Psychogeriatric Nursing Home Wards Research Articles

Feasibility of DAIly NURSE: A nursing intervention to change nursing staff behaviour towards encouraging residents' daily activities and independence in the nursing home.

Aims and objectivesTo examine the feasibility of DAIly NURSE and a nursing intervention to encourage nursing home residents’ daily activities and independence.BackgroundNursing home residents are mainly inactive during the day. DAIly NURSE was developed to change nursing behaviour towards encouraging nursing home residents’ activities and independence by creating awareness. It consists of three components: education, coaching‐on‐the‐job and policy.DesignA mixed‐method study.MethodsThe feasibility of DAIly NURSE in practice was tested in six psychogeriatric nursing home wards, using attendance lists (reach), evaluation questionnaires (fidelity, dose received and barriers), notes made by the researcher (dose delivered and fidelity) and a focus group interview (dose received and barriers) with nursing home staff (n = 8) at the end of the study.ResultsThe feasibility study showed that all three components (education, coaching‐on‐the‐job and policy) were implemented in practice. The attendance rate in the workshops was high (average: 82%). Nursing home staff were satisfied with the workshops (mean score 9 out of 10 points) and agreed that DAIly NURSE was feasible in daily nursing care practice. Recommendations to optimise the feasibility of DAIly NURSE included the following: Add video observations of a specific moment of the day to create awareness of nursing behaviour; educate all nursing staff of the ward during the workshops; and organise information meetings for family members before the start of the intervention. Nursing staff were satisfied with the intervention and provided recommendations for adjustments to the content of the three components. The most important adjustment is the use of video observations to create awareness of nursing staff behaviour.ConclusionsDAIly NURSE, consisting of education, coaching‐on‐the‐job and policy, is feasible in nursing home practice.Relevance to clinical practiceDAIly NURSE might help to change nursing behaviour towards encouraging residents’ daily activities and independence.

An explorative study of the beliefs of staff of psychogeriatric nursing homes regarding the use of dynamic lighting systems

Dynamic lighting systems (DLS) are an innovative way to improve the behavioural symptoms of older people with dementia residing in nursing homes. The use of such systems by care professionals and underlying beliefs of these professionals are essential in the successful implementation of DLS. Therefore, this study investigated the beliefs of staff of nursing homes in relation to the use of DLS. Through focus group sessions and interviews, a number of beliefs emerged which influence the use of DLS in practice. The intention to use is influenced by the control options of the system, and the way DLS is embedded in care routines. The most important factor impacting the use of DLS is the creation of homelike living conditions. The identified factors can help in the implementation and design of DLS in psychogeriatric nursing home wards.

The implementation of integrated emotion-oriented care: Did it actually change the attitude, skills and time spent of trained caregivers?

Successful implementation is a vital precondition for investigating the outcome of care innovation. This study concerned the evaluation of the implementation of integrated emotion-oriented care (IEOC) in psychogeriatric nursing home wards. The main question was whether the trained caregivers actually applied the knowledge and techniques of IEOC during their daily work. The study was conducted within the framework of a randomized clinical trial into the effectiveness of IEOC in 16 wards. Preceding the experimental period, staff from 16 wards were educated and trained to work with a standardized care plan, resulting in a similar level of quality of care at the start of the trial. On the experimental wards IEOC was then implemented by training on the job in addition to training courses for personnel. To examine the implementation effectiveness, a self-report questionnaire, 'Emotion-oriented Skills in the Interaction with Elderly People with Dementia', was administered at baseline and after 7 months to a sample of caregivers from the experimental and the control wards. In addition, participant observation was conducted on four experimental and four control wards, and time spent by care personnel on different type of care tasks was registered. The implementation of IEOC resulted in increased emotion-oriented skills and more knowledge of the residents among the caregivers. Providing IEOC was not more time consuming for the caregivers than providing usual care. This study shows that the implementation of IEOC was effective. It is recommended that in intervention studies the correct application of a new intervention or care approach is examined before jumping to conclusions about the effectiveness of the intervention or care approach itself.

