Wearable technology use in long-term care facilities for older adults: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to explore how wearable technology is being used to care for older adults in long-term care facilities. INTRODUCTION: The use of digital health technologies to support care delivery in long-term care facilities for older adults has grown significantly in recent years, especially since the COVID-19 pandemic. Wearable technology refers to devices worn or attached to the body that can track a variety of health-related data, such as vital signs, falls, and sleep patterns. Despite the evidence that wearable devices are playing an increasing role in older adults' care, no review has been conducted on how wearable technology is being used in long-term care facilities. INCLUSION CRITERIA: This review will consider studies that include people aged over 65, with any health condition or level of disability, who live in long-term care facilities. Primary and secondary studies using quantitative, qualitative, and mixed methods study designs will be included. Dissertations and policy documents will also be considered. METHODS: Data sources will include comprehensive searches of electronic databases (MEDLINE, Embase, CINAHL, and Scopus), gray literature, and reference scanning of relevant studies. Two independent reviewers will screen titles, abstracts, and full texts of the selected studies. Data extraction will be performed using a tool developed by the researchers. Data will be mapped and analyzed. Descriptive frequencies and content analysis will be included, along with the tabulated results, which will be used to present the findings with regard to the review objectives. REVIEW REGISTRATION: Open Science Framework https://osf.io/r9qtd.

Quality improvement interventions to prevent the use of hospital services among nursing home residents: protocol for a systematic review and meta-analysis.

INTRODUCTION: Quality improvement interventions are a promising strategy for reducing hospital services use among nursing home residents. However, evidence for their effectiveness is limited. It is unclear which characteristics of the quality improvement intervention and activities planned to facilitate implementation may promote fidelity to organisational and system changes. This systematic review and meta-analysis will assess the effectiveness of quality improvement interventions and implementation strategies aimed at reducing hospital services use among nursing home residents. METHODS AND ANALYSIS: The MEDLINE, CINAHL, Cochrane Library, Embase and Web of Science databases will be comprehensively searched in September 2023. The eligible studies should focus on the implementation of a quality improvement intervention defined as the systematic, continuous approach that designs, tests and implements changes using real-time measurement to reduce hospitalisations or emergency department visits among long-stay nursing home residents. Quality improvement details and implementation strategies will be deductively categorised into effective practice and organisation of care taxonomy domains for delivery arrangements and implementation strategies. Quality and bias assessments will be completed using the Quality Improvement Minimum Quality Criteria Set and the Joanna Briggs Institute Critical Appraisal Tools.The results will be pooled in a meta-analysis, by combining the natural logarithms of the rate ratios across the studies or by calculating the rate ratio using the generic inverse-variance method. Heterogeneity will be assessed using the I2 or H2 statistics if the number of included studies will be less than 10. Raw data will be requested from the authors, as required. ETHICS AND DISSEMINATION: Ethical approval is not required. The results will be published in a peer-review journal and presented at (inter)national conferences. PROSPERO REGISTRATION NUMBER: CRD42022364195.

The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home.

BACKGROUND: Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care. AIMS: To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication. METHOD: This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed. FINDINGS: Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory. CONCLUSION: Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.

Interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes: A mixed-methods systematic review.

BACKGROUND: Most people with dementia transition into nursing homes as their disease progresses. Their family caregivers often continue to be involved in their relative's care and experience high level of strain at the end of life. AIM: To gather and synthesize information on interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes and provide a set of recommendations for practice. DESIGN: Mixed-Methods Systematic Review (PROSPERO no. CRD42020217854) with convergent integrated approach. DATA SOURCES: Five electronic databases were searched from inception in November 2020. Published qualitative, quantitative, and mixed-method studies of interventions to support family caregivers of people with advanced dementia at the end of life in nursing home were included. No language or temporal limits were applied. RESULTS: In all, 11 studies met the inclusion criteria. Data synthesis resulted in three integrated findings: (i) healthcare professionals should engage family caregivers in ongoing dialog and provide adequate time and space for sensitive discussions; (ii) end-of-life discussions should be face-to-face and supported by written information whose timing of supply may vary according to family caregivers' preferences and the organizational policies and cultural context; and (iii) family caregivers should be provided structured psychoeducational programs tailored to their specific needs and/or regular family meetings about dementia care at the end of life. CONCLUSION: The findings provide useful information on which interventions may benefit family caregivers of people with advanced dementia at the end of life and where, when, and how they should be provided.

