Nursing Home Care Research Articles

Addressing healthcare vulnerabilities in nursing homes : Insights from human rights monitoring in two Austrian provinces.

Current demographic changes bear challenges for national care systems due to higher life expectancy of older citizens. Largely cut off from society, nursing home residents are at risk for violence, neglect, and other potential human rights violations. This study aimed to investigate healthcare vulnerabilities in nursing homes and evaluate the Austrian National Preventive Mechanism (NPM). Between 2017 and 2019, 55 monitoring visits were conducted in 32 nursing homes. Study outcomes from two Austrian provinces included data on infrastructure, occupancy, staffing, resident's demographics and medical conditions, as well as measures related to the functioning of the NPM. Accessibility with mobility aids was sufficient in 87%, but assistance for persons with visual or hearing impairments solely in 20-40% of the institutions. An understaffing with nursing assistants (-5.2 full-time equivalents in Carinthia) and home helpers (-1.6 in Carinthia and Styria) was present. Less than 20% of the personnel received advanced training related to dementia and neuropsychiatric care. While 50% of the residents were diagnosed with apsychiatric disorder, approximately 36% received support from an appointed legal guardian. Of the monitoring visits 58.1% were conducted due to anonymous complaints and urgent referrals. The median processing times of the NPM and the provincial governments exceeded 250 days. Human rights monitoring reveals critical aspects in nursing home care, including insufficient accessibility, understaffing and inadequate training. Although the authorities' handling times hinder prompt responses, the NPM may foster systemic improvements and accountability within nursing homes.

2143 Minimal ingredient wipes for geriatric care

Abstract Introduction Wipes are a practical solution for cleansing skin and widely used in children, neonates, and in geriatric care. Effective cleansing requires low liquid surface tension (<40 mN/m), and many wipes contain surfactants to achieve this [1, 2]. However, these compounds may cause dryness, itching, irritation, and inflammation [1]. Age-related degeneration in skin suppleness decreases skin viability, often leading to irritation and incontinence-associated dermatitis, especially in frail nursing home residents [3]. By utilising purification technology, it is possible to lower liquid surface tension for cleansing and mitigate negative skin reactions caused by surfactants and additives. One minimal ingredient surfactant-free wipe (SF-wipe) achieves a solution surface tension of <35 mN/m, facilitating effective cleansing without surfactants [2]. These SF-wipes demonstrated superior results in a prospective study where neonates experienced significantly fewer days of clinically significant irritant diaper dermatitis [4]. The aim of this exploratory study was to understand current behaviours around personal hygiene and attitude towards SF-wipes in nursing homes. Method Four nursing care homes (n = 71 residents) received SF-wipes to trial. Feedback on effects and usability was gathered through interviews and reported qualitatively. Results Nursing staff indicated that the SF-wipes were soft, non-drying, non-abrasive, and facilitated faster in-bed bathing versus previous methods. Using SF-wipes did not lead to skin irritation in most residents, though some experienced transient skin coldness after use. Conclusions The high prevalence of skin conditions like incontinence-associated dermatitis in nursing home residents [5] means SF-wipes may prove beneficial versus surfactant-containing wipes, mirroring findings in neonates. Further studies are needed to prove this.

Evaluating the health outcomes of aging in place: the role of medicaid aging waiver program on U.S. older adults

The Medicaid Aging Waiver program (MAW) subsidizes the cost of long-term care (LTC) at home or in communities to satisfy older people’s increasing desire to age in place. The MAW program might be health improving for older people by allowing them to age at home. However, less quality and quantity of home-based care comparing to nursing home care could offset some of the potential benefits. I use policy expenditure across states over time linked with detailed health information from the Health and Retirement Study (HRS) to identify the associated effects of MAWs on health outcomes of older adults who are at risk of needing LTC and who are resources constrained to be potentially eligible for Medicaid. Overall, the findings suggest that the MAW program is beneficial to health: a $1,000 increase in MAW spending for each older person results is associated with a 1.4 percent improvement in self-reported health status, a 1.5 percent reduction in functional mobility limitations, a 1.6 percent decrease in Instrumental Activities of Daily Living (IADL) limitations, and a 1.7 percent improvement in negative psychological feelings. For older people who are most likely not eligible for MAWs, such as those who are wealthy or in good health and do not require LTC, these health-improving effects have not been observed.

