Background: Many nursing home residents are at risk of developing a pressure ulcer, which is an area of localised damage to the skin and/or underlying tissue due to immobility, increasing age and co-morbidities. Whilst guidelines for the prevention of pressure ulcers exist, their implementation can be sub-optimal. Care bundles are a set of research-informed practices used to facilitate the implementation of evidence into practice and incorporating psychological theory within their development may enhance their effectiveness. I aimed to co-design and assess the feasibility of implementing a theory and research-informed pressure ulcer prevention care bundle intervention in a nursing home setting. Method: This thesis comprised four separate studies as part of an overall mixed methods research design. Firstly, I conducted a systematic review and meta-analysis to determine the effects of care bundles per se on patient outcomes. I then conducted theory-informed qualitative, semi-structured interviews with nursing home care staff and NHS community-based nurses to explore the context of, and the barriers and facilitators to, pressure ulcer prevention in nursing homes. Next I co-designed a pressure ulcer prevention care bundle with 13 healthcare workers during a four hour workshop and supplemental email consultation. Using the Nominal Group Technique, we reached a consensus about the content of the care bundle. Following the steps of the Behaviour Change Wheel, I finalised the care bundle intervention. The final study involved a before-after study design where one nursing home implemented the care bundle intervention. I collected and analysed quantitative and qualitative data to gain a more holistic understanding of the feasibility issues related to the implementation. Findings: Findings from the systematic review suggested that care bundles may reduce the risk of negative outcomes in patients. These findings were based on very low quality evidence and the original study authors rarely reported adherence to the care bundle interventions. The theoretical understanding of the complexities in the prevention of pressure ulcers in nursing homes suggested there were four barriers and six facilitators, which my final care bundle intervention addressed. The co-designed care bundle intervention comprised three elements: support surfaces, skin inspection, repositioning; alongside three intervention functions and seven behaviour change techniques. In the final feasibility study, during the baseline period, there were 462 resident bed days and 5 new pressure ulcers recorded and in the intervention phase there were 1,181 resident bed days and no new pressure ulcers. The care bundle intervention appeared to be acceptable to the nursing home care staff and we have identified specific issues relating to the feasibility of implementing the care bundle intervention. Conclusions: The current research evidence-base for care bundles is poor. However, it was possible to co-design and implement a pressure ulcer prevention care bundle intervention for a nursing home setting. Further feasibility research is necessary before we can assess whether the care bundle intervention is effective in preventing pressure ulcers in nursing homes.

The purpose of this research project is to develop concepts for doing cost-benefit analyses for governmental and nonprofit homes. Such concepts should facilitate a differential diagnosis which recognizes the wide individual differences among those served. Developing relevant concepts is a first step in measurement. An aim is to develop appropriate concepts and instruments that will make an ordinal measurement of resident satisfaction possible. This study makes no effort to develop monetary measures of either costs or benefits. These measures and the related cost-benefit analyses must await further developments. Of the home's employees, the nurses and nurses' assistants usually have the most prolonged and intimate contact with the residents. The nurses and nurses' assistants often are the home personified in that they provide the bulk of a home's services to the less able residents. This explains why the environment of the home, which includes the values, needs, and attitudes of nurses and nurses' assistants, is believed to influence resident satisfaction.

