two-way perspective. Other interventions focused on single components, such as including family members in formal decisions (n = 9), enabling them to make better informed decisions and/or participate more actively (n = 7), or providing psychoeducation for family members (n = 3). Within the interventions, family and staff members are often treated differently. Effects on actual increase in family inclusion remain unclear.ConclusionsVery few interventions exist that try to enhance equal family-staff partnerships in nursing homes. Future interventions should pay specific attention to mutual exchange and reciprocity between family and staff. As little is known about promising (components of) interventions to foster family inclusion in nursing homes for people with dementia, more effectiveness research is needed.

Contains fulltext : 233654.pdf (Publisher’s version ) (Open Access) Aim: This study aims to explore the relationship between work environment, job characteristics and person-centered care for people with dementia in nursing homes. Background Person-centered care approaches have become a dominant indicator for good quality of care in nursing homes. Little is known about the relationship between work environment, job characteristics and person-centered care in nursing homes. Method(s): Cross-sectional data from the LAD-study were used. Direct care staff (n = 552) of nursing homes (n = 49) filled in an online questionnaire about work environment characteristics and person-centered care. To examine relationships, multilevel linear regression analyses were conducted. Results: Associations were found between a higher transformational leadership style, less social support from a leader, a higher unity in philosophy of care, higher levels of work satisfaction, more development opportunities, better experienced teamwork and staff-reported person-centered care. Conclusion(s): In a complex nursing home environment, person-centered care is influenced by organizational and work characteristics, shared values and interpersonal relationships. Implications for Nursing Leaders may consider facilitating collaboration and creating unity between care staff, clients and family members in order to provide person-centered care. Therefore, a transformational leadership style, educational programs and coaching for leaders are recommended. 9 p.

Background Partnerships between family and nursing staff in nursing homes are essential to address residents’ needs and wishes. Collaboration is needed to create partnerships; nonetheless, challenges exist. Aim This study aimed to gain insights into the experiences of families collaborating with staff. Method Semi-structured interviews were held with 30 family caregivers of nursing home residents with dementia. Findings Data reflected three themes, which shaped collaboration with staff from families’ perspective, ‘communication’, ‘trust and dependency’ and ‘involvement’. Discussion Good communication appeared to be a requisite condition for having trust in staff and quality of involvement in residents’ life. Good communication was described as having informal contact with staff, which enabled family and staff to build a personal connection. Consequently, this seemed to increase trust and satisfaction regarding involvement. Conclusion Findings suggest that increasing informal contact and building a personal connection should be a priority for staff in order to improve collaboration and to create partnerships with families.

Background To protect nursing home residents, many governments around the world implemented blanket visitor bans in March and April 2020. As a consequence, family caregivers, friends, and volunteers were not allowed to enter nursing homes, while residents were not allowed to go out. Up until now, little is known on the long-term consequences and effects of visiting bans and re-opening of nursing homes. The aim of the study was to assess the long-term effects of the pandemic on residents, family members, and staff, and their preparedness for the next coronavirus wave. Methods A mixed-methods approach was used, consisting of a questionnaire and analyses of documentation (local visiting protocols). Of the 76 nursing home locations that participated in a Dutch national pilot on welcoming visitors back into nursing homes, 64 participated in this follow-up study. Data were collected in September/October 2020. For each nursing home, one contact person completed the questionnaire. Descriptive statistics were calculated for quantitative questionnaire data. Data on open-ended questions, as well as data from the documentation, were analyzed thematically. Results The study demonstrated that the consequences of strict visiting bans do not disappear at the moment the visiting ban is lifted. Although in October 2020, daily life in nursing homes was more “back to normal,” more than one-third of the respondents indicated that they still applied restrictions. Compared to the situation before the pandemic, fewer volunteers were working in the nursing homes, grandchildren visited their relative less often, and visits differed. Conclusions Five months after the visiting ban in Dutch nursing homes had been lifted, it still had an impact on residents, family members, and staff. It is questionable whether nursing homes feel prepared for welcoming visitors in the case of new COVID-19 infections. Nursing homes indicated that they felt prepared for the next wave, while at the same time, they were particularly concerned about staff well-being and vitality. It seems wise to invest in staff well-being. In addition, it seems desirable to think about how to support nursing homes in seeking a balance between infection prevention and well-being of residents, family members, and staff.