Workload of home care nurses: Italian adaptation, validity, and reliability of the National Aeronautics and Space Administration Task Load Index questionnaire.

The aim of this study was to adapt the National Aeronautics and Space Administration Task Load Index (NASA-TLX) to the home care setting and translate and validate it in Italian. An online questionnaire containing the Italian version of the NASA-TLX adapted to the home care setting was administered to home care nurses to measure workload. Content Validity Index, Exploratory, and Confirmatory Factor Analyses were used to measure the psychometric characteristics of the modified NASA-TLX. The modified Italian version of NASA-TLX_HC-IT showed good psychometric characteristics in measuring the workload of home care nurses, with excellent fit indices. The reliability, calculated with Cronbach's alpha, was 0.73, indicating adequate reliability. A negative correlation between workload and job satisfaction among home care nurses, as well as a positive association between high workload and intention to leave the workplace, was verified. The modified Italian version of the NASA-TLX_HC-IT was confirmed to be a valid and reliable instrument to measure workload in home care nursing. Furthermore, the correlation between workload and the intention to leave the workplace among home care nurses was an important result that community nursing managers should consider preventing the shortage of home care nurses.

Support Needed by Home Care Nurses for Terminally Ill Cancer Residents

Support Needed by Home Care Nurses for Terminally Ill Cancer Residents

Dementia-Sensitive Environmental Design of Living Units in German Nursing Homes: First Results of the German Environmental Audit Tool (G-EAT).

The built environment is a key component of dementia-specific care. Little is known about the characteristics of dementia-sensitive environmental elements in living units of nursing homes in Germany. The German Environmental Audit Tool (G-EAT) is a systematic assessment tool for describing these elements in detail. To describe the extent of dementia-sensitive design principles and environmental elements in a regionally limited sample of living units in Germany. The built environment was assessed using G-EAT and analysed quantitatively and descriptively. Definitions of living units were developed based on site visits and analysed using qualitative content analysis. The 42 participating living units were heterogeneous in terms of space and composition. Dementia-sensitive design principles varied greatly in their implementation in the built environment; on average, 87.7% of the environmental elements were oriented towards a familiar environment. In contrast, visual accessibility was much less frequently enabled by the built environment (mean 37.3%). The characteristics of various dementia-sensitive environmental elements need to be further investigated against the background of the nursing home care concept and the homogeneity of the resident group to enable the initiation of tailored environmental adaptation that can be implemented by interdisciplinary teams in nursing homes. This also requires a follow-up study with a larger sample of living units to identify the factors that promote and inhibit the development of a dementia-sensitive environment.

High Prevalence of ESBL Genes in Commensal Escherichia coli of the Urinary Tract: Implications for Antibiotic Stewardship among Residents of Ghanaian Elderly Nursing Care Homes.

The emergence and spread of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) pose significant challenges to the treatment and control of urinary tract infections, particularly among vulnerable populations, such as the elderly living in nursing care homes. In this study, we investigated the occurrence of ESBL genes in commensal E. coli isolated from urine samples of 118 elderly individuals residing in Ghanaian nursing care homes. A total of 195 ESBL genes were detected among 41 E. coli isolated from the study participants. All the isolates harboured at least one ESBL gene, and the majority of them (70.1%) carried at least four ESBL genes. Among the ESBL genes detected, CTXM825 was the predominant (14.1%). In antimicrobial susceptibility testing, 65.9% of the isolates showed resistance to cefepime, a fourth-generation cephalosporin, while 56.1% showed resistance to cefotaxime, a third-generation cephalosporin. Additionally, 46.3% of the isolates were multidrug-resistant, indicating resistance to antibiotics from multiple classes. In summary, we observed relatively high rates of resistance to antibiotics as well as alarming rates of ESBL genes in the isolated pathogens. These findings emphasise the urgent need for antimicrobial stewardship and infection control programmes to mitigate the spread of multidrug-resistant pathogens in nursing care homes.

Home Care Nursing on Long-Term Illness Management in the French Healthcare System.

This study explores the role of home care nurses in managing long-term illnesses (L-TI) within the French healthcare system, utilizing data from the SNDS. Focused on data from 2022, it categorizes nursing actions into medical procedures, care procedures, and nursing processes, revealing significant involvement in patient care. The findings highlight the crucial, evolving role of home care nurses in addressing the complex needs of millions suffering from chronic conditions like diabetes and cardiovascular diseases in France.