Les sujets résidant dans les établissements d'hébergement pour personnes âgées dépendantes (EHPAD) sont fréquemment exposés à une polypathologie et sont polymédiqués, ce qui augmente le risque de prescriptions potentiellement inappropriées (PPI) et ainsi le risque d'événements iatrogènes tels que le décès et l'hospitalisation. La plupart des études réalisées en France sur la PPI se sont focalisées sur des classes médicamenteuses précises, et peu ont évalué l'impact des caractéristiques structurelles et organisationnelles des EHPAD sur la PPI des résidents, indépendamment des caractéristiques individuelles. Cette thèse a eu pour objectif de développer un nouvel indicateur de PPI, reflétant au mieux la prise en charge médicamenteuse globale des résidents d'EHPAD. Les travaux de thèse ont été réalisés sur un échantillon issu de l'étude IQUARE (Impact d'une démarche QUAlité sur l'évolution des pratiques et le déclin fonctionnel des REsidents), étude quasi expérimentale (NCT01703689) évaluant l'impact d'une intervention basée sur l'éducation gériatrique du personnel de l'EHPAD sur des indicateurs de qualité des soins. Dans un premier temps, nous avons construit un outil original de détection de PPI, combinant des critères explicites et implicites, identifiant 71% des résidents avec une PPI à l'inclusion. Des caractéristiques organisationnelle (accès à un avis psychiatrique) et structurelle (présence d'une unité de soins spécialisée) de l'EHPAD expliquaient une part de cette PPI. Dans un second temps, afin de valider la pertinence de cet outil, nous avons évalué l'impact clinique de la PPI sur la survenue d'événements indésirables au cours du suivi. Nous n'avons pas retrouvé de risque augmenté de décès ou d'hospitalisation. Enfin, l'intervention gériatrique générale de l'étude IQUARE a significativement réduit la PPI des résidents à 18 mois. Ces travaux ont fourni des éléments importants à prendre en considération, lors de la construction de nouvelles études visant à modifier les pratiques de prescription et à réduire le nombre de médicaments prescrits chez les résidents d'EHPAD, mais aussi pour déterminer l'impact clinique de ces changements. / Older people living in nursing homes (NHs) suffer from numerous comorbidities and functional decline. Polymedication is frequent in this population. This increases the risk of potentially inappropriate drug prescribing (PIDP), which can lead to adverse drug events such as falls and hospitalization. Most French studies did not examine PPI with a global perspective, but focused on specific drug classes. Moreover, few studies have investigated, irrespective of the individual characteristics of residents, the structural and organizational characteristics of nursing homes on the quality of drug prescribing. Thesis work aimed to develop a new indicator of PIDP, which best reflects the global medication use of residents. Thesis works have been performed using the data of the IQUARE study (Impact d'une démarche Qualité sur l'évolution des pratiques et le déclin fonctionnel des REsidents), a quasi-experimental study (trial registration number: NCT01703689) investigating the impact of an intervention based on geriatric education with NH staff on quality indicators of care. First, we developed an indicator of PIDP, combining explicit and implicit criteria, identifying 71% of PIDP in NH residents at baseline. NH organizational (access to psychiatric advice and/or to hospitalization in a psychiatric unit) and structural (presence of a special care unit for dements) variables explained part of PIDP. In a second part, in order to validate the usefulness of this PIDP detection tool, we verified the long-term clinical impact of PIDP on adverse outcomes (death, number of hospitalizations...). We did not find any significant association between PIDP and death, nor between PIDP and number of hospitalizations. Finally, the general intervention implemented in the IQUARE study significantly reduced PIDP among NH residents at 18-month follow-up. Our research has provided important aspects that should be consider when constructing further new studies seeking to change prescribing patterns and to reduce the total number of drugs taken, but also to determine the final impact of these changes on clinical outcomes.

Vulnerable older adults residing in nursing homes continue to experience poor care outcomes due to nurse staffing levels that are below the levels required for maintaining their well-being. Studies have shown that patient care outcomes in nursing homes are related to nurse staffing standards/levels, which are affected by profit maximization on adherence to registered nurses and licensed nurse staffing standards. The purpose of this descriptive study was to determine if there was a relationship between adherence to staffing standards and care outcomes in for-profit (FP) and not-for-profit religious-based (NFPRB) nursing homes using the profit maximization theory. Research questions focused on the relationships that profit maximization and nurse staffing standards had on the quality of care outcomes measures and the differences between the nursing homes on these variables. Secondary data were collected from public database and analyzed using the descriptive and inferential statistics, nonparametric tests, and binary logistic regression. Findings showed that profit measures were not related to staffing standards and care outcome measures in the NFPRB. There was a significant relationship between FP nursing homes and standards to care outcomes in FP but not in the NFPRB nursing homes. FP nursing homes did worse than NFPRB on care outcomes. Further research, using qualitative and mixed methodologies, is needed to study the effects of profit measures on nursing home care outcomes. The results of this study can effect positive social change by informing policy makers and healthcare professionals/leaders, and, by reducing adverse events, untimely death, and positively affecting the quality of care and life of the frail and vulnerable older adults residing in nursing homes.