Belt Restraint Reduction in Nursing Homes: Effects of a Multicomponent Intervention Program

To test the effects of a multicomponent intervention program to reduce the use of belt restraints in psychogeriatric nursing homes. A quasi-experimental longitudinal design. Study duration was 8 months. Twenty-six psychogeriatric nursing home wards in 13 Dutch nursing homes were assigned to intervention or control groups. Seven hundred fourteen residents were selected for participation. Legal representatives of 520 residents agreed on participation; complete data are available for 405 residents. The intervention program included four major components: promotion of institutional policy change that discourages use of belt restraint, nursing home staff education, consultation by a nurse specialist aimed at nursing home staff, and availability of alternative interventions. The primary outcome measure was the frequency of belt restraint use. Secondary outcomes included other types of physical restraints, psychoactive drug use, falls, and fall-related injuries. These data were collected at baseline and after 4 and 8 months. A trained, blinded observer measured the use of belts and other physical restraints types four times during a 24-hour period. The intervention resulted in a 50% decrease in belt use (odds ratio = 0.48, 95% confidence interval = 0.28-0.81; P = .005). No increase occurred in the use of other types of restraints. No marked differences between the groups were found regarding psychoactive drugs, falls, and fall-related injuries. A multicomponent intervention program led to a substantial reduction in use of belts, full-enclosure bedrails, and sleep suits without increasing the use of other physical restraints, psychoactive drugs, or falls and fall-related injuries.

Response to Hayden and Glenn (2011)

We thank the authors Hayden and Glenn for commenting on our paper ‘The introduction of a nursing guideline on depression at psychogeriatric nursing home wards: Effects on Certified Nurse Assistants’, which was published in the International Journal of Nursing Studies (Verkaik et al., 2011). In our paper we conclude that the introduction of the nursing guideline ‘Depression in dementia’ had a positive, though small, significant effect on the perceived professional autonomy of Certified Nurse Assistants. We found that effects could probably be enlarged if non-Certified Nurse Assistants and nursing helpers were also trained, and managers paid more attention to the necessary conditions for successful introduction.

The effects of a nursing guideline on depression in psychogeriatric nursing home residents with dementia

To study the effects of introducing a nursing guideline on depression in residents with dementia of psychogeriatric nursing home wards. A multi-center controlled clinical trial with randomization at ward level was used to study the effects of the guideline introduction. Nursing teams were trained in applying the guideline to their own residents diagnosed with depression in dementia. Key elements of the nursing guideline are increasing individualized pleasant activities and decreasing unpleasant events. Participating residents were 97 residents diagnosed with dementia and comorbid depression, from 18 psychogeriatric nursing home wards, in 9 Dutch nursing homes. Measurements took place at pre-test, post-test and follow-up. Primary outcome was severity of depression measured with the MDS/RAI-Depression Rating Scale (DRS) and the Cornell Scale for Depression in Dementia. Secondary outcome is mood as measured by the FACE-observation scale. Compliance with the nursing guideline was moderate. Despite this, residents on the experimental wards showed a significant reduction in depression on the DRS. With the Cornell scale a reduction of depression was found as well, although not significantly different from that in the control group. No effects on observed mood were found. This study shows significant reductions in depression severity by introducing a nursing guideline on psychogeriatric nursing home wards. Better compliance with the guideline could probably enlarge the effects. Some ways to achieve enhanced compliance are: (1) additionally train non-certified nurse assistants, and (2) emphasize necessary conditions for successful introduction of the guideline to nursing team managers.