Collaboration between care teams and care experts in home care nursing: A qualitative case study

Collaboration between care teams and care experts in home care nursing: A qualitative case study Abstract: Background: As a result of demographic change and the associated ageing population, the number of people affected by multimorbidity is increasing, and with it the complexity of home care nursing. In a home care nursing service (Spitex), care teams work with employees of different levels of competence. For support in complex situations, they can seek help from nursing experts (PEX). Aim: The aim was to investigate the collaboration between the care teams and the PEX of a regional Spitex organization and to work out measures for optimization. The research question was: "How do the care teams of a regional Spitex organization experience the collaboration with the nursing experts?" Methods: A qualitative case study design with four sub-cases was used to describe in detail how collaboration with PEX is experienced. Four Focus group interviews were evaluated using content analysis and cross-case analysis. Results: The Cross-Case analysis reveals the categories for optimal collaboration: present, professionally versatile, relieving in coordination tasks, supportive in complex situations. The following categories are categorized as disruptive factors in collaboration: varying levels of commitment, collaboration low priority and confusing. Conclusions: The PEX are to be made better known through targeted information dissemination. Implications for practice include the importance of presence and mutual understanding of roles so that collaboration is experienced as added value.

Navigating Religious Refusal to Nursing Home Care for LGBTQ+ Residents: Comparisons Between Floor Staff and Managers.

Religious exemptions (exceptions to nondiscrimination laws for individual religious/moral beliefs) in health care have surged, negatively affecting LGBTQ+ older adults in nursing homes with some of the highest caregiving needs. Given job differences between floor staff and managers, this study asks: How does meaning-making differ between nursing home floor staff and managers when staff refuse to care for LGBTQ+ residents? To answer this question, this study uses social coherence as a conceptual framework to understand the process of reflection that staff employ when a colleague invokes a religious exemption to care. This qualitative comparative study uses in-depth semistructured interviews to compare responses from nursing home floor staff and managers (n = 80). Qualitative content analysis incorporated inductive and deductive coding approaches. Staff invoked 5 frames to reach social coherence: fairness, resident safety and comfort, individual religious beliefs, job obligations, and laws/policies. Floor staff and managers invoked the same 2 reasons (fairness, resident safety and comfort) to reach social coherence. However, floor staff differed from managers by also invoking individual religious beliefs and job obligations; whereas managers turned to laws and policies to reconcile tensions between religious rights and LGBTQ+ resident rights to care. In an increasingly polarized world, findings from this study illuminate nuances (and potential new areas of allyship) in how floor staff and managers understand and use various frames when deciding whether or not to accommodate a colleague who refuses care to an LGBTQ+ resident because of religious or moral reasons.

Bridging the gaps in pediatric complex healthcare: the case for home nursing care among children with medical complexity

BackgroundChildren with medical complexity (CMC) comprise < 1% of the pediatric population, but account for nearly one-third of healthcare expenditures. Further, while CMC account for up to 80% of pediatric inpatient hospital costs, only 2% of Medicaid spending is attributed to home healthcare. As a result, the current health system heavily relies on family caregivers to fill existing care gaps. This study aimed to: (1) examine factors associated with hospital admissions among CMC and (2) contextualize the potential for home nursing care to improve outcomes among CMC and their families in South Carolina (SC).MethodsThis mixed-methods study was conducted among CMC, their family caregivers, and physicians in SC. Electronic health records data from a primary care clinic within a large health system (7/1/2022-6/30/2023) was analyzed. Logistic regression examined factors associated with hospitalizations among CMC. In-depth interviews (N = 15) were conducted among physicians and caregivers of CMC statewide. Patient-level quantitative data is triangulated with conceptual findings from interviews.ResultsOverall, 39.87% of CMC experienced ≥ 1 hospitalization in the past 12 months. CMC with higher hospitalization risk were dependent on respiratory or neurological/neuromuscular medical devices, not non-Hispanic White, and demonstrated higher healthcare utilization. Interview findings contextualized efforts to reduce hospitalizations, and suggested adaptations related to capacity and willingness to provide complex care for CMC and their families.ConclusionsFindings may inform multi-level solutions for accessible, high-quality home nursing care among CMC and their families. Providers may learn from caregivers’ insight to emphasize family-centered care practices, acknowledging time and financial constraints while optimizing the quality of medical care provided in the home.