Factors Associated With Missed Nursing Care in Nursing Homes: A Multicentre Cross-sectional Study.

BACKGROUND: Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care. METHODS: In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs' judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner. RESULTS: Younger RNs (P=.026), freelance RNs (P=.046), RNs with a permanent contract (P=.035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P<.012). Public ownership (odds ratio [OR]=9.88; 95% CI 2.22-44.03; P=.003), a higher proportion of residents with severe clinical conditions (OR=2.45; 95% CI 1.12-5.37; P=.025), a lower proportion of RNs (OR=2.24; 95% CI 1.10-4.54; P=.026), and perceived lack of time to care for residents (OR=2.33; 95% CI 1.04-5.26; P=.041) were statistically significantly associated with missed nursing care. CONCLUSION: Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.

A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home.

BACKGROUND: With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly. AIM: To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents. DESIGN: A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted. RESULTS: Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences. CONCLUSION: This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.

Missed Nursing Care in a Sample of High-Dependency Italian Nursing Home Residents: Description of Nursing Care in Action.

OBJECTIVE: The aim of the study was to describe omitted or delayed nursing care (i.e., missed nursing care [MNC]) in a sample of Italian nursing homes (NHs). METHODS: Nurses from 50 NHs located in Northern Italy selected the 20 most dependent residents in their care and reported instances of MNC for three to five consecutive shifts. They described the type of MNC, its cause(s), management, recurrence, and severity of possible consequences for the resident. Information on the residents and the NH was also collected. The instances of MNC were classified as potentially avoidable/preventable or not. RESULTS: Overall, 266 (85.3%) of 312 nurses participated and 1000 residents were observed during 381 shifts (164 mornings, 164 afternoons, and 53 nights); 101 (38%) nurses reported 223 instances of MNC among 175 residents (17.5%). Ninety-seven omissions and 109 delays occurred during the day shift (56 omissions were delegated to the next shift). The most frequent MNC was drug administration (n = 71, 34.5%). In 24 (44.4%) of 54 instances of delayed drug administration, the delay was less than 30 minutes. Nurses rated approximately 20% of MNC (n = 41) as highly severe because of the discomfort caused to the resident, the clinical impact, or the repetitiveness of the situation. Nurses ascribed almost half of MNC (n = 100, 48.5%) to inadequate staffing, and they categorized 26 (11.6%) instances of MNC as unavoidable. CONCLUSIONS: The number of nurse-reported instances of MNC we reported was much lower than that previously collected with available instruments. Most MNC did not impact the comfort and safety of residents. A certain proportion of MNC was unavoidable.

What contributes to family carers' decision to transition towards palliative-oriented care for their relatives in nursing homes? Qualitative findings from bereaved family carers' experiences.

OBJECTIVES: Family carers (FCs) of nursing home (NH) residents are best placed to notice deteriorations that signal impending death in their relative, which can open a conversation with healthcare professionals (HCPs) about adjusting the care plan. We explored contributors to bereaved FCs' decision to transition towards palliative-oriented care for their relatives in NHs. METHODS: This qualitative descriptive study used a phenomenological design. Thirty-two bereaved FCs across 13 Italian NHs completed semi-structured interviews. Additional data were collected on NH referrals to palliative care services (PCS) in the 6 months before study start and treatments provided in the last week of life. Content analysis with a combined inductive and deductive approach was applied to identify codes and fit them into an a priori framework. When codes did not fit, they were grouped into new categories, which were finally gathered into themes. RESULTS: FCs reported four types of "trigger events" that made them doubt that their relative would recover: (1) physical deterioration (e.g., stopping eating/walking or swallowing problems); (2) social confirmation (e.g., confirming their relative's condition with friends); (3) multiple hospitalizations; and (4) external indicators (e.g., medical examinations by external consultants). A "resident-centered environment" helped FCs recognize trigger events and "raise awareness of the possibility of death"; however, the "need for reassurance" was pivotal to a "gradual transition towards palliative-oriented care". When participants did not recognize the trigger event, their relative continued to receive curative-oriented care. NHs that referred residents to PCS discussed palliative-oriented care more frequently with FCs, had a lower nurse-to-resident and nurse aide-to-resident ratio, and administered more palliative-oriented care. SIGNIFICANCE OF RESULTS: Trigger events represent an opportunity to discuss residents' prognosis and are the starting point for a gradual transition towards palliative-oriented care. Adequate staffing, teamwork, and communication between FCs and healthcare professionals contribute to a sensitive, timely shift in care goals.