Dementia Care Redesigned: Effects of Small-Scale Living Facilities on Residents, Their Family Caregivers, and Staff

The purpose of this study was to evaluate the effects of small-scale living facilities in dementia care on residents, family caregivers, and staff. This was a quasi-experimental study including 2 types of institutional nursing care: small-scale living facilities (experimental group), and regular psychogeriatric nursing home wards (control group). Three measures were conducted: at baseline and follow-ups after 6 and 12 months. Twenty-eight houses in small-scale living facilities and 21 regular psychogeriatric nursing home wards. In total, 259 residents were included in the study: 124 in small-scale living facilities and 135 controls, matched on cognitive and functional status. Furthermore, 229 family caregivers were included and 305 staff members. For residents, main outcome measures were quality of life, neuropsychiatric symptoms, and agitation. Main outcome measures for family caregivers included perceived burden, satisfaction, and involvement with care. Main outcome measures for staff were job satisfaction and motivation. No effects were found for residents' total quality of life, neuropsychiatric symptoms, and agitation. Family caregivers in small-scale living reported significantly less burden (adjusted mean difference 0.8, 95% CI 0.1-1.5) and were more satisfied with nursing staff (0.3, 0.2-0.5) than family caregivers in regular wards. No differences were found in their involvement with care. Overall, no significant differences were found for staff's job satisfaction and motivation, although subgroup analyses using contrast groups (regarding typical small-scale living and regular wards) revealed more job satisfaction (2.0, 0.5-3.5) and motivation (0.6, 0.0-1.3) in small-scale living compared with regular wards. This study was unable to demonstrate convincing overall effects of small-scale living facilities. Because governmental policies and, in some countries, financial support, are increasingly aimed at providing small-scale, homelike care, it is suggested that this may not be a final solution to accomplish high-quality dementia care and that other options should be considered.

The introduction of a nursing guideline on depression at psychogeriatric nursing home wards: Effects on Certified Nurse Assistants

Background To improve care for residents with depression in dementia, an evidence based nursing guideline was developed. Using the guideline has already shown positive effects on depression in psychogeriatric nursing home residents. Objective To study the effects of the introduction of the nursing guideline ‘depression in dementia’ on perceived professional autonomy, workload and feelings of powerlessness and confidence in Certified Nurse Assistants. Design A multi-center controlled intervention study with randomization at ward level, using pre-test, post-test and follow-up measurements. Setting 18 psychogeriatric wards in 9 Dutch nursing homes. Participants : 193 Certified Nurse Assistants working on psychogeriatric nursing home wards for at least 20 h per week. Methods An evidence based guideline for nursing teams of psychogeriatric nursing home wards was introduced on nine experimental wards to reduce depression in residents diagnosed with depression in dementia. The guideline introduction consisted of team training and the installation of a promotion group. The nine control wards continued providing usual care. Primary outcomes are: (1) perceived professional autonomy and (2) experienced workload in Certified Nurse Assistants measured with the VBBA subscales ‘autonomy’ and ‘pace and amount of work’. Secondary outcomes are perceived powerlessness and confidence in caring for depressed and demented residents, using two self-developed scales. Results The guideline introduction had a small, significant, positive effect on generally perceived professional autonomy in the Certified Nurse Assistants of the experimental wards. No short-term effects were found on generally experienced workload, or on confidence and powerlessness in caring for depressed residents with dementia. Conclusion The introduction of the nursing guideline ‘depression in dementia’ has small, positive effects on perceived professional autonomy among the Certified Nurse Assistants. Long-term effects on experienced workload should be studied.

Small-scale, homelike facilities versus regular psychogeriatric nursing home wards: a cross-sectional study into residents' characteristics