This was the first study to quantitatively test the use of SEIPS (Systems Engineering Initiative for Patient Safety) model to identify factors influencing a medication safety outcome. By using a SEIPS model, our study developed a comprehensive approach to identifying potential factors influencing adverse drug events (ADEs). The SEIPS work system is composed of five components which include person, organization, technologies and tools, tasks, and environment. SEIPS model successfully explained the work system factors influencing ADEs and falls in nursing homes (NHs). The second important contribution of our study is that it used the CMS (Centers for Medicare and Medicaid Services) ADE Trigger Tool not only to detect actual ADEs, but also to identify specific potential ADEs in NHs. This study had five objectives: 1) calculate actual ADE incidence rate (number of incidents per 100 residents per month) in NHs using the ADE trigger tool, 2) measure potential ADE incidence rate based on abnormal lab data, vital signs and non-harmful falls, 3) identify the classes of medications most likely to cause ADEs, 4) evaluate the relationships between work system characteristics and the incidence of ADEs, and 5) assess the relationships between work system characteristics and resident fall incidents. This study was an observational quantitative study. It included two quantitative methods: retrospective resident medical chart extraction and survey four types of healthcare practitioners. The staff surveys included four categories of NH practitioners at each facility to ensure comprehensive assessment of the work system: Director of nursing (DON), registered nurse (RN), certified nurse assistant (CNA) and consultant pharmacist. The surveys included questions about the facility conditions, environment, technology, task, and staff/practitioners. Both methods were conducted within the same facilities and during the same period. The study was conducted in 11 NHs in nine cities in Iowa. Data collection was conducted over fall 2016 and spring 2017. Binary logistic regression with Generalized Estimated Equation (GEE) was used to measure the association between the ADE incidence (Yes/No) and characteristics of residents and facilities. The secondary outcome was the incidence of falls. We reviewed 755 medical charts and conducted 44 staff surveys. The rate of ADEs was 6.13 incidents per 100 residents per month. Approximately (64.1%) of the ADEs were preventable. More than half of the ADEs were fall-related (51.1%) and half of those harmful falls were due to hypotension. We considered all the harmful falls as ADEs in residents with one or more psychotropic, antihypertensive, opioid and/or anti-diabetic medications, which can cause fall. The most common ADEs included medication (opioid)-induced constipation (24.6%), psychotropic induced confusion, dizziness or drowsiness (6.5%), antibiotic-induced Clostridium difficile diarrhea (4.2%), anticoagulant induced bleeding (3.9%) and antidiabetic induced hypoglycemia (3.2%). The most common fall-related ADEs were bruise (9.7%) and abrasion or laceration (9.4%). Psychotropic medications (74.9%), antidepressants (61.3%), antihypertensive agents (58.7%), and opioids (51.9%) were the most common medications associated with ADEs. The rate of potential ADEs was 48.6 per 100 residents per month. The rate of falls was 23.38 per 100 residents per month. The regression analysis revealed significant associations between the ADEs and opioid analgesics, psychotropic medications, warfarin, skilled care, consultant pharmacist accessibility, nurse-physician collaboration, CNA skills in taking vital signs, number of physician visits to the facility, nurse workload and the use of electronic health records. On the other hand, the regression analysis showed non-significant relationships between ADEs and cardiac arrhythmia (AFib), DON years in the facility and distracting noise during medication administration. The six significant facility characteristics represent five concepts of the SEIPS model: organization, task, environment, person and technology. In the fall regression analysis, twelve of the resident and the facility SEIPS variables had significant relationships with the incidence of resident falls. The significant variables represent four concepts of the SEIPS model: organization, task, environment, and person. Longer DON years in the facility and more nurse time per resident per day were associated with lower number of fall incidents. The CNA skills in taking vital signs have significant negative association with both ADEs and falls. Finally, the variable “CNAs work fast” and the nurse workload also have positive association with the incidence of falls

Certified nurse aides provide approximately 65% of care to more than 1.4 million older adults residing in nursing homes who have been diagnosed with 1 or more chronic illnesses or debilitating conditions. Licensed nurses rely on nurse aides to report potentially harmful status changes in geriatric residents. Nurse aides often receive limited education and do not have a structured care process to guide them in their practice in the geriatric population. The purpose of this educational quality improvement project was to develop a geriatric-specific nurse aide care process to increase the knowledge of student nurse aides regarding processes to identify and observe potentially harmful status changes in geriatric residents, and what changes to report immediately to a licensed nurse. The knowledge-to-action model was used to address the practice problem and to guide the translation of this evidence-based project into practice. The methodology used to guide data collection and analysis was a 1-group, quasi experimental, pretest/posttest design to compare participants' knowledge before the intervention with their learning outcomes after the educational intervention was implemented. The findings revealed an increase in the knowledge of student nurse aides after the educational intervention. The project may promote social change on an organizational level by demonstrating the need for a structured geriatric care process for nurse aides prior to their entry into the long-term care workforce to improve care outcomes for geriatric residents. The project may involve social change at the state level because incorporating this process may require additional hours in the nurse aide education program curriculum.