Context: In most countries, registered nurse retention and role development in nursing homes is a challenge.Objective: To obtain insight into factors contributing to successful retention of registered nurses in nursing homes and into how to differentiate the role of vocationally trained registered nurses and baccalaureate-educated registered nurses.Method: A qualitative, descriptive, explorative study. In June 2019, World Café was held, a method for hosting group dialogs, in which direct care professionals, managers, human resources employees, and teachers participated. A theme-based content analysis was used to analyze data.Findings: Identified factors expected to contribute to retention were role clarity, role content, role model availability, room for professional development, learning on the job, a match between education and actual work, management and board-level support, adequate salaries, and a positive image of working in nursing homes. Vocationally trained registered nurses were considered to perform a key role resident care by serving as case managers. Baccalaureate-educated registered nurses were considered to focus on indirect care (e.g., coaching staff, stimulating evidence-based practices, implementing innovations).Limitations: Due to the limited sample size and the qualitative, explorative nature of the study, findings can only be generalized with caution.Implications: To refine registered nurse roles in nursing homes, it seems crucial to rethink the current roles and hierarchies. Even though management and human resources departments are considered responsible for contributing to role clarity and the creation of supportive practice environments, the registered nurses themselves are also expected to come up with their role.

Background: Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.Objectives: To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents. Design: A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities. Setting: Long-term residential care facilitiesParticipants: Long-term care facility staff, residents, and relatives Methods: The realist review, (i) was co-developed with stakeholders to determine initial programme the-ories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) vali-dated and refined emergent theory with stakeholder groups.Results: 66 research papers were included in the review. Three key findings explain the relationship be-tween staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an im-portant influence on how organisational resources (sufficient staff effectively deployed, with the knowl-edge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.Conclusion: Leaders (at all levels) through their role-modelling behaviours can use organisational re-sources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.Crown Copyright (c) 2021 Published by Elsevier Ltd. All rights reserved.

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link. Blanket and total bans of nursing home visitors were widespread at the beginning of the COVID-19 pandemic when governments and homes were unprepared to prevent and manage outbreaks. However, these visitor restrictions have been prolonged and often reinstated after having been lifted, despite increased home and health system readiness and mounting evidence of harms to residents. Further, in most nursing homes, visitor bans were introduced without discussion or consent from residents or their advocates, constituting a violation of the resident’s rights to have visitors.

Contains fulltext : 229777.pdf (Publisher’s version ) (Closed access)

Objectives To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents’ well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context, the compliance to local protocols and the impact on well-being of residents, their family caregivers and staff. Design A mixed-methods cross-sectional study was conducted Setting and participants In total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study. Methods A mixed-method cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (i.e. local visiting protocols) and a WhatsApp group. Results Variation in local protocols was observed, for example related to the use of personal protective equipment, location and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time. Conclusions and implications These results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance., Positive results from a study of the safety and impact of following national guidelines for nursing home visitors during COVID-19 led the Dutch national government to permit all nursing homes to cautiously allow visitors.

Aims To understand how nursing homes employ baccalaureate-educated Registered Nurses (BRNs) and how they view the unique contributions of baccalaureate-educated Registered Nurses to staff and residents in their organizations. Background Although providing care for nursing home residents is complex and thus requires a high level of skills, organizations often struggle to recruit and retain BRNs. Some nursing home organizations do not employ baccalaureate-educated Registered Nurses at all. Among those that do, it is unknown how well these organizations make use of baccalaureate-educated Registered Nurses' expertise or if their roles are different from those of other staff. Design A qualitative study, consisting of 26 individual and three group interviews was conducted in the Netherlands. Methods Interviews were conducted at the board-, management- and staff-level in six nursing home organizations. Data were collected between January 2016–May 2016. Results Organizations employed baccalaureate-educated Registered Nurses to fulfil an informal leadership role for direct care teams. Organizations that do not employ baccalaureate-educated Registered Nurses were unable to articulate their role in the nursing home setting. Difficulties baccalaureate-educated Registered Nurses experienced during role implementation depended on role clarity, the term used to refer to the baccalaureate-educated Registered Nurse, the extent to which nurses received support, openness from direct care teams and baccalaureate-educated Registered Nurses’ own behaviour. The unique contribution of baccalaureate-educated Registered Nurses perceived by respondents differed between and in organizations. Conclusion Our findings suggest that there is no “one size fits all” approach to employing baccalaureate-educated Registered Nurses in nursing homes. To ensure the satisfaction of both baccalaureate-educated Registered Nurses and the organizations that employ them, careful implementation and evaluation of their role is crucial.