Receiving home care forms and the risk for emergency department visits in community-dwelling Dutch older adults, a retrospective cohort study using national data

BackgroundOlder adults receiving home care have a higher risk of visiting the emergency department (ED) than community-dwelling older adults not receiving home care. This may result from a higher incidence of comorbidities and reduced functional autonomy in home care recipients. Since people receive different types of home care because of their different comorbidities and autonomy profiles, it is possible that distinguishing between the form of home care can help identify subpopulations with different risks for ED visits and help develop targeted interventions. This study aimed to compare the risk of visiting the ED in older adults receiving different forms of home care with those living at home without receiving home care in a national cohort in one year.MethodsA retrospective cohort study using claims data collected in 2019 on the Dutch population aged ≥ 65 years (N = 3,314,440) was conducted. Participants were classified as follows: no claimed home care (NO), household help (HH), personal care (PC), HH + PC, and nursing home care at home (NHH). The primary outcome was the number of individuals that visited the ED. Secondary outcomes were the number of individuals whose home care changed, who were institutionalized, or who died. Exploratory logistic regression was applied.ResultsThere were 2,758,093 adults in the NO group, 131,260 in the HH group, 154,462 in the PC group, 96,526 in the HH + PC group, and 34,612 in the NHH group. More ED visits were observed in the home care groups than in the NO group, and this risk increased to more than two-fold for the PC groups. There was a significant change to a more intensive form of home care, institutionalization, or death in all groups.ConclusionsDistinguishing between the form of home care older adults receive identifies subpopulations with different risks for ED visits compared with community-dwelling older adults not receiving home care on a population level. Home care transitions are frequent and mostly involve more intensive care or death. Although older adults not receiving home care have a lower risk of ED visits, they contribute most to the absolute volume of ED visits.

Reflections of nurses and primary healthcare managers on integrating hospital at home into public primary healthcare services: a Norwegian focus group study

Background Hospital at home (HaH) is an innovative approach to healthcare delivery that brings specialized services to patients’ homes. HaH services are typically available in urban areas where hospitals can easily reach nearby patients. An integrated care model that utilizes the public primary healthcare system may extend HaH services to include patients residing further away from hospitals. However, there is limited evidence of primary healthcare employees’ views on integrating HaH care into primary healthcare services. This study aimed to explore the reflections of primary healthcare employees on integrating HaH care into primary healthcare services. Methods Ten focus group interviews were conducted with homecare nurses and managers of primary healthcare services in five municipalities in Mid-Norway. Reflexive thematic analysis was used to analyze the data. Results The analysis resulted in three key themes regarding the integration of HaH care into primary healthcare. Participants discussed how they capture the distinctiveness of HaH care within the primary healthcare landscape. Moreover, they identified that the introduction of HaH care reveals opportunities to address challenges. Lastly, the study uncovered a strong primary healthcare commitment and a sense of professional pride among the participants. This resilience and dedication among primary healthcare employees appeared as an incentive to make the integration of HaH work. Conclusions This study offers valuable insights into integrating HaH into primary healthcare services, highlighting opportunities to address challenges. The resilience and dedication of primary healthcare employees underscore their commitment to adapting to and thriving with HaH care. To establish a sustainable HaH care model, it is important to address geographical limitations, consider the strain on providers, maintain robust relationships, enhance funding, and formalize decision-making processes.

Unravelling hidden inequities in a universal public long-term care system

We study the socioeconomic horizontal inequity in the allocation of publicly subsidised long-term care (LTC) in Spain, using administrative data from the universe of applicants in Catalonia. We find that, after controlling for needs, cash subsidies for informal care are disproportionately concentrated among wealthier individuals, while the use of formal care services (home care and nursing homes) is concentrated among the less well-off. This suggests that cash benefits may inadvertently facilitate access to wealthier individuals’ private care. We also find inequity in the form of provision, with in-kind services being more prevalent among the worse-off while wealthier beneficiaries are more likely to receive vouchers. While this duality in provision does not lead to significant differences in overall time to access LTC, we find that lower-income individuals wait longer for telecare, and wealthier individuals opting for in-kind nursing home care wait longer, suggesting potential differences in preferences or constraints. We find no evidence of socioeconomic inequity in the time spent navigating the administrative application process. Our findings highlight the need for policymakers to consider the potential unintended consequences of cash benefits and different forms of provision to ensure equitable access to LTC services.