BackgroundNursing home care for people with dementia is increasingly organized in small-scale and homelike care settings, in which normal daily life is emphasized. Despite this increase, relatively little is known about residents' characteristics and whether these differ from residents in traditional nursing homes. This study explored and compared characteristics of residents with dementia living in small-scale, homelike facilities and regular psychogeriatric wards in nursing homes, focusing on functional status and cognition.MethodsA cross-sectional study was conducted, including 769 residents with dementia requiring an intensive level of nursing home care: 586 from regular psychogeriatric wards and 183 residents from small-scale living facilities. Functional status and cognition were assessed using two subscales from the Resident Assessment Instrument Minimum Data Set (RAI-MDS): the Activities of Daily Living-Hierarchy scale (ADL-H) and the Cognitive Performance Scale (CPS). In addition, care dependency was measured using Dutch Care Severity Packages (DCSP). Finally, gender, age, living condition prior to admission and length of stay were recorded. Descriptive analyses, including independent samples t- tests and chi-square tests, were used. To analyze data in more detail, multivariate logistic regression analyses were performed.ResultsResidents living in small-scale, homelike facilities had a significantly higher functional status and cognitive performance compared with residents in regular psychogeriatric wards. In addition, they had a shorter length of stay, were less frequently admitted from home and were more often female than residents in regular wards. No differences were found in age and care dependency. While controlling for demographic variables, the association between dementia care setting and functional status and cognition remained.ConclusionsAlthough residents require a similar intensive level of nursing home care, their characteristics differ among small-scale living facilities and regular psychogeriatric wards. These differences may limit research into effects and feasibility of various types of dementia care settings. Therefore, these studies should take resident characteristics into account in their design, for example by using a matching procedure.

Comorbid Depression in Dementia on Psychogeriatric Nursing Home Wards: Which Symptoms are Prominent?

To provide insight into the prevalence and clinically relevant symptoms of comorbid depression among dementia patients in psychogeriatric nursing home wards, to enhance depression recognition. Cross-sectional analyses of multicenter diagnostic data. Psychogeriatric wards of Dutch nursing homes. Five hundred and eighteen residents with dementia. 1) Diagnosis of depression in dementia (Provisional Diagnostic Criteria for Depression of Alzheimer disease [PDC-dAD]), 2) dementia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-PC), and 3) stage of dementia (Geriatric Depression Scale). The point prevalence of comorbid depression in dementia (Stages 2-6) on psychogeriatric nursing home wards was 19%. "Depressed mood," "irritability," and "fatigue" were the most prevalent depressive symptoms. Residents taking antidepressants at the time of the PDC-dAD depression diagnosis showed more depressive symptoms than residents who were not. The mean number of depressive symptoms was 5.6 (SD 1.84), which did not differ between the dementia stages. Also, no differences were found in the point prevalence of the shown symptoms between dementia stages. Irritability was put forward by the developers of the PDC-dAD, as one of the specific symptoms of depression in Alzheimer disease. This study shows that irritability is one of the most prevalent depressive symptoms in psychogeriatric nursing home residents diagnosed with comorbid depression. Irritability should therefore alert caregivers to the presence of depression and could help early recognition. The high-prevalence rate of comorbid depression in dementia in this setting justifies attention to early recognition and intervention.

A Cluster‐Randomized Trial of an Educational Intervention to Reduce the Use of Physical Restraints with Psychogeriatric Nursing Home Residents

To investigate the effects of an educational intervention on the use of physical restraints with psychogeriatric nursing home residents. Cluster-randomized trial. Fifteen psychogeriatric nursing home wards in the Netherlands. In total, 432 psychogeriatric nursing home residents from 15 psychogeriatric nursing home wards in seven nursing homes were selected for participation; 404 consented, and 371 of these were available at baseline. Two hundred forty-one from 14 wards had complete data and were included in the data analyses. The nursing home wards were assigned at random to educational intervention or control status. The educational intervention consisted of an educational program for nursing staff combined with consultation with a nurse specialist (registered nurse (RN) level). Data were collected at baseline and 1, 4, and 8 months postintervention. At each measurement, the use of physical restraints was measured using observations of blinded, trained observers on four separate occasions over a 24-hour period. Other resident characteristics, such as cognitive status, were determined using the Minimum Data Set. Logistic and linear regression analyses showed no treatment effect on restraint status, restraint intensity, or multiple restraint use in any of the three postintervention measurements. Furthermore, only small changes occurred in the types of restraints used with residents in the experimental group. An educational program for nursing staff combined with consultation with a nurse specialist (RN level) had no effect on the use of physical restraints with psychogeriatric nursing home residents. In addition to restraint education and consultation, new measures to reduce the use of physical restraints with psychogeriatric nursing home residents should be developed.

