Time-limited home-care reablement services for maintaining and improving the functional independence of older adults

Background: Reablement, also known as restorative care, is one possible approach to home-care services for older adults at risk of functional decline. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and aims to maximise independence by offering an intensive multidisciplinary, person-centred and goal-directed intervention. Objectives:Objectives To assess the effects of time-limited home-care reablement services (up to 12 weeks) for maintaining and improving the functional independence of older adults (aged 65 years or more) when compared to usual home-care or wait-list control group. Search methods:We searched the following databases with no language restrictions during April to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (OvidSP); Embase (OvidSP); PsycINFO (OvidSP); ERIC; Sociological Abstracts; ProQuest Dissertations and Theses; CINAHL (EBSCOhost); SIGLE (OpenGrey); AgeLine and Social Care Online. We also searched the reference lists of relevant studies and reviews as well as contacting authors in the field.Selection criteria:We included randomised controlled trials (RCTs), cluster randomised or quasi-randomised trials of time-limited reablement services for older adults (aged 65 years or more) delivered in their home; and incorporated a usual home-care or wait-list control group. Data collection and analysis:Two authors independently assessed studies for inclusion, extracted data, assessed the risk of bias of individual studies and considered quality of the evidence using GRADE. We contacted study authors for additional information where needed.Main results:Two studies, comparing reablement with usual home-care services with 811 participants, met our eligibility criteria for inclusion; we also identified three potentially eligible studies, but findings were not yet available. One included study was conducted in Western Australia with 750 participants (mean age 82.29 years). The second study was conducted in Norway (61 participants; mean age 79 years). We are very uncertain as to the effects of reablement compared with usual care as the evidence was of very low quality for all of the outcomes reported. The main findings were as follows. Functional status: very low quality evidence suggested that reablement may be slightly more effective than usual care in improving function at nine to 12 months (lower scores reflect greater independence; standardised mean difference (SMD) -0.30; 95% confidence interval (CI) -0.53 to -0.06; 2 studies with 249 participants). Adverse events: reablement may make little or no difference to mortality at 12 months’ follow-up (RR 0.97; 95% CI 0.74 to 1.29; 2 studies with 811 participants) or rates of unplanned hospital admission at 24 months (RR 0.94; 95% CI 0.85 to 1.03; 1 study with 750 participants). The very low quality evidence also means we are uncertain whether reablement may influence quality of life (SMD -0.23; 95% CI -0.48 to 0.02; 2 trials with 249 participants) or living arrangements (RR 0.92, 95% CI 0.62 to 1.34; 1 study with 750 participants) at time points up to 12 months. People receiving reablement may be slightly less likely to have been approved for a higher level of personal care than people receiving usual care over the 24 months’ follow-up (RR 0.87; 95% CI 0.77 to 0.98; 1 trial, 750 participants). Similarly, although there may be a small reduction in total aggregated home and healthcare costs over the 24-month follow-up (reablement: AUD 19,888; usual care: AUD 22,757; 1 trial with 750 participants), we are uncertain about the size and importance of these effects as the results were based on very low quality evidence. Neither study reported user satisfaction with the serviceAuthors’ conclusions:There is considerable uncertainty regarding the effects of reablement as the evidence was of very low quality according to our GRADE ratings. Therefore, the effectiveness of reablement services cannot be supported or refuted until more robust evidence becomes available. There is an urgent need for high quality trials across different health and social care systems due to the increasingly high profile of reablement services in policy and practice in several countries. 