Nursing homes across the world have taken very restrictive measures, including a ban for visitors, to prevent and control COVID-19 infections. This study reports on findings of a study investigating guidelines on allowing visitors in nursing homes and the impact on residents’ well-being, family caregivers and staff. In total, 76 nursing homes in the Netherlands were followed using a survey study, including three waves of data collection in (May 2020, September 2020, March 2021. Results indicated a negative impact of a visitation ban for residents’ overall well-being. There was a variety in guidelines of allowing visitors in nursing homes, and showed that safe visiting was possible during the COVID-19 pandemic. Staff perceived a fragile balance between infection prevention and the impact of restriction on residents. In conclusion, a general ban for visitors is not necessary and may do more harm than good for residents living in nursing homes.

The culture change movement within long-term care in which radical changes in the physical, social and organizational care environments are being implemented provides opportunities for the development of innovative long-term care facilities. The aim of this study was to investigate which competencies care staff working at green care farms and other innovative types of small-scale long-term dementia care facilities require, according to care staff themselves and managers, and how these competencies were different from those of care staff working in more traditional large-scale long-term dementia care facilities. A qualitative descriptive research design was used. Interviews were conducted with care staff (n = 19) and managers (n = 23) across a diverse range of long-term facilities. Thematic content analysis was used. Two competencies were mainly mentioned by participants working in green care farms: (1) being able to integrate activities for residents into daily practice, and (2) being able to undertake multiple responsibilities. Two other competencies for working in long-term dementia care in general were identified: (3) having good communication skills, and (4) being able to provide medical and direct care activities. This study found unique competencies at green care farms, showing that providing care in innovative long-term care facilities requires looking further than the physical environment and the design of a care facility; it is crucial to look at the role of care staff and the competencies they require.

Background A lack of relationship between direct care staffing levels and quality of care, as found in prior studies, underscores the importance of considering the quality of the work environment instead of only considering staff ratios. Only a few studies, however, have combined direct care staffing with work environment characteristics when assessing the relationship with quality of care in nursing homes. Objectives To examine the relationship between direct care staffing levels, work environment characteristics and perceived quality of care in Dutch nursing homes. Design Cross-sectional, observational study in cooperation with the Dutch Prevalence Measurement of Care Problems. Settings: Twenty-four somatic and 31 psychogeriatric wards from 21 nursing homes in the Netherlands. Participants: Forty-one ward managers and 274 staff members (registered nurses or certified nurse assistants) from the 55 participating wards. Methods Ward rosters were discussed with managers to obtain an insight into direct care staffing levels (i.e, total direct care staff hours per resident per day). Participating staff members completed a questionnaire on work environment characteristics (i.e., ward culture, team climate, communication and coordination, role model availability, and multidisciplinary collaboration) and they rated the quality of care in their ward. Data were analyzed using multilevel linear regression analyses (random intercept). Separate analyses were conducted for somatic and psychogeriatric wards. Results In general, staff members were satisfied with the quality of care in their wards. Staff members from psychogeriatric wards scored higher on the statement ‘In the event that a family member had to be admitted to a nursing home now, I would recommend this ward'. A better team climate was related to better perceived quality of care in both ward types (p≤0.020). In somatic wards, there was a positive association between multidisciplinary collaboration and agreement by staff of ward recommendation for a family member (p=0.028). In psychogeriatric wards, a lower score on market culture (p=0.019), better communication/coordination (p=0.018) and a higher rating for multidisciplinary collaboration (p=0.003) were significantly associated with a higher grade for overall quality of care. Total direct care staffing, adhocracy culture, hierarchy culture, as well as role model availability were not significantly related to quality of care. Conclusions Our findings suggest that team climate may be an important factor to consider when trying to improve quality of care. Generating more evidence on which work environment characteristics actually lead to better quality of care is needed.

People with dementia become increasingly dependent on others in achieving autonomy. This is especially the case when people with dementia are living in a nursing home. This study aims to gain insight in the opinion of family caregivers on factors influencing autonomy of people with dementia within nursing homes. In this qualitative study, data are collected by means of in-depth, semi-structured interviews with 30 primary family caregivers of nursing home residents with dementia from four different care organizations in the Netherlands. A qualitative thematic approach was used to analyze the data. According to family caregivers, a person-centered approach, the ability to hold on to family traditions in the nursing home, the ability to bring personal belongings of the residents to the nursing home, and the resident being involved in meaningful activities, seem to be important in achieving resident autonomy. Barriers to autonomy that were mentioned by family caregivers were frequent changes in care staff, restriction in resident freedom of movement, lack of time for person-centered activities, lack of personal attention, having to adapt to the needs of other residents, and offering group activities that do not sufficiently suit resident interests. Family caregivers have identified various factors that may improve or impede autonomy of residents with dementia in nursing homes. Based on these insights, nursing homes could develop new approaches aimed at improving the autonomy of residents with dementia in nursing homes.