A qualitative study of family carers views on how end-of-life communication contributes to palliative-oriented care in nursing home.

BACKGROUND: Although family-centered communication about end-of-life care has been recognized to promote palliative-oriented care in nursing home (NH), how this communication may work is still unknown. Therefore, we explored the mechanisms by which end-of-life communication may contribute to palliative-oriented care in NH from the perspective of bereaved family carers. METHODS: A descriptive qualitative design was performed. Interviews were conducted with 32 bereaved family carers whose relative had died between 45 days to 9 months prior from 13 different NHs. A two-steps analysis process firstly with deductive and then with inductive content analysis was adopted. RESULTS: Four mechanisms by which end-of-life communication contributed to palliative-oriented care were identified: a) promoting family carers understanding about their relative's health conditions, prognosis, and treatments available; b) fostering shared decision-making between healthcare professionals and residents/family carers; c) improving knowledge of residents' preferences; and d) improving knowledge of family carers' preferences. CONCLUSION: Clear and in-depth communication provides insight into residents' and family carers' preferences for care and treatment at the end-of-life, and increases understanding and shared decision-making.

The last week of life of nursing home residents with advanced dementia: a retrospective study.

BACKGROUND: Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS: This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS: Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS: Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.

Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review.

OBJECTIVE: End-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents' likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs. METHODS: Using the framework proposed by Arksey and O'Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study. RESULTS: Three mechanisms were identified: a) promotion of family carers' understanding about their family member's health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents' preferences. CONCLUSION: Family carers' understanding, shared decision-making, and knowledge of residents' preferences contribute to palliative-oriented care in NHs. PRACTICE IMPLICATIONS: Discussions about end-of-life should take place early in a resident's disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.

Good end-of-life care in nursing home according to the family carers' perspective: A systematic review of qualitative findings.

BACKGROUND: Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase. AIM: To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective. DESIGN: Systematic review (PROSPERO no. 95581) with meta-aggregation method. DATA SOURCES: Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied. RESULTS: In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care. CONCLUSION: The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.

The Impact of Nursing Homes Staff Education on End-of-Life Care in Residents With Advanced Dementia: A Quality Improvement Study.

CONTEXT: End-of-life care in nursing homes (NHs) needs improvement. We carried out a study in 29 NHs in the Lombardy Region (Italy). OBJECTIVES: The objective of this study was to compare end-of-life care in NH residents with advanced dementia before and after an educational intervention aimed to improving palliative care. METHODS: The intervention consisted of a seven-hour lecture, followed by two 3-hour meetings consisting of case discussions. The intervention was held in each NH and well attended by NH staff. This multicenter, comparative, observational study included up to 20 residents with advanced dementia from each NH: the last 10 who died before the intervention (preintervention group, 245 residents) and the first 10 who died at least three months after the intervention (postintervention group, 237 residents). Data for these residents were collected from records for 60 days and seven days before death. RESULTS: The use of "comfort hydration" (<1000 mL/day subcutaneously) tended to increase from 16.9% to 26.8% in the postintervention group. The number of residents receiving a palliative approach for nutrition and hydration increased, though not significantly, from 24% preintervention to 31.5% postintervention. On the other hand, the proportion of tube-fed residents and residents receiving intravenous hydration decreased from 15.5% to 10.5%, and from 52% to 42%, respectively. Cardiopulmonary resuscitations decreased also from 52/245 (21%) to 18/237 (7.6%) cases (P = 0.002). CONCLUSION: The short educational intervention modified some practices relevant to the quality of end-of-life care of advanced dementia patients in NHs, possibly raising and reinforcing beliefs and attitudes already largely present.