Preventing the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards: A cluster-randomized trial

Background Although there is an urgent need for restraint-free care, the number of randomized clinical trials on preventing or reducing physical restraints has been limited. Objectives To investigate the effectiveness of an educational intervention to prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards. Design Cluster-randomized trial. Setting Fourteen Dutch psycho-geriatric nursing home wards. Participants 138 residents admitted to 14 psycho-geriatric nursing home wards after baseline measurement of the trial were selected, out of which 33 residents died or informed consent had not been obtained. A total of 105 residents were included in the analyses. Methods The nursing home wards were randomly assigned to either educational intervention or control status. The educational intervention consisted of an educational programme for nurses combined with a nurse specialist's consultation. The data were collected at 1, 4 and 8 months post-intervention. The use of physical restraints was measured by blinded, trained observers on four separate occasions over a 24-h period. The Minimum Data Set was used to determine residents’ characteristics, such as their cognitive status. Results During the study period, no statistically significant differences between the experimental group and the control group regarding restraint status, restraint intensity, multiple restraints and types of restraints were found. One month post-intervention, 38% of the residents newly admitted to the experimental wards were restrained. Bilateral bedrails were the most frequently used restraints at Post-test 1 (24%), Post-test 2 (23%) and Post-test 3 (28%), followed by the use of infrared systems at Post-tests 2 and 3. Conclusion An educational programme combined with the consultation of a nurse specialist does not prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards. Although other studies have shown promising results with the effectiveness of these types of intervention on restraint reduction, the development of additional interventions to prevent restraint usage is recommended.

Organisational determinants of the use of physical restraints: A multilevel approach

This paper reports a study of the relationship between the use of physical restraints with psycho-geriatric nursing home residents and the characteristics of organisations and residents. It is hypothesised that impairment in residents and organisational characteristics, such as a high workload of nursing staff and a low full-time equivalent (FTE) ratio on the wards, are associated with increased restraint use. In a cross-sectional study involving 15 Dutch psycho-geriatric nursing home wards, 432 residents were selected for participation, of which 371 actually participated. Restraint status was measured using observations. Other resident characteristics, such as cognitive status, were determined using the Minimum Data Set (MDS). Job characteristics, such as workload, were determined by different self-reported measures. Characteristics of the wards, such as the FTE ratio, were derived from the registration system of the wards. Physical restraints were used with 56% of the psycho-geriatric nursing home residents. Bivariate analysis showed that job and ward characteristics were not associated with restraint use. Bivariate and multilevel analysis showed that residents’ characteristics, such as mobility and cognitive status were significantly associated with restraint use. Furthermore, multilevel analysis showed that higher job autonomy experienced by nursing staff and a higher FTE ratio on the wards were also associated with increased restraint use. In conclusion, job and ward characteristics were not as strongly associated as residents’ characteristics with restraint use. Impairments in residents, such as immobility, were strongly related to the use of restraints. Therefore, education and support of nursing staff in caring for psycho-geriatric nursing home residents with poor mobility is recommended to reduce the use of physical restraints in nursing homes.

Short-term effects of an educational intervention on physical restraint use: a cluster randomized trial

BackgroundPhysical restraints are still frequently used in nursing home residents despite growing evidence for the ineffectiveness and negative consequences of these methods. Therefore, reduction in the use of physical restraints in psycho-geriatric nursing home residents is very important. The aim of this study was to investigate the short-term effects of an educational intervention on the use of physical restraints in psycho-geriatric nursing home residents.MethodsA cluster randomized trial was applied to 5 psycho-geriatric nursing home wards (n = 167 residents with dementia). The wards were assigned at random to either educational intervention (3 wards) or control status (2 wards). The restraint status was observed and residents' characteristics, such as cognitive status, were determined by using the Minimum Data Set (MDS) at baseline and 1 month after intervention.ResultsRestraint use did not change significantly over time in the experimental group (55%–56%), compared to a significant increased use (P < 0.05) in the control group (56%–70%). The mean restraint intensity and mean multiple restraint use in residents increased in the control group but no changes were shown in the experimental group. Logistic regression analysis showed that residents in the control group were more likely to experience increased restraint use than residents in the experimental group.ConclusionAn educational programme for nurses combined with consultation with a nurse specialist did not decrease the use of physical restraints in psycho-geriatric nursing home residents in the short term. However, the residents in the control group experienced more restraint use during the study period compared to the residents in the experimental group. Whether the intervention will reduce restraint use in the long term could not be inferred from these results. Further research is necessary to gain insight into the long-term effects of this educational intervention.

