Norwegian Nursing Home Research Articles

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program – a nested qualitative study

BackgroundAntibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.MethodsAfter implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.ResultsWe identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents’ next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.ConclusionsOur qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

Despite Symptom Severity, do Nursing Home Residents Experience Joy-of-Life? The Associations Between Joy-of-Life and Symptom Severity in Norwegian Nursing Home Residents

Despite Symptom Severity, do Nursing Home Residents Experience Joy-of-Life? The Associations Between Joy-of-Life and Symptom Severity in Norwegian Nursing Home Residents

Understanding Spiritual Care—Perspectives from Healthcare Professionals in a Norwegian Nursing Home

Nursing home professionals have reported that spiritual care is an unclear concept, and research suggests that healthcare professionals have a limited understanding of this dimension of care. The provision of spiritual care is well-investigated internationally, but research is sparse within Norway’s secularized society. This study investigated healthcare professionals’ understanding of spiritual care in one nursing home. Methods: Data were collected from individual interviews (N = 8) and one focus group (N = 5) of nursing home personnel; the study used qualitative content analysis and a hermeneutic methodology. Results: One central question emerged during the data analysis: what is spiritual care versus good care? This starting point resulted in four themes (1) caring for the whole person, (2) having a personal touch, (3) seeing the person behind the diagnosis, and (4) more than religiousness. Some healthcare professionals had not heard of spiritual care, and many were not aware of this in their daily work with older patients. Nevertheless, they facilitated and cared for the patient’s spiritual needs, but they did not address it as spiritual care. Other participants were familiar with the concept and understood spiritual care as an essential part of daily care. Conclusion: healthcare professionals’ understanding of spiritual care is broad and varied, including practical and non-verbal aspects. The results indicated a need for an open dialogue about spiritual needs and resources in clinical practice and the teaching of personnel about how to facilitate older people’s spirituality. Moreover, there is a need for more research into spiritual care and how it differs from the concept of good fundamental care.

The Effect of the NorGeP-NH on Quality of Life and Drug Prescriptions in Norwegian Nursing Homes: A Randomized Controlled Trial.

Background: The effect of the Norwegian General Practice–Nursing Home (NorGeP–NH) criteria has never been tested on clinical outcomes in nursing home (NH) residents. We performed a cluster-randomized trial in Norwegian NHs and tested the effect of NorGeP–NH on QoL (primary outcome), medication prescriptions, and physical and mental health (secondary outcomes) for the enrolled residents; Methods: Fourteen NHs were randomized into intervention NHs (iNHs) and control NHs (cNHs). After baseline data collection, physicians performed NorGeP–NH on the enrolled residents. We assessed the difference between cNHs and iNHs in the change in primary outcome from baseline to 12 weeks and secondary outcomes from baseline to eight and 12 weeks by linear mixed models; Results: One hundred and eight residents (13 lost to follow-up) and 109 residents (nine lost to follow-up) were randomized to iNHs and cNHs, respectively. Difference in change in QoL at 12 weeks between cNHs and iNHs was not statistically significant (mean (95% CI)): −1.51 (−3.30; 0.28), p = 0.101). We found no significant change in drug prescriptions over time. Difference in depression scores between cNHs and iNHs was statistically significant after 12 weeks. Conclusions: Our intervention did not affect QoL or drug prescriptions, but reduced depression scores in the iNHs. NorGeP–NH may be a useful tool, but its effect on clinical outcomes may be scarce in NH residents. Further studies about the effectiveness of NorGeP–NH in other healthcare contexts and settings are recommended.

No Increase in Short-Term Mortality Following COVID-19 Vaccination Among Nursing Home Residents

Reports of fatal adverse events following mRNA-based vaccination for COVID-19 in Norwegian nursing home (NH) residents have raised concern regarding vaccine safety in very old and frail persons. A limitation of these reports, however, is the absence of contemporaneous control groups, particularly given the high baseline mortality in this population. Using electronic health records’ data on resident deaths, hospital transfer, vaccination, and daily census from Genesis Healthcare, a large NH provider spanning 24 U.S. states, we compared 7-day mortality and hospitalization rates for vaccinated versus unvaccinated NH residents. Between December 18, 2020 and December 31, 2020, 7006 residents across 118 NHs were vaccinated with the first dose. Mortality and hospital transfer rates within 7 days of vaccination were compared to rates for: (1) unvaccinated residents in the same facility within 7 days of the vaccine clinic (n=4414), and (2) residents in 166 yet-to-be-vaccinated facilities between December 25, 2020 and January 1, 2021 (n=17,076). We excluded residents with a positive SARS-CoV-2 diagnostic test within 20 days prior to their 7-day observation window. Mortality rates per 100,000 residents were lower among vaccinated (587, 95%CI: 431, 798) versus unvaccinated residents within the same facilities (984, 95%CI: 705, 1382), and compared to residents in not-yet-vaccinated facilities (912, 95%CI: 770-1080), with overlapping 95% CIs. Hospital transfers were lower among vaccinated residents than in either comparison group, but with overlapping CIs. Our findings suggest that short term mortality rates appear unrelated to vaccination for COVID-19 in NH residents, and should dispel concerns raised by previous reports.