Lessons learned from CMS's National Partnership to Improve Dementia Care: a thematic synthesis of multiple stakeholder-engaged studies.

Antipsychotic prescribing in United States nursing homes (NHs) has decreased since the Center for Medicare & Medicaid Service debuted the National Partnership to Improve Dementia Care in Nursing Homes (NP); however, reductions have stalled. To help explain persistent antipsychotic use despite the NP's reduction efforts, the perspectives of diverse NP stakeholders were qualitatively assessed. This study aimed to re-evaluate these individual perspectives in combined thematic synthesis to discover NP improvement opportunities undetectable in single stakeholder assessments. Thematic synthesis. Through immersive crystallisation, original source coding results were organised into related descriptive themes. Similarities and differences were identified, and descriptive themes were regrouped into new, increasingly abstract, analytical themes. This cycle continued until variances were resolved and analytic themes sufficiently described and explained all initial descriptive themes. Three analytic themes emerged regarding NP improvement opportunities. The NP's positive impacts would be augmented by: (i) a deeper and expanded appreciation of stakeholder perspectives; (ii) more urgent and rapid adaptation to unintended adverse outcomes; and (iii) greater recognition of the contextual and environmental factors influencing decisions to prescribe or not prescribe antipsychotic medications. Stakeholder groups described: perspectives they perceived as inadequately considered by the NP; insufficient NP engagement with the stakeholders capable of creating evidenced, affordable, and available non-pharmacologic therapies for dementia symptoms; recognition that dementia interventions effective for a specific individual at a specific time in a specific community may not generalise; and diverse ongoing undesirable outcomes from NP policies that could be mitigated by NP modifications. The NP has done much to advance dementia care in NHs. Notwithstanding, these results suggest the NP would only be improved through increasingly comprehensive inclusion of stakeholder perspectives, enhanced incorporation of individual contextual factors, and a more decisive mechanism for ongoing and continual adaptation.

Culture of Nursing Care in Iranian Nursing Homes: An Ethnographic Study

Background: The aging of the population and an increase in the number of older adults require long-term care and a greater number of nursing homes (NHs). Consequently, identifying relevant cultural factors in NHs may contribute to meeting care needs. This study aimed to explore the culture of nursing care for older adults in NHs in Iran. Methods: This interpretive ethnographic study was conducted in two NHs in Kerman. The data were collected through fieldwork, participant observations, field notes, and semi-structured in-depth interviews with 26 staff and 7 residents. The collected data were analyzed through content analysis. Results: The culture of care in NHs revolves around 3 themes including "task-oriented care", "care deficiency", and "enthusiastic care". Conclusion: The results emphasized the value of the cultural atmosphere embedded in NHs. The provided care mostly met the physical and immediate needs of older adults (task-oriented care). In addition, establishing an emotional relationship with older adults can help them better accept care and reduce illness and disability in them.

Families’ importance in nursing care–families’ opinions: a cross-sectional survey study in the homecare setting

BackgroundInformal care is an essential part of support provided in the homecare setting. To ensure effective healthcare provision, good communication and collaboration between informal and formal care providers are crucial. To achieve this aim, it is necessary to have a clear understanding of the perspectives of all stakeholders. In the scientific literature, limited knowledge is available regarding family members’ opinions about their involvement in care. To date, no instruments have been developed that accurately measure these opinions. This study aims to elucidate the opinions of family members about their involvement in nursing care.MethodsA cross-sectional survey approach was employed. The methodological steps in this study were (1) convert the Families’ Importance in Nursing Care–Nurses’ Attitudes (FINC-NA) from a nurses’ perspective to a family perspective and thus develop the Families’ Importance in Nursing Care–Families’ Opinions (FINC-FO) and (2) measure families’ opinions regarding their involvement in home nursing care. The questionnaire was sent to 3,800 patients with activated patient portals, which accounts for about 17% of the total patient base. Responses were received from 1,339 family members, a response rate of 35%.ResultsThe developed FINC-FO questionnaire showed homogeneity and internal consistency. The results of the questionnaire indicate that family members consider it important to be involved in care and that they wish to be acknowledged as participants in discussions about care (planning) but are less inclined to actively participate in the provision of care by nurses. Family members expressed less explicit opinions about their own support needs. Factors such as level of education, type of partnership, and amount of care provided are seemingly associated with these opinions.ConclusionsFamily members in the homecare setting wish to be involved in discussions about care (planning). The transition in care from primarily formal to more informal care necessitates an awareness and clear definition—on part of both healthcare professionals and families—of their respective roles in the provision of care. Communication about wishes, expectations, and the need for support in care is essential to ensure quality of care and that the family can sustain caregiving.