Sodium valproate in aggressive behaviour in dementia: a twelve-week open label follow-up study.

Short-term randomised clinical trials on valproate in distinct types of disturbed behaviour in dementia showed no effects on aggressive behaviour. To assess the course of disturbed behaviour during medium term treatment with sodium valproate for aggressive behaviour. An open label observational 12-week follow-up study consecutive to a preceding randomised control trial; assessments at 4-week interval. A psychogeriatric medium-stay ward at a psychiatric teaching hospital and psychogeriatric nursing home wards. Patients who completed a preceding randomised placebo controlled clinical trial on sodium valproate in aggressive behaviour in dementia were included. The starting dose of sodium valproate was 2 x 6 ml of a 40 mg/ml suspension (daily defined dose of 480 mg). The patient's regular physicians managed all treatment decisions, including decisions on dosage and plasma level measurements of sodium valproate and decisions regarding discontinuation. Co-medication was allowed and any change in prescription was recorded. The Social Dysfunction and Aggression Scale-9 (SDAS-9), the Behaviour Observation scales for Intramural Psychogeriatrics (in Dutch: Gedragsobservatieschaal voor Intramurale Psychogeriatrie (GIP) and the Clinical Global Impression of aggressive behaviour (CGI) were performed at the last week of each 4-week interval. Data of 39 patients (F=24 and M=15) were analysed. At week 12 compared to week 0 mean sodium valproate prescriptions were higher; aggressive behaviour as measured by the SDAS-9 improved. Non-social behaviour, apathetic behaviour, disoriented behaviour and distorted memory improved, but rebellious behaviour increased as measured by the GIP. Seven patients died during this study. Open label observational design; absence of placebo/reference prescription; no systematic measurements of sodium valproate plasma levels and the allowance of psychotropic co-medication. Low dose sodium valproate may be effective reducing a broad range of types of disturbed behaviours in aggressive demented patients. The high death rate underlines the fragility of demented patients with aggressive behaviour.

Untying the elderly: response to quality-of-life issues.

Although there is an urgent need for restraint-free care, the number of randomized clinical trials on preventing or reducing physical restraints has been limited.To investigate the effectiveness of an educational intervention to prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards.Cluster-randomized trial.Fourteen Dutch psycho-geriatric nursing home wards.138 residents admitted to 14 psycho-geriatric nursing home wards after baseline measurement of the trial were selected, out of which 33 residents died or informed consent had not been obtained. A total of 105 residents were included in the analyses.The nursing home wards were randomly assigned to either educational intervention or control status. The educational intervention consisted of an educational programme for nurses combined with a nurse specialist's consultation. The data were collected at 1, 4 and 8 months post-intervention. The use of physical restraints was measured by blinded, trained observers on four separate occasions over a 24-h period. The Minimum Data Set was used to determine residents’ characteristics, such as their cognitive status.During the study period, no statistically significant differences between the experimental group and the control group regarding restraint status, restraint intensity, multiple restraints and types of restraints were found. One month post-intervention, 38% of the residents newly admitted to the experimental wards were restrained. Bilateral bedrails were the most frequently used restraints at Post-test 1 (24%), Post-test 2 (23%) and Post-test 3 (28%), followed by the use of infrared systems at Post-tests 2 and 3.An educational programme combined with the consultation of a nurse specialist does not prevent the use of physical restraints on residents newly admitted to psycho-geriatric nursing home wards. Although other studies have shown promising results with the effectiveness of these types of intervention on restraint reduction, the development of additional interventions to prevent restraint usage is recommended.