Despite Symptom Severity, do Nursing Home Residents Experience Joy-of-Life? The Associations Between Joy-of-Life and Symptom Severity in Norwegian Nursing Home Residents.

Background: Finding new approaches to increase health and well-being among nursing home (NH) residents is highly warranted. From a holistic perspective, several Norwegian municipalities have implemented the certification scheme framed “Joy-of-Life Nursing Home” Aims: In a holistic perspective on NH care, this study investigated if NH residents despite potential symptom severity experience joy-of-life (JoL). Therefore, we examined the frequency of common symptoms and the association between common symptoms and JoL in cognitively intact NH residents. Methods: A cross-sectional design was employed. Using the QLQ-C15–PAL quality-of-life questionnaire, hospital anxiety and depression scale, and JoL scale, a total of 188 cognitively intact NH residents participated. Results: Symptom severity was high; 54% reported fatigue, 52% reported constipation, 45% reported pain, 43% reported dyspnea, 32% reported insomnia, 22% reported appetite loss, and 20% reported nausea, while 20% reported anxiety and 23% reported depressive symptoms. Nevertheless, 59% of the NH residents reported high JoL, which was significantly positively related to the quality of life and negatively associated with anxiety and depression.

Pain in nursing home residents with dementia and its association to quality of life

Objectives We aimed to describe pain, use of analgesics and quality of life (QoL) in people with dementia admitted to a Norwegian nursing home (NH), and to explore if and how pain was associated with their QoL when adjusting for sociodemographic characteristics, other health conditions and use of analgesics. Method A total of 953 Norwegian NH residents with dementia (mean age 84.0, SD 7.5 years, 35.8% men) were included at admission to the NH. Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the use of psychotropic drugs and analgesics were assessed. Results In total, 36% of the participants had clinically relevant pain intensity (MOBID-2 ≥ 3) and 52% received analgesics. Paracetamol was most frequently prescribed (45%). In an adjusted linear mixed model, more severe pain was associated with higher QUALID total scores, indicating poorer QoL (regression coefficient 0.52, 95% CI 0.36-0.69). Conclusion Pain prevalence at NH admission was high in residents with dementia; half used analgesics, particularly paracetamol. More severe pain was associated with poorer QoL when adjusting for sociodemographic characteristics, other health conditions, and use of analgesics. The routine assessment of pain at NH admission can uncover undiagnosed and untreated pain and allow for adequate non-pharmacological and pharmacological pain management and likely increased QoL.

Health professionals’ experience of nursing home residents’ consumption of alcohol and use of psychotropic drugs

Background:Nursing home (NH) residents are in most cases in older ages and use prescription drugs. As alcohol interacts with many commonly prescribed drugs, NH residents may be more vulnerable to the effects of alcohol.Aim:To investigate the experiences of health professionals in Norwegian NHs when it comes to residents' alcohol consumption and use of psychotropic drugs, and the facilitation of such use in the NH.Method:Focus-groups and individual interviews with NH health professionals were performed in 2017 and 2018. The data were analysed using content analysis.Findings:Two main themes emerged: (1) the balancing of alcohol consumption, and (2) the use of psychotropic drugs. Each of these themes involved reasoning, which revealed that the informants in general had little attention regarding alcohol consumption among residents, and few institutions had policies regarding serving and consumption of alcohol. The informants reported an increased attention regarding use of psychotropic drugs and a tendency towards less use of psychotropic drugs among the residents than before, but few informants reported use of standardised observations tools of symptoms related to prescribing and discontinuation of drugs.Conclusion:Alcohol policies or procedures related to alcohol consumption were uncommon at the NH that the interviewees of this study represented, and the professionals regarded infrequent serving and consumption of alcohol among the residents as a part of everyday life. In cases when residents frequently consumed alcohol, the professionals used dialogue to underpin the adherent risks and they also tried to control the consumption of the resident in different ways. The interviewees were aware of various side-effects of psychotropic drugs; they were also aware of their effects in combination with alcohol.