Staffing practices in long-term care lack a clear evidence base and often seem to be guided by opinions instead of evidence. While stakeholders believe intuitively that there is a positive relationship between staffing levels and quality in nursing homes, the research literature is contradictory (1). In this editorial we consider the evidence found in a literature study that we conducted for the Dutch Ministry of Health, Welfare and Sports (VWS). The aim of this study was to summarize all available evidence on the relationship between staffing and quality in nursing homes. Specifically, we focused on the quantity and the educational background of staff and quality in nursing homes. The literature study has contributed to the recent Dutch quality framework for nursing homes (Kwaliteitskader verpleeghuiszorg in Dutch) of the National Health Care Institute. This quality framework was published in January 2017 and provides norms – among other quality aspects – for nursing home staffing. As well as a description of the main findings of the literature study, we present implications for different stakeholders charged with staffing issues in nursing homes.

Background: In 2017, the Dutch National Health Care Institute developed a quality framework describing what high quality nursing home care entails, aimed to improve nursing home care. The current study focuses on evaluating whether Dutch nursing homes comply to the framework, specifically regarding norms about staffing and formation of care teams (skill mix and educational level). Care teams that were experimenting with new staffing levels were monitored to evaluate what changes in staffing occurred and which obstructing or promoting factors they experienced. Methods: Quantitative data about staffing and team characteristics were gathered. Further, qualitative data about motives for wanting to change, the change approach, obstructing and promoting factors and evaluation of changes was collected. Telephone interviews were held at baseline, after 3 months and after 6 months. Thirty-two teams participated in the study. Results: Challenges for making changes in staffing consisted of attracting new care staff, dealing with sickness leave, communication within and between teams, communication with informal carers and combining care for and having attention for well-being of residents in the daily work routine. Additionally, teams wanted to better adjust the skill mix of staff to the needs of residents. Conclusion: For the formation of care teams, there seems to be no ‘one-size fits all’ approach. A quantitative norm that applies to all nursing homes in the Netherlands as described in the quality framework (e.g. a minimum of two care professionals for eight residents during intensive moments of care) is therefore not always the route to high quality care.

Despite heterogeneity across countries, nursing homes worldwide have to ensure the delivery of high quality care. At the same time, adequately staffing the homes remains a major concern in most countries. It is a significant challenge to determine the numbers and type of staff as well as staff’s competencies that are necessary to meet the complex needs of nursing home residents. While, especially in the US, research on the relationship between staffing and quality in nursing homes has received considerable attention, the research literature is contradictory. Evidence shows that employing more staff or more registered nurses instead of nurse assistants will not automatically lead to better nursing home quality. This inconsistency of evidence might be explained by a myriad of methodological and theoretical challenges. This symposium aims to provide an international perspective on how researchers from different European countries contribute to the development of an evidence base for nursing home staffing. The first presenter will draw on findings from a realist review conducted in the UK, focusing on the mechanisms (how, why and in what circumstances) under which staff influence care home quality. The second presenter will offer insights into a Swiss study, taking a broader perspective on measuring staffing and quality in nursing homes. The third presenter will present a new instrument to identify staffing ratios in German nursing homes and provide insight into its development process. The fourth presenter will discuss the results of a critical review on the evidence base of a Dutch nursing home staffing guideline.

Background: Recent evidence suggests that an increase in baccalaureate-educated registered nurses (BRNs) leads to better quality of care in hospitals. For geriatric long-term care facilities such as nursing homes, this relationship is less clear. Most studies assessing the relationship between nurse staffing and quality of care in long-term care facilities are US-based, and only a few have focused on the unique contribution of registered nurses. In this study, we focus on BRNs, as they are expected to serve as role models and change agents, while little is known about their unique contribution to quality of care in long-term care facilities.Methods: We conducted a cross-sectional study among 282 wards and 6,145 residents from 95 Dutch long-term care facilities. The relationship between the presence of BRNs in wards and quality of care was assessed, controlling for background characteristics, i.e. ward size, and residents' age, gender, length of stay, comorbidities, and care dependency status. Multilevel logistic regression analyses, using a generalized estimating equation approach, were performed.Results: 57% of the wards employed BRNs. In these wards, the BRNs delivered on average 4.8 min of care per resident per day. Among residents living in somatic wards that employed BRNs, the probability of experiencing a fall (odds ratio 1.44; 95% CI 1.06-1.96) and receiving antipsychotic drugs (odds ratio 2.15; 95% CI 1.66-2.78) was higher, whereas the probability of having an indwelling urinary catheter was lower (odds ratio 0.70; 95% CI 0.53-0.91). Among residents living in psychogeriatric wards that employed BRNs, the probability of experiencing a medication incident was lower (odds ratio 0.68; 95% CI 0.49-0.95). For residents from both ward types, the probability of suffering from nosocomial pressure ulcers did not significantly differ for residents in wards employing BRNs.Conclusions: In wards that employed BRNs, their mean amount of time spent per resident was low, while quality of care on most wards was acceptable. No consistent evidence was found for a relationship between the presence of BRNs in wards and quality of care outcomes, controlling for background characteristics. Future studies should consider the mediating and moderating role of staffing-related work processes and ward environment characteristics on quality of care.