Sjuksköterskans upplevelse av att ge personcentrerad vård till personer med demenssjukdom : En litteraturstudie

Background: Dementia impairs cognitive functions, such as memory and speech, changing a person’s life forever. Providing person-centred care to these persons intend to retain their identities, dignity and autonomy. Such care demands time, devotion and good knowledge of the caring nurse. Dementia is expected to increase in the future and therefore nurses will have to face new challenges. Aim: To describe nurses’ experience of providing person-centred care for people with dementia. Method: A literature review of 15 articles, published between 2009-2016, that have been read and analysed through content-analysis. Results: Nurses experience a positive change in their attitudes, when providing person-centred care to people with dementia, as they gained better understanding of their patients’ dignity and integrity. Education, training and support from management were seen as key factors for providing up-to-date care. Time was viewed as a hindrance for person-centred care, and often led to nurses prioritizing other routines. Two common outcomes of person-centred care were increased satisfaction as well as emotional burnout. Conclusion: Since dementia is increasing and nurses find person-centred care time-consuming, there is a risk of such care becoming poor. To prevent this nurses need good leadership and education.

An Action Research Study Engaging in the Use of Storyboarding as Research-based Approach to Teaching to Identify Issues Faced when Working with People with Dementia from Minority Ethnic Communities

The common view that research informs teaching assumes a linear approach whereby teaching is considered an output of research. This paper reports the findings of an action research project that identified the issues and challenges faced by those working across health and social care when working with people with dementia from minority ethnic communities. It explored the research-teaching nexus by using an approach to teaching that was research-based as opposed to research-led. A storyboarding technique was used which involved identifying and dissecting real life experiences for discussion. The realisation that each story was unique to the individual demonstrated the benefits and importance of education and training for applying a person-centred approach to dementia care. This project also revealed the benefits of actively engaging course participants with research moving them from being recipients of research, to research- active. Such a process not only encouraged their intrinsic motivations but, also, critical thinking and reflective practice to support deep learning. Such findings demonstrate the benefits of linking teaching with research.

Healthcare Staffs’ Experiences and Perceptions of Caring for People with Dementia in the Acute Setting: Qualitative Evidence Synthesis

Background Dementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting. Objectives The aim of this qualitative synthesis was to explore health care staffs’ experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development. Settings A screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings. Participants Twelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers. Methods Framework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings. Results Key themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia. Conclusions This review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.

Doctors' thinking about the system as a threat to patient safety

‘Systems thinking’ is an important feature of the emerging ‘patient safety’ agenda. As a key component of a ‘safety culture’, it encourages clinicians to look past individual error to recognise the latent factors that threaten safety. This paper investigates whether current medical thinking is commensurate with the idea of ‘systems thinking’ together with its implications for policy. The findings are based on qualitative semistructured interviews with specialist physicians working within one NHS District General Hospital in the English Midlands. It is shown that, rather then favouring a 'person-centred’ perspective, doctors readily identify ‘the system’ as a threat to patient safety. This is not necessarily a reflection of the prevailing safety discourse or knowledge of policy, but reflects a tacit understanding of how services are (dis)organised. This line of thinking serves to mitigate individual wrong-doing and protect professional credibility by encouraging doctors to accept and accommodate the shortcomings of the system, rather than participate in new forms of organisational learning.

‘Old and ill’ : death anxiety and coping strategies influencing health professionals' well-being and dementia care

Nursing care of the family before and after a death in the ICU - an exploratory pilot study

This qualitative descriptive study was undertaken in two metropolitan ICUs utilising focus groups to describe the ways in which ICU nurses care for the families of dying patients during and after the death. Participants shared their perspectives on how they care for families, their concerns about care, and detailed the strategies they use to provide timely and person-centred family care. Participants identified that their ICU training was inadequate in equipping them to address the complex care needs of families leading up to and following patient deaths, and they relied on peer mentoring and role-modelling to improve their care. Organisational constraints, practices and pressures impacting on the nurse made ‘ideal’ family care difficult. They also identified that a lack of access to pastoral care and social work after hours contributed to their concerns about family care. Participants reported that they valued the time nurses spent with families, and the importance of ensuring families spent time with the patient, before and after death.

Transferring from an acute hospital and settling into a subacute facility: the experience of patients with dementia

Background.  In a Melbourne metropolitan health network, patients with dementia can have difficulty settling into a subacute rehabilitation facility after transfer from the acute hospital.