Association Between End-of-Life Conversations in Nursing Homes and End-of-Life Care Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionals-residents and health care professionals-family EOL conversations and EOL care outcomes. DESIGN: Systematic review with meta-analysis. SETTING AND PARTICIPANTS: Seven databases were searched in December 2017 to find studies that focused on health care professionals-residents (without oncologic disease) and health care professionals-family EOL conversations and aimed to explore the impact of EOL conversations on resident's or family's EOL care outcomes. MEASURES: Random effects meta-analyses with subsequent quality sensitivity analysis and meta-regression were performed to assess the effects of EOL conversations on the decision to limit or withdraw life-sustaining treatments. A funnel plot and Eagger test were used to assess publication bias. RESULTS: 16 studies were included in the qualitative and 7 in the quantitative synthesis. Health care professionals-family EOL conversations were positively associated with the family's decision to limit or withdraw life-sustaining treatments (odds ratio = 2.23, 95% confidence interval: 1.58-3.14). The overall effect of health care professionals-family EOL conversations on the family's decision to limit or withdraw life-sustaining treatments remained stable in the quality sensitivity analysis. In the meta-regression, family members with a higher level of education were less influenced by EOL conversations with health care professionals when making decisions about limiting or withdrawing life-sustaining treatments. No publication bias was detected (P = .4483). CONCLUSIONS/IMPLICATIONS: This systematic review shows that EOL conversations promote palliative care. Structured conversations aimed at exploring NH resident preferences about EOL treatment should become routine. NH administrators should offer health care professionals regular training on EOL conversations, and resident-centered care that involves residents and their families in a shared decision-making process at EOL needs to be promoted.

[The missed care in Nursing Homes: a pilot study]. / Le Missed Care negli ospiti delle residenze sanitarie per anziani:risultati di uno studio pilota.

. The missed care in Nursing Homes: a pilot study. INTRODUCTION: To date missed care have been described mostly in hospitals and data on nursing homes (NH) are missing. AIM: To describe missed care in NH residents identifying their perceived impact and seriousness. METHODS: A pilot study was conducted in 10 Piedmont NHs. For each omitted or delayed care on 20 residents observed for 3 consecutive days, the nurses provided information on the type of care, and information on the residents and on the organization were collected. RESULTS: Twenty-three nurses reported 57 missed care for 44/200 residents (22%; median 5 for each NH, range 0-13). Twenty-five missed/omitted care on 20 residents were considered of medium/high severity: 14 (56%) involved drug therapies and 5 (20%) the monitoring of vital signs. The level of severity derived from the distress caused to the resident, the risk of deterioration of residents'conditions and the repeated omissions on the same resident. Of the 32 missed care on 25 residents, judged of limited impact, the more frequent were dressing changes (12, 37.5%), and drugs administration (10, 31.3%). The most frequent reasons for delay/omission were unplanned events (16, 28.1%), shortage of nurses (12, 21.1%), and residents' clinical conditions (9, 15.7%). CONCLUSIONS: Missed care occur also in NHs. If staff shortage play a key role among potentially modifiable factors, a sizeable number of omission is associated to unlikely forseeable or avoidable events.

[The Emergency Department visits of Nursing Home residents: descriptive study in a Nursing Home]. / Gli accessi ai Dipartimenti di Emergenza degli ospiti delle Residenze Sanitarie Assistenziali: un'indagine descrittiva monocentrica.

