Facilitators and barriers to implementing a specialized care unit for persons with cognitive impairment in an acute geriatric hospital: a process evaluation.

BACKGROUND: Implementing dementia care interventions in an acute hospital poses multiple challenges. To understand factors influencing the implementation, in-depth knowledge about specific facilitators and barriers is necessary. The aim of this study was to identify facilitators and barriers to implementing an interprofessional, multicomponent intervention of a specialized unit for persons with cognitive impairment in an acute geriatric hospital. METHODS: We conducted a process evaluation as part of a participatory action research study. For data collection, semi-structured individual interviews with fifteen professionals involved in the implementation of the specialized unit. We further conducted two focus groups with twelve professionals working on other units of the geriatric hospital. We performed a qualitative content analysis following Kuckartz's content-structuring analysis scheme. RESULTS: We identified the following barriers to implementing the specialized unit: uncontrollable contextual changes (e.g., COVID-19 pandemic), staff turnover in key functions, high fluctuation in the nursing team, traditional work culture, entrenched structures, inflexible and efficiency-oriented processes, monoprofessional attitude, neglect of project-related communication, and fragmentation of interprofessional cooperation. An established culture of interprofessionalism, an interprofessionally composed project group, cooperation with a research partner, as well as the project groups' motivation and competence of managing change facilitated the implementation. CONCLUSIONS: The implementation faced numerous barriers that can be described using the key constructs of the i-PARIHS framework: context, recipients, innovation, and facilitation. Overcoming these barriers requires an organizational development approach, extended project duration and increased process orientation. Furthermore, strategically planned, precise and ongoing communication towards all persons involved seems crucial. Differences between the work cultures of the professions involved deserve particular attention with regard to project-related roles and processes.

Aggressive behaviour of persons with dementia towards professional caregivers in the home care setting-A scoping review.

AIMS AND OBJECTIVES: To outline and to examine the current research and grey literature on aggressive incidents of persons with dementia towards professional caregivers in the home care setting. We intended to identify evidence and research gaps in this field. BACKGROUND: Worldwide, around fifty million people are living with dementia. Current research indicates that aggressive behaviour of persons with dementia towards professional caregivers occurs frequently in inpatient settings. However, there has been little research on this phenomenon in the home care setting. DESIGN: The design entails a scoping review using the methodological framework of Arksey and O'Malley and PRISMA-ScR. METHODS: A systematic literature search in five databases and a web search in Google Scholar was conducted. Title and abstract screening and a full-text screening were conducted by two independent authors. A free web search for grey literature was conducted in Google. RESULTS: The search yielded 1,376 hits. A total of seven journal articles met the inclusion criteria. In the free web search, six references were identified for inclusion, resulting in a total of 13 references. We identified the following four themes: (1) aggressive behaviour in the context of dementia, (2) triggering factors of aggressive behaviour in persons with dementia, (3) skills and educational needs and (4) hindrances to solving the problem of aggressive behaviour. CONCLUSIONS: There is a lack of literature on aggressive behaviour of persons with dementia in the home care setting, and various hindrances to solving this problematic behaviour have been identified. RELEVANCE TO CLINICAL PRACTICE: For home caregivers, specific education concerning communication skills and responding to aggressive behaviour may help to deal with the situation. A further approach may involve specific training aimed to improve caregivers' confidence.

Dementia care in acute hospitals: A framework for practice development and theory-based evaluation.

AIM: The aim was to generate a framework for dementia care in acute hospitals. DESIGN: Framework development with logic modelling. METHODS: In phase one, we identified relevant elements of the framework by analysing several sources and by critically discussing them within the research team. We created the framework with logic modelling. In phase two, we adapted the framework in expert workshops and by reanalysing the included sources. We used the first stage of CReDECI 2 checklist for reporting. RESULTS: The framework describes necessary activities within four main bundles of measures: "developing structures and processes," "developing competences and attitudes," "building relationships" and "ensuring a social environment and adequate stimulation." The overarching outcome is a person-centred hospital culture, manifesting itself on different levels. The framework illustrates the necessity of an organization-wide person-centred culture for achieving positive outcomes for people with dementia, their relatives and health professionals.

Effectiveness of a group-walking intervention for people with dementia based on quality of life and caregivers' burden.

AIMS: To test the effectiveness of a 28-week group-walking intervention for person with dementia. Participants were accompanied by trained volunteers. The effectiveness was assessed according to the quality of life, ability to perform activities of daily living, independence, mobility, cognition, challenging behaviours and the burden on their caregiving relatives. DESIGN: Quasi-experimental, one-group, pretest-posttest trial. METHODS: Thirty-two persons with dementia and their caregiving relatives were recruited. The nursing intervention consists on easy walking tours lasting three and a half hours. The walks were performed biweekly and each person with dementia had support from one or two trained volunteer helpers. RESULTS: The quality of life was stable through all seasons. The secondary outcomes were uneven. While the impairment (WHODAS) and the dependence (IADL) increased, the challenging behaviours and the burden on the caregivers were stable through all seasons.

Overlaps of multiple database retrieval and citation tracking in dementia care research: a methodological study.