Aims and objectives.  To understand how older patients with mild to moderate dementia experienced the transfer from acute to subacute care and settling-in period.

Design.  A descriptive design was used. Eight patients with mild to moderate dementia were recruited, one to 5 days after transfer.

Method.  A qualitative method using in-depth interviews was used. The data were analysed using content analysis.

Results.  Four main themes were identified: ‘Settling into a new environment’, ‘staff attitudes to people with dementia’, ‘loss of control’ and ‘family support’.

Conclusions.  Person-centred care that comes from the perspective of respect for the individual transcends all these issues. People with dementia require more support to settle after transfer. Family involvement can assist in facilitating a smooth transition.

Implications for practice.  Nurses who understand the specific needs of patients with dementia can develop ways of working with patients to ensure person-centred care. More conversations with people with dementia are needed to investigate how this can be achieved. Orientation procedures should ensure that support for people with dementia is optimized during the settling-in phase.

Advance care planning in nephrology care

On completion of this continuing professional development (CPD) activity, participants will be able to:
• describe advanced care planning and its relationship to person-centred care
• identify who is responsible for initiating advance care planning discussions in their nephrology department
• identify the benefits of advanced care planning• recall conversation triggers for raising the topic of advanced care planning.

Food rescue: investigating directions for the future

This research helps explain how organisations can be structured to best respond to the needs of people experiencing food insecurity; an integrated person-centred approach must be employed. There is capacity for food charities to advocate and collaborate to promote long-term solutions and also, deliver acute support for people’s health.

Time-limited home-care reablement services for maintaining and improving the functional independence of older adults

Background: Reablement, also known as restorative care, is one possible approach to home-care services for older adults at risk of functional decline. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and aims to maximise independence by offering an intensive multidisciplinary, person-centred and goal-directed intervention. Objectives: To assess the effects of time-limited home-care reablement services (up to 12 weeks) for maintaining and improving the functional independence of older adults (aged 65 years or more) when compared to usual home-care or wait-list control group. Search methods: We searched the following databases with no language restrictions during April to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (OvidSP); Embase (OvidSP); PsycINFO (OvidSP); ERIC; Sociological Abstracts; ProQuest Dissertations and Theses; CINAHL (EBSCOhost); SIGLE (OpenGrey); AgeLine and Social Care Online. We also searched the reference lists of relevant studies and reviews as well as contacting authors in the field. Selection criteria: We included randomised controlled trials (RCTs), cluster randomised or quasi-randomised trials of time-limited reablement services for older adults (aged 65 years or more) delivered in their home; and incorporated a usual home-care or wait-list control group. Data collection and analysis: Two authors independently assessed studies for inclusion, extracted data, assessed the risk of bias of individual studies and considered quality of the evidence using GRADE. We contacted study authors for additional information where needed. Main results: Two studies, comparing reablement with usual home-care services with 811 participants, met our eligibility criteria for inclusion; we also identified three potentially eligible studies, but findings were not yet available. One included study was conducted in Western Australia with 750 participants (mean age 82.29 years). The second study was conducted in Norway (61 participants; mean age 79 years). We are very uncertain as to the effects of reablement compared with usual care as the evidence was of very low quality for all of the outcomes reported. The main findings were as follows. Functional status: very low quality evidence suggested that reablement may be slightly more effective than usual care in improving function at nine to 12 months (lower scores reflect greater independence; standardised mean difference (SMD) -0.30; 95% confidence interval (CI) -0.53 to -0.06; 2 studies with 249 participants). Adverse events: reablement may make little or no difference to mortality at 12 months' follow-up (RR 0.97; 95% CI 0.74 to 1.29; 2 studies with 811 participants) or rates of unplanned hospital admission at 24 months (RR 0.94; 95% CI 0.85 to 1.03; 1 study with 750 participants). The very low quality evidence also means we are uncertain whether reablement may influence quality of life (SMD -0.23; 95% CI -0.48 to 0.02; 2 trials with 249 participants) or living arrangements (RR 0.92, 95% CI 0.62 to 1.34; 1 study with 750 participants) at time points up to 12 months. People receiving reablement may be slightly less likely to have been approved for a higher level of personal care than people receiving usual care over the 24 months' follow-up (RR 0.87; 95% CI 0.77 to 0.98; 1 trial, 750 participants). Similarly, although there may be a small reduction in total aggregated home and healthcare costs over the 24-month follow-up (reablement: AUD 19,888; usual care: AUD 22,757; 1 trial with 750 participants), we are uncertain about the size and importance of these effects as the results were based on very low quality evidence. Neither study reported user satisfaction with the service. Authors' conclusions: There is considerable uncertainty regarding the effects of reablement as the evidence was of very low quality according to our GRADE ratings. Therefore, the effectiveness of reablement services cannot be supported or refuted until more robust evidence becomes available. There is an urgent need for high quality trials across different health and social care systems due to the increasingly high profile of reablement services in policy and practice in several countries.