. The Emergency Department visits of Nursing Home residents: descriptive study in a Nursing Home. INTRODUCTION: Many Emergency Departments (ED) transfers of Nursing Home (NH) residents are potentially avoidable or even inappropriate since problems could be prevented or managed in the NH. AIM: To describe characteristics and outcomes of NH residents transferred to ED for respiratory, cardiovascular and neurological problems and symptoms of infection. METHODS: A retrospective descriptive study using clinical records data from 2013-2016 of a NH was conducted. RESULTS: In 4 years (2013-2016), 143 ED accesses occurred, 55 (38.6%) for medical problems in 48 residents. The residents were mainly women, with advanced age. Forty-two/55 accesses (76.4%) resulted in an hospital admission and 16 residents (38.1%) died in hospital; of the 13 discharged, 3 died the NH after a few days. The most frequent reason for hospitalization was an infection (22): respiratory (18), urinary (2) or both (2). The week before ED admission 1/3 of residents was asymptomatic, 1/3 had only one typical symptom accompained by drowsiness or agitation (7), gastrointestinal problems (5), or other non-specific symptoms. On ED admission prevalent signs and symptoms were desaturation (13), dyspnea (10) and fever (9). Six/22 residents had started an antibiotic treatment in the NH. CONCLUSIONS: Proactive management policies need to be promoted for residents with infections, based on explicit criteria to promptly monitor changes in clinical conditions and on the education educate professionals to suspect an infection even with non-specific symptoms.

[The voice of nurses on cuts and restructurations of National Health Systems]. / La voce degli infermieri sui tagli e le ristrutturazioni dei sistemi sanitari.

. The recent global economic recession has affected nursing working conditions in terms of salary reductions, increased workload and staff shortages. Poor nursing working conditions are associated with higher levels of burnout. A literature review was conducted to identify contributions of European nurses from 2010 on the consequences of the economic crisis on the health services. Only few contributions were identified and from a limited number of countries (UK, Italy, Spain and Greece).

[Nurses' decisions in the care of advanced dementia patients: a survey]. / Indagine sulle decisioni degli infermieri sull'assistenza del paziente con demenza avanzata.

INTRODUCTION: The aim of treatment for most dementia patients should be comfort, symptoms control and withholding of futile or invasive treatments. AIM: To describe the decision of Nursing Home (NH) nurses towards some critical situations for advanced dementia patients. METHODS: A questionnaire with 7 clinical cases was administered to the nurses of 7 Italian NHs. The cases described a common or exemplar situation in an advanced dementia patient (FAST stage >7a) and limited life expectation. For each case the 4 closed ended questions described a behavior oriented to comfort (one answer) or aggressive treatment (3 answers). RESULTS: Sixty-three/92 nurses (68.5%) answered the questionnaire. The majority (39, 61.9%) would feed the patient until death; 53 (84.1%) would favor hospital admission or resuscitation attempts while 55 (87.3%) would administer antibiotics for pneumonia even without distressing symptoms. With an expected survival <15 days 34 (54%) would favor a terminal sedation with refractory symptoms and 35 (55.6%) would stop unnecessary treatments (only 4 would prefer subcutaneous route). Thirty-two nurses (50.8%) would assess pain while 28 (44.4%) would contain an agitated patient. Continuing education is associated to cestrain behaviors, specifically for sedation (p 0.01) and revision of drug regimens (p 0.05). CONCLUSIONS: Nurses are not fully competent in providing palliative care. Due to the impact of education, courses should be developed to improve the care of the dying and make nurses aware of the natural course of dementia.

[Safety culture of nursing staff. A descriptive study in a Piedmont Hospital]. / La cultura della sicurezza tra le figure di assistenza. Una indagine conoscitiva presso un'Azienda Ospedaliera Piemontese.

Assessing safety culture is the first step towards a responsible and wary system to the errors and to the quality of the performance. The aim of the study was to assess nurses' safety culture, in order to identify improvement's priorities. A survey of nursing staff, using a questionnaire was carried out in a Piedmont hospital. Of 1056 health care workers, 707 participated (67%). The staff's perception of patient safety was positive: the results of the domains "Information and communication", "Suggestions and development" and "Safety guarantees" tend to be fair, while "Teamwork" was sufficient. The weakest areas were related to involvement (Items: "We are consulted when choosing equipment and devices to be used", 25.9% agreement, "At the end of the year we discuss together activities carried out and results" 31,8%), and "Work organization (shifts, workload) doesn't cause overload and stress", 25.3% agreement, "When an error occurs we know how to communicate with the patient as we have a guideline to lead us" 35.8% agreement. The study shows that, even if the safety culture is overall positive, there are some critical aspects that lead to distress and uncertainty between nursing staff. Improvement strategies may include: staff training to improve teamwork skills and staff involvement, increasing opportunities for discussion, organizing systematic multi-professional audit, to reflect in a structured way on clinical practice.