Facilitators and Inhibitors of Transition for Elderly Ghanaian Persons and Their Stakeholders to Nursing Home Care

Facilitators and Inhibitors of Transition for Elderly Ghanaian Persons and Their Stakeholders to Nursing Home Care

Active listening, shared decision-making and participation in care among older women and primary care nurses: a critical discourse analysis approach from a gender perspective

BackgroundNursing care for older women represent a challenge worldwide due to its characteristics. When communication is impaired between primary care nurses and older women living alone, an imbalance in power relations occurs. The main objective of this study is to analyse the power relations between older women and primary care nurses in situations of active listening, shared decision-making and participation in care.MethodsWe developed a qualitative study in southern Spain using a discursive and gender approach. We used purposeful sampling to interview older women who lived alone and received home nursing care. Simultaneously, we conducted focus groups with primary care nurses who provided home care to older women. A linguistic analysis of the transcripts was carried out.ResultsNine semi-structured face-to-face interviews were conducted with older women who lived alone and two face-to-face focus groups with four primary care nurses in each. The discourse of the participants demonstrated an imbalance in power relations. Influenced by work overload, active listening was considered a privilege in primary care nurses´ discourse. Regarding shared decision-making, older women´s discourses revealed “mirages” of real situations where they thought they were deciding. Participation in care was difficult since older women saw themselves as a nuisance in nurses´ presence, and primary care nurses did not facilitate older women’s engagement. Older women weren´t considered when organising home visits and had interiorised a subordinated feeling. Similarly, a strict sense of identity made primary care nurses feel powerful in their relationships with older women.ConclusionsThe discourse of older women represented them as victims of a hostile panorama whilst they were sometimes satisfied with the deficient care received. The discourse of primary care nurses used more discursive strategies to represent themselves as professionals committed to caring. However, it also revealed deficiencies in care, discriminatory elements, and feelings of being limited by their working conditions. Active listening to older women and engagement in decision-making readjust empower the older women. Attending to the needs and concerns of primary care nurses could recalibrate the power imbalance between them and healthcare organisations.

End-of-life care in German and Dutch nursing homes: a cross-sectional study on nursing home staff’s perspective in 2022

BackgroundAs society ages, the need for nursing home care is steadily increasing and end-of-life care of nursing home residents has become increasingly more important. End-of-life care differs between Germany and the neighbouring Netherlands. For example, a much higher proportion of German compared to Dutch nursing home residents is hospitalized at the end of life. Therefore, the aim of this study was to evaluate end-of-life care in German and Dutch nursing homes.MethodsIn this cross-sectional study, a postal survey was sent to 600 randomly selected German and Dutch nursing homes each and addressed to the nursing staff management. Participants were asked to estimate the percentage of nursing home residents whose wishes for emergency situations (e.g. cardiopulmonary resuscitation) are known and to indicate whether facilities offer advanced care planning (ACP). They were also asked to estimate whether general practitioners (GPs)/elder care physicians (ECPs) and nursing home staff are usually well trained for end-of-life care. Finally, participants were asked to estimate the proportion of nursing home residents who die in hospital rather than in the nursing home and to rate overall end-of-life care provision.ResultsA total of 301 questionnaires were included in the analysis; 199 from German and 102 from Dutch nursing homes (response 33.2% and 17.0%). German participants estimated that 20.5% of residents die in the hospital in contrast to the Dutch estimation of 5.9%. In German nursing homes, ACP is offered less often (39.2% in Germany, 75.0% in the Netherlands) and significantly fewer wishes for emergency situations of residents were known than in Dutch nursing homes. GPs were considered less well-trained for end-of-life care in Germany. The most important measures to improve end-of-life care were comparable in both countries.ConclusionDifferences in (the delivery and knowledge of) end-of-life care between Germany and the Netherlands could be observed in this study. These could be due to structural differences (ECPs available 24/7 in the majority of Dutch nursing homes) and cultural differences (more discussion on quality of life versus life-sustaining treatments in the Netherlands). Due to these differences, a country-specific approach is necessary to improve end-of-life care.