Quality in palliative care from the patient perspective : Instrument development, perceptions of care received and the importance of care

The overall aim was to investigate the quality of palliative care from the patient perspective, to adapt and psychometrically evaluate the Quality from Patients’ Perspective instrument specific to palliative care (QPP-PC) and investigate the relationship between the combination of person- and organization-related conditions and patients’ perceptions of care quality. Methods: In the systematic literature review (I), 23 studies from 6 databases and reference lists in 2014 were synthesized by integrative thematic analysis. The quantitative studies (II–IV) had cross-sectional designs including 191 patients (73% RR) from hospice inpatient care, hospice day care, palliative units in nursing homes and home care in 2013–2014. A modified version of QPP was used. Additionally, person- and organization-related conditions were assessed. Psychometric evaluation, descriptive and inferential statistics were used. Main findings: Patients’ preferences for palliative care included living a meaningful life and responsive healthcare personnel, care environment and organization of care (I). The QPP-PC was developed, comprising 12 factors (49 items), 3 single items and 4 dimensions: medical–technical competence, physical–technical conditions, identity–oriented approach, and socio-cultural atmosphere (II). QPP-PC measured patients’ perceived reality (PR) and subjective importance (SI) of care quality. PR differed across settings, but SI did not (III). All settings exhibited areas of strength and for improvement (II, III). Person-related conditions seemed to be related to SI, and person- and organization-related conditions to PR, explaining 18–30 and 22-29% respectively of the variance (IV). Conclusions: The patient perspective of care quality (SI and PR) should be integrated into daily care and improvement initiatives in palliative care. The QPP-PC can measure patients’ perceptions of care quality. Registered nurses and other healthcare personnel need awareness of person- and organization-related conditions to provide high-quality person-centred care.

Personcentrerad omvårdnad vid demens : En deskriptiv kvalitativ studie

Bakgrund: Demens är en av de stora folksjukdomarna och vårdpersonal möter dessa personer med demens både inom akutsjukvård och kommunal vård. På slutet av sitt liv bor de flesta personer som drabbats av demens på institution. Personcentrerad vård beskrivs vara gynnsamt i vården av personer med demens och personalens erfarenhet av detta har stor betydelse. Syfte: Syftet var att studera sjuksköterskors, enhetschefers och undersköterskors erfarenhet av personcentrerad omvårdnad inom kommunal hälso och sjukvård. Metod: Designen var en deskriptiv studie med kvalitativ ansats som har analyserats med hjälp av en induktiv innehållsanalys. Deltagarna som inkluderades i intervjustudien kom från samma kommun. Det var tio personer och bestod av fyra sjuksköterskor, fyra undersköterskor och två enhetschefer. De valdes ut av verksamhetschefen där inklusionskriteriet var att ha arbetat med personer med demens i minst fem år. Resultat: I resultatet framkom fyra kategorier och 12 subkategorier. Personcentrerad omvårdnad ansågs relevant i samband med god omvårdnad av personer med demens. I arbetet med personcentrerad vård var fokus att; anpassa sig till personen med demens, att se till dennes identitet och personlighet. Vidare lades vikt vid anhörigas deltagande, bemötande och ett gemensamt arbetssätt, vilket bestod av att identifiera behov och se personen bakom sjukdomen. Slutsats: Resultatet visade att de flesta intervjupersonerna hade liknande erfarenheter i att arbeta med personer med demens. Det framkom i studien att bemötandet hade stor betydelse i omvårdnaden. Fokus i personcentrerad omvårdnad var de redovisade kategorierna och dess innehåll och ansågs betydelsefull och nödvändig för att personer med demens får ett så bra och värdigt liv som möjligt efter sjukdomsdebuten.