This study attempted to identifj and explore the role the building plays in the organisation culture of nursing homes. To do this a research plan was formulated in which the central plank was a case-study of a seventy-five bed high care nursing home. As part of the case-study, interviews were conducted at the nursing home with ten members of staff, two residents and a daughter of a resident. The study was also informed by interviews with two architects, who specialise in the design of nursing homes and aged care facilities. A theoretical model entitled the 'Conceptual Framework' was developed prior to the case-study. It was tested by applying it to findings related to the physical context and the organisation culture of the case-study venue. The hypothesis that the building does influence the culture of the nursing home environment was explored by studying the manner in which the building influenced the lives of those who work in the nursing home and those who live there. This challenge was met with the use of theoretical contributions from organisation theory and psychodynamics, which together provided a vehicle for analysis of the culture and the building's role in it.

<p>Changes in swallowing function are common in elderly and chronically ill individuals. Therefore it is important to be aware of these changes and their prevalence. The aim of this study was to assess the prevalence of dysphagia in nursing homes in the municipality of Linköping, and to correlate dysphagia with variables that can be a cause or a consequence of dysphagia. These variables were gender, age, MMT-result, dentition, weight loss, medical diagnose or number of medications. The intention was also to examine the additional information regarding dysphagia supplied by pulse oximetry.</p><p>Sixty nursing home residents aged 74-101 years were chosen to participate in the study. The individual's ability to participate was based on their result on Mini-mental state and subjective judgements made by staff members and the authors. The material to assess oral motor and sensory function was the Nordic Orofacial Test - Screening. During the clinical swallowing examination the Standardised Swallowing Assessment (SSA) and pulse oximetry were used. In addition, data regarding the participants' medical diagnoses, number of medications and possible weight loss was collected.</p><p>The result showed that the prevalence of dysphagia and suspected dysphagia was 40 %. Oral dysphagia was present in 20 participants and pharyngeal dysphagia in seven participants. With pulse oximetry one participant with dysphagia and two with suspected dysphagia were identified in addition to those identified by SSA. Analysis of the assessed variables showed no correlations or any significant results.</p> / <p>Förändringar av sväljförmågan är vanligt hos äldre och kroniskt sjuka individer. Det är viktigt att vara medveten om dessa förändringar och hur vanligt förekommande det är med nedsatt sväljförmåga. Syftet med föreliggande studie var att undersöka förekomsten av dysfagi på äldreboenden i Linköpings kommun samt att korrelera dysfagi med parametrar som kan vara orsak till eller konsekvens av dysfagi. Dessa parametrar var kön, ålder, MMT-resultat, tandstatus, viktnedgång, sjukdomsdiagnos och antal läkemedel. Ett delsyfte i studien var att undersöka om man med hjälp av pulsoximetri kan upptäcka fler fall av dysfagi.</p><p>Sextio vårdtagare på äldreboenden, i åldern 74-101 år, valdes ut att delta i studien. Urvalet baserades på resultat på Mini-Mental Test samt personalens och testledarnas subjektiva bedömning om vårdtagarens möjlighet att delta. Materialet som användes för att bedöma oral motorik och sensorik var Nordiskt Orofacialt Test – Screening. Vid den kliniska sväljningsbedömningen användes Standardised Swallowing Assessment (SSA) och pulsoximetri. Utöver detta inhämtades uppgifter för samtliga deltagare om sjukdomsdiagnos, antal stående läkemedel samt eventuell viktnedgång.</p><p>Resultatet visade att förekomsten av dysfagi och misstänkt dysfagi var 40 %. Oral dysfagi förekom hos 20 deltagare och faryngeal dysfagi hos sju deltagare. Pulsoximetern identifierade en deltagare med dysfagi och två med misstänkt dysfagi utöver dem som identifierats med hjälp av SSA. Korrelations- och signifikansberäkningar av de undersökta parametrarna visade inga signifikanta resultat.</p>