Opioids, Pain Management, and Palliative Care in a Norwegian Nursing Home From 2013 to 2018

In Norway, approximately 50% of older people die in nursing homes (NH). Holistic care and pharmacological management are key factors in quality at the end of life. The purpose of this longitudinal study was to describe the use of opioids in an NH during a 5-year period. We focused on palliative care, symptoms, and suffering during the last 3 days before death. Data were collected from spring 2013 to spring 2018. We used the interRAI assessment instrument annually and when the resident died. We conducted a semi-structured interview with nurses on duty at the deathbed. At the time of death, the residents had an average age of 88.9 years and an average stay of 2.9 years (N = 100). At the first assessment, 19% of the residents used 1 or more type of opioids. On the day of death, 55% had an active prescription for opioids, mainly as subcutaneous injections. The results illustrate the different uses of opioids, including managing pain, dyspnoea, sedation, for comfort, as a prophylaxis, or a combination of reasons. Cancer- and cardiovascular diagnoses were the strongest predictor for using morphine (P < 0.05). Identification of the residents’ needs for opioids is a challenge for palliative care nurses, both ethically and legally.

THE RESPONSE OF AGITATED BEHAVIOR TO PAIN MANAGEMENT IN PERSONS WITH DEMENTIA. RCT TRIAL

Behavioral disturbances and pain are common in nursing home (NH) patients with dementia. Reduction of agitation by pain treatment was demonstrated. It is, however, unclear which specific agitated behaviors respond to analgesics. 352 patients with advanced dementia and behavioral disturbances were included from 60 clusters of 18 Norwegian NHs. According to a pre-defined scheme for 8 weeks, intervention groups received individual pain treatment with acetaminophen, morphine, buprenorphine patch, and/or pregabaline. Control groups received usual care. We used linear random intercept mixed model in two-way repeated measure with adjustment for heteroscedasticity. Assessed by Cohen-Mansfield Agitation Inventory (CMAI), verbally agitated behaviors (factor 3), such as complaining, negativism, and/or cursing or verbal aggression, showed largest significant difference (p<0.001), followed by physically non-aggressive behaviors (Factor 2) (p=0.008), and aggressive behaviour (Factor 1) (p=0.037) after 8 weeks. Especially, restlessness and pacing were sensible to analgesics, and should lead to assessment and treatment of pain.

Antipsychotic Drug Use Is Not Associated With Long-Term Mortality Risk in Norwegian Nursing Home Patients

ObjectivesTo assess the long-term mortality risk associated with antipsychotic drug (AP) use in nursing homes. DesignA longitudinal study with 5 assessments over a 75-month follow-up period. SettingA representative sample of nursing home patients in 4 Norwegian counties. ParticipantsAt baseline, 1163 patients were included. At the last follow-up, 98 patients were still alive. MeasurementsPrevalent drug use at each assessment was registered. Level of dementia, neuropsychiatric symptoms, level of functioning, medical health, and use of restraints were recorded at each assessment. A Cox regression model with time-dependent psychotropic drug use as the main predictor was estimated and adjusted for confounders. ResultsIn unadjusted Cox regression, a lower mortality risk was associated with the use of other psychotropic drugs, but not APs, compared with nonusers. In the adjusted analysis, neither use of APs nor other psychiatric drugs was associated with increased mortality risk. Higher age, male gender, not being married, medical disease burden, lower level of functioning, more severe degree of dementia, and a higher number of drugs were all associated with increased mortality risk. ConclusionIn this long-term study of nursing home patients, AP drug use was not associated with increased risk of mortality. This is in line with results from earlier studies of clinical samples, but contrasts with results from randomized controlled trials and registry-based studies. The findings should be interpreted with caution. Taking into account the modest benefit and high risk of adverse effects of AP drug use, nonpharmacological treatment remains the first-line treatment approach.

COMPARISON OF ITALIAN AND NORWEGIAN POSTACUTE CARE SETTINGS FOR OLDER PATIENTS IN NEED OF FURTHER TREATMENT AND REHABILITATION AFTER HOSPITALIZATION

Background/Objectives: Little is known regarding the influence of sociodemographic and clinical factors, on the short term outcomes of different postacute care (PAC) models in different countries. Design and setting: Prospective cohort study of a 19- bed Italian hospital subacute care (SAC) unit and a 19-bed Norwegian nursing home (NH) intermediate care (IC) unit, both based on Comprehensive Geriatric Assessment and similar multidisciplinary staffing. Participants: A total of 664 Italian and 961 Norwegian community-dwelling patients ≥70 years of age, in need of postacute geriatric based treatment, rehabilitation and care. The patients were admitted from acute medical, surgical and orthopaedic hospital units. Measurements: Demographic data, clinical information, comprehensive geriatric assessment (CGA), discharge destination and length of stay were recorded in an Italian and a Norwegian database and compared. Results: The Italian patients receiving hospital SAC, were more seriously affected by the acute disease and trauma, median Barthel index (BI) at admission/discharge was 40/60, compared to 75/85 in the Norwegian patients, and fewer of them were able to return to own home as compared to the Norwegian patients ( 64% vs. 82%). Although the Italian patients had a lower BI at discharge, fewer of them were transferred to nursing homes (9%), as compared to the Norwegian patients (14%), while more of them were discharged to further rehabilitation, acute hospitalization, hospice or died (27%), as compared to the Norwegian patients (4%). Of the patients discharged to own home, only 8% of the Italian compared to 71% of the Norwegian patients received nurse assisted home care. Admission BI and improvement in BI, were highly significant predictors for the ability to return home in multivariate logistic regression analysis both in the Italian and the Norwegian patients. Conclusions: Both clinical and sociodemographic factors influenced the clinical outcome of older patients receiving PAC in Italy and Norway. Such differences should be taken into account when results from different PAC models in different countries are compared. Both the Italian hospital SAC model and the Norwegian NH IC model are feasible and good alternatives, but more firm inclusion criteria may further optimize the selection of patients suitable for different PAC options.