The quality of care in Dutch nursing homes is a popular topic, with continuous calls for more hands-on care. The assumption is that more or more highly-trained staff will increase the quality of care. Based on this dissertation, there is no evidence to suggest that more staff will lead to higher-quality care. A large-scale study carried out at 282 nursing home units reveals that there are too few vocational nurses at Dutch nursing homes to objectively determine their impact on the quality of care. It was found that vocational nurses can indeed contribute to a positive team climate and can serve as leaders in the workplace. The results also demonstrate that organisations with a clear vision about the use of vocational nurses are more equipped to recruit and bind these nurses. Nursing homes can only become attractive internship organisations for vocational nurses-in-training if they have vocational role models who are held accountable for their skills.

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.

Related to the Dutch nursing home quality framework implemented in 2017, a staffing guideline was developed, aimed at assisting nursing homes to adequately staff their wards. For the Dutch Ministry of Health, we investigated the evidence base of this guideline. We critically reviewed scientific literature (n=65) and interviewed (inter)national experts (n=8) and potential guideline users (n=5). We found that departing a quality improvement dialogue directly from teams, clients and their families is positive. However, weaknesses were identified as well. Several risks exist for employees to adequately assess resident needs. Furthermore, buy-in is needed from board level to develop a vision on which competencies and amount of staff are needed to fulfill these needs. Examples of guideline improvement recommendations were assisting teams in how to assess resident needs, critically reflect on care provision and considering a role for (top)management. Overall, it was concluded that the value of the guideline was limited.

People with dementia in nursing homes need their social environment in supporting their autonomy. This study explored how this relational autonomy is supported by staff for residents with dementia during morning care in nursing homes. Structured observations (n=1815) were carried out to assess how resident choice is supported within staff-resident interaction. Observation of morning care consisted of four main categories: ‘getting up’, ‘physical care’, ‘physical appearance’ and ‘breakfast’. In addition, qualitative field notes were taken to support observations. In total, 55 residents with dementia were included from eight nursing home wards in The Netherlands. Results indicated that resident autonomy during morning care was only limitedly supported. Individual staff members took over tasks, regardless of resident’s individual capabilities to make a choice. Staff controlled resident’s choice for almost all observed categories. The findings of this study implicate that person-centered care during morning routine can be improved by addressing individual needs

In Dutch nursing homes, few registered nurses (RNs) work in direct resident care and baccalaureate-educated RNs (BRNs) are an especially scarce resource. It is unknown yet to which extent organizations make use of the BRNs’ expertise and how their roles are differentiated from those of other staff members.

Background Dutch out-of-hours (OOH) centers find it difficult to attract sufficient triage staff. They regard home-based triage as an option that might attract employees. Specially trained nurses are supposed to conduct triage by telephone from home for after-hours medical care. The central aim of this research is to investigate the views of employees of OOH centers in The Netherlands on home-based telephone triage in after-hours care. Methods The study is a Q methodology study. Triage nurses, general practitioners (GPs) and managers of OOH centers ranked 36 opinion statements on home-based triage. We interviewed 10 participants to help develop and validate the statements for the Q sort, and 77 participants did the Q sort. Results We identified four views on home-based telephone triage. Two generally favor home-based triage, one highlights some concerns and conditions, and one opposes it out of concern for quality. The four views perceive different sources of credibility for nurse triagists working from home. Conclusion Home-based telephone triage is a controversial issue among triage nurses, GPs and managers of OOH centers. By identifying consensus and dissension among GPs, triagists, managers and regulators, this study generates four perspectives on home-based triage. In addition, it reveals the conditions considered important for home-based triage.