Changes in swallowing function are common in elderly and chronically ill individuals. Therefore it is important to be aware of these changes and their prevalence. The aim of this study was to assess the prevalence of dysphagia in nursing homes in the municipality of Linköping, and to correlate dysphagia with variables that can be a cause or a consequence of dysphagia. These variables were gender, age, MMT-result, dentition, weight loss, medical diagnose or number of medications. The intention was also to examine the additional information regarding dysphagia supplied by pulse oximetry. Sixty nursing home residents aged 74-101 years were chosen to participate in the study. The individual's ability to participate was based on their result on Mini-mental state and subjective judgements made by staff members and the authors. The material to assess oral motor and sensory function was the Nordic Orofacial Test - Screening. During the clinical swallowing examination the Standardised Swallowing Assessment (SSA) and pulse oximetry were used. In addition, data regarding the participants' medical diagnoses, number of medications and possible weight loss was collected. The result showed that the prevalence of dysphagia and suspected dysphagia was 40 %. Oral dysphagia was present in 20 participants and pharyngeal dysphagia in seven participants. With pulse oximetry one participant with dysphagia and two with suspected dysphagia were identified in addition to those identified by SSA. Analysis of the assessed variables showed no correlations or any significant results. / Förändringar av sväljförmågan är vanligt hos äldre och kroniskt sjuka individer. Det är viktigt att vara medveten om dessa förändringar och hur vanligt förekommande det är med nedsatt sväljförmåga. Syftet med föreliggande studie var att undersöka förekomsten av dysfagi på äldreboenden i Linköpings kommun samt att korrelera dysfagi med parametrar som kan vara orsak till eller konsekvens av dysfagi. Dessa parametrar var kön, ålder, MMT-resultat, tandstatus, viktnedgång, sjukdomsdiagnos och antal läkemedel. Ett delsyfte i studien var att undersöka om man med hjälp av pulsoximetri kan upptäcka fler fall av dysfagi. Sextio vårdtagare på äldreboenden, i åldern 74-101 år, valdes ut att delta i studien. Urvalet baserades på resultat på Mini-Mental Test samt personalens och testledarnas subjektiva bedömning om vårdtagarens möjlighet att delta. Materialet som användes för att bedöma oral motorik och sensorik var Nordiskt Orofacialt Test – Screening. Vid den kliniska sväljningsbedömningen användes Standardised Swallowing Assessment (SSA) och pulsoximetri. Utöver detta inhämtades uppgifter för samtliga deltagare om sjukdomsdiagnos, antal stående läkemedel samt eventuell viktnedgång. Resultatet visade att förekomsten av dysfagi och misstänkt dysfagi var 40 %. Oral dysfagi förekom hos 20 deltagare och faryngeal dysfagi hos sju deltagare. Pulsoximetern identifierade en deltagare med dysfagi och två med misstänkt dysfagi utöver dem som identifierats med hjälp av SSA. Korrelations- och signifikansberäkningar av de undersökta parametrarna visade inga signifikanta resultat.

This essay focuses on the elderly and their religious beliefs and is based on the origin idea of a secular Sweden, but where immigration has been the source of additional various religious affiliations. This study intends to nuance the problems that previous researchers focused on when doing research on immigration, by interviewing staff members of nursing homes in immigrant dense areas, especially Malmoe, Gothenburg and Stockholm. The aim is to investigate how the allocation of residents, with different religious than Protestant Christians, is distributed at nursing homes and to see if there is a need for adjustments. Additionally, the thesis about immigrants and immigrants' identity and attitudes to Swedish society is discussed with John Berry´s acculturation theories and strategies. The results show that the majority of the nursing homes have residents with different religious affiliations and that some practical adjustments have been done, but it also shows that nursing homes have changed to the extent that they have adapted to a secular society. Ignorance and prejudice contribute to the problem in terms of seeing all residents as individuals and at the same time ensuring adaption according to all their needs, which is exemplified in the solutions made by using multi-cultural staff members and specialized departments. The relationship between nursing homes and the Swedish church continues but the role of the church service has changed. However, the idea that residents with different affiliations are free to exercise their religion in private occurs simultaneously as it is highlighted that immigrants is assimilated into a secular Swedish society. This in turn means that not every residents need is seen to at the investigated nursing homes.