The quality of the physical environment and its association with activities and well-being among older people in residential care facilities

The physical environment can influence older people’s health and well-being, and is often mentioned as being an important factor for person-centred care. Due to high levels of frail health, many older people spend a majority of their time within care facilities and depend on the physical environment for support in their daily life. However, the quality of the physical environment is rarely evaluated, and knowledge is sparse in terms of how well the environment meets the needs of older people. This is partly due to the lack of valid and reliable instruments that could provide important information on environmental quality. Aim: The aim of this thesis was to study the quality of the physical environment in Swedish care facilities for older people, and how it relates to residents’ activities and well-being. Methods: The thesis comprises four papers where both qualitative and quantitative methods were used. Study I involved the translation and adaptation of the Sheffield Care Environment Assessment Matrix (SCEAM) into a Swedish version (S-SCEAM). Several methods were used including forward and backward translation, test of validity via expert consultation and reliability tests. In Study II, S-SCEAM was used to assess the quality of the environment, and descriptive data were collected from 20 purposively sampled residential care facilities (RCFs). Study III was a comparative case study conducted at two RCFs using observations, interviews and S-SCEAM to examine how the physical environment relates to older people’s activities and interactions. In study IV, multilevel modeling was used to determine the association between the quality of the physical environment and the psychological and social well-being of older people living in RCFs. The data in the thesis were analysed using qualitative content analysis, and descriptive, bivariate and multilevel statistics. Results: A specific result was the production of the Swedish version of SCEAM. The instrument contains 210 items structured into eight domains reflecting the needs of older people. When using S-SCEAM, the results showed a substantial variation in the quality of the physical environment between and within RCFs. In general, private apartments and dining areas had high quality, whereas overall building layout and outdoor areas had lower quality. Also, older people’s safety was supported in the majority of facilities, whereas cognitive support and privacy had lower quality. Further, the results showed that environmental quality in terms of cognitive support was associated with residents’ social well-being. Specific environmental features, such as building design and space size, were also noted, through observation, as influencing residents’ activities, and several barriers were found that seemed to restrict residents’ full use of the environment. Conclusions: This thesis contributes to the growing evidence-based design field. The S-SCEAM can be used in future research on the association between the environment and people’s health and well-being. The instrument could also serve as a guide in the planning and design process of new RCFs.

Nursing Interventions in Prevention and Healing of Leg Ulcers: Systematic Review of the Literature.

Abstract Aim: To identify nursing interventions aimed at persons with venous, arterial or mixed leg ulcers. Methodology: Carried out research in the EBSCO search engine: CINAHL Plus with Full Text, MEDLINE with Full Text, MedicLatina, Academic Search Complete, sought full text articles, published between 2008/01/01 and 2015/01/31, with the following keywords [(MM "leg ulcer") OR (wound care) OR (wound healing)] AND [(nursing) OR (nursing assessment) OR (nursing intervention)], filtered through initial question in PI[C]O format. Results: The different etiologies of leg ulcer require a specific therapeutic and prophylactic approach. Factors that promote healing were identified: individualization of care, interpersonal relationship, pain control, control of the exudate, education for health self-management, self-care, therapeutic adherence, implementation of guidelines of good practice and auditing and feedback of the practices. Conclusion: Person-centred care and practices based on evidence improves health results in prevention and treatment of leg ulcers.