Norwegian Nursing Home—A Care Facility or a Home?

This article focuses on the function of Norwegian nursing homes. A brief history of institutionalisation of older people in Norway is presented. An expressed task for Norwegian nursing homes is active treatment, and even though the “Guarantee of dignity” was implemented from January 2011, there are proofs that the rights of the residents are constantly violated. Another task for Norwegian nursing homes is to be home for the residents. This double function of the nursing home, being both a care facility and a home is discussed, and whether the nursing homes succeed in fulfilling these tasks or not is questioned. It is also questioned if Goffman’s descriptions of total institutions are applicable on nursing homes of today.

MRSA: A Challenge to Norwegian Nursing Home Personnel

In Norway, methicillin-resistant Staphylococcus aureus (MRSA) is increasing in primary healthcare, associated with imported cases and outbreaks in long-term care. According to Norwegian national guidelines, MRSA-exposed healthcare workers (HCWs) and patients are tested. Carriage of MRSA leads to exclusion from work in healthcare institutions. In this study, 388 staff members in 42 nursing homes in Oslo County responded to questions about personal experience with MRSA and of own attitudes to challenges associated with the control and treatment of MRSA patients. Half (52%) of the nursing staff were concerned of becoming infected with MRSA and the consequences of this would be for own social life, family, economy, and work restriction. The concern was associated with risk factors like old buildings not suitable for modern infection control work, low staffing rate (70% without specific training in healthcare and 32% without formal healthcare education), defective cleaning and decolonization, and lack of formal routines and capacity for isolation of MRSA patients. Since the Norwegian MRSA guideline permits patients with persistent MRSA infections to move freely around in nursing homes, the anxiety of the staff to become infected and excluded from job was real.

Factor Analysis of the Brief Agitation Rating Scale in a Large Sample of Norwegian Nursing Home Patients

Background: Agitation and aggression are prevalent in dementia and put heavy strains on caregivers. Validated assessment tools measuring these symptoms are required to evaluate patients before therapy and during the follow-up period. Given the daily routine in nursing homes, abbreviated instruments are preferable. The Brief Agitation Rating Scale (BARS) is a short form of the Cohen-Mansfield Agitation Inventory. Our aim was to examine the Norwegian version of the BARS by performing a factor analysis. Methods: The data came from 1,870 nursing home patients. The primary caregivers were interviewed by research nurses using the Clinical Dementia Rating Scale, Lawton’s Physical Self-Maintenance Scale and the BARS. Results: The exploratory factor analysis of the BARS revealed 3 dimensions: physically aggressive behavior, physically nonaggressive behavior and verbal agitation. Linear regression analysis showed that reduced functioning in activities of daily living was associated with physically aggressive behavior and verbal agitation, whereas increased severity of dementia and better functioning in activities of daily living were related to physically nonaggressive behavior. In addition, verbal agitation was positively related to a higher number of drugs being taken per day. Conclusions: The factor analyses confirmed that the Norwegian version of the BARS measures the clinically relevant dimensions of agitation in dementia.

Mot opplevelse av integritet og verdighet — en streben og strid?

The purpose of this hermeneutic study is to describe and discuss meaningful experiences as they appear through talks with residents in a Norwegian Nursing Home. The question at issue is: In what way do the residents keep up their feelings of integrity and dignity? The investigation is based on the philosophy of Gadamer. The investigators fore-understanding is also influenced by other theoretical works, thus exploring a relation between integrity, dignity and the experience of control. The empirical part of the study is based on interviews using a sample of five residents from three wards in one nursing home in the Oslo region. The data are analysed by three steps. The result show that elderly people in increasing need of other peoples help, is vulnerable to loss of dignity and integrity. The staffs interaction pattern is one crucial item. In addition, being relocated to a nursing home, makes it necessary to compensate old values with new ones, or enhance existing values. This correspond with other comparable research findings. In order to experience control it seems necessary to exchange old values to new ones.