OBJECTIVE: We aimed to determine overlaps and optimal combination of multiple database retrieval and citation tracking for evidence synthesis, based on a previously conducted scoping review on facilitators and barriers to implementing nurse-led interventions in dementia care. METHODS: In our 2019 scoping review, we performed a comprehensive literature search in eight databases (CENTRAL, CINAHL, Embase, Emcare, MEDLINE, Ovid Nursing Database, PsycINFO, and Web of Science Core Collection) and used citation tracking. We retrospectively analyzed the coverage and overlap of 10,527 retrieved studies published between 2015 and 2019. To analyze database overlap, we used cross tables and multiple correspondence analysis (MCA). RESULTS: Of the retrieved studies, 6,944 were duplicates and 3,583 were unique references. Using our search strategies, considerable overlaps can be found in some databases, such as between MEDLINE and Web of Science Core Collection or between CINAHL, Emcare, and PsycINFO. Searching MEDLINE, CINAHL, and Web of Science Core Collection and using citation tracking were necessary to retrieve all included studies of our scoping review. CONCLUSIONS: Our results can contribute to enhancing future search practice related to database selection in dementia care research. However, due to limited generalizability, researchers and librarians should carefully choose databases based on the research question. More research on optimal database retrieval in dementia care research is required for the development of methodological standards.

A systematic review of interventions to improve acute hospital care for people with dementia.

The aim of this study was to provide an overview of interventions targeting hospital care of patients with dementia. We conducted a systematic review, including interventional study designs. We searched five electronic databases, conducted a hand search and performed citation tracking. To assess risk of bias, we used Cochrane Collaboration's tool, ROBANS and AMSTAR. We narratively summarized the outcomes. The findings of twenty studies indicated a broad range of interventions and outcomes. We categorised the interventions into eight intervention types. Educational programmes were the most reported intervention type and resulted in improved staff outcomes. Family-/person-centred care programmes, use of specially trained nurses and delirium management programmes were effective in improving some patient-related outcomes. However, current evidence is insufficient to declare which interventions are effective in improving dementia care in acute hospitals. Future research should focus on relevant patient and family caregiver outcomes and must consider the complexity of the interventions when evaluating them.

Facilitators and barriers to implement nurse-led interventions in long-term dementia care: a qualitative interview study with Swiss nursing experts and managers.

BACKGROUND: To support the implementation of nurse-led interventions in long-term dementia care, in-depth knowledge of specific supporting factors and barriers is required. Conditions and structures of caring for people with dementia differ widely, depending on the country and the care context. Our study aimed to describe the experiences and opinions of nursing experts and managers with regard to facilitators and barriers to the implementation of nurse-led interventions in long-term dementia care. METHODS: We conducted a qualitative descriptive study using individual interviews based on qualitative vignettes as a useful stimulus to generate narrations allowing to study peoples' perceptions and beliefs. The study took place in nursing homes in the German-speaking part of Switzerland and in the Principality of Liechtenstein using purposive sampling. We intended to conduct the interviews face-to-face in a quiet room according to the participant's choice. However, due to the lockdown of nursing homes during the COVID-19 pandemic in spring 2020, we performed interviews face-to-face and by video. We analysed data thematically following Braun and Clarke to achieve a detailed, nuanced description. To verify our interpretation and to ensure congruence with participants' perspectives, we conducted member checks. The Standards for Reporting Qualitative Research (SRQR) served to structure our manuscript. RESULTS: Six dyads of nursing home managers and nursing experts from six nursing homes took part in our study (n = 12). Our thematic analysis yielded seven themes reflecting facilitators and barriers to implementing nurse-led interventions in long-term dementia care: «A common attitude and cohesion within the organization¼, «Commitment on several levels¼, «A needs-oriented implementation¼, «The effect and the public perception of the intervention¼, «A structured and guided implementation process¼, «Supporting knowledge and competencies¼, as well as «Resources for implementing the intervention¼. CONCLUSIONS: To support the implementation of nurse-led interventions in long-term dementia care, active commitment-building seems essential. It is necessary that the value of the intervention is perceptible.Commitment-building is the precondition to reach the persons involved, such as nursing home managers, nursing staff, residents and relatives. Furthermore, nurses should precisely inform about the intervention. It is necessary that the value of the intervention is perceptible. In addition, nurses should adjust the interventions to the situational needs of people with dementia, thus. Therefore, it is important to support dementia-specific competencies in long-term care. Findings indicate that the barrier is determined by the intervention and its implementation - and not by the behaviour of the person with dementia.

What hinders and facilitates the implementation of nurse-led interventions in dementia care? A scoping review.

BACKGROUND: The implementation of evidence-based interventions for people with dementia is complex and challenging. However, successful implementation might be a key element to ensure evidence-based practice and high quality of care. There is a need to improve implementation processes in dementia care by better understanding the arising challenges. Thus, the aim of this study was to identify recent knowledge concerning barriers and facilitators to implementing nurse-led interventions in dementia care. METHODS: We performed a scoping review using the methodological framework of Arksey and O'Malley. Studies explicitly reporting on the implementation process and factors influencing the implementation of a nurse-led intervention in dementia care in all settings were included. We searched eight databases from January 2015 until January 2019. Two authors independently selected the studies. For data analysis, we used an inductive approach to build domains and categories. RESULTS: We included 26 studies in the review and identified barriers as well as facilitators in five domains: policy (e.g. financing issues, health insurance), organisation (e.g. organisational culture and vision, resources, management support), intervention/implementation (e.g. complexity of the intervention, perceived value of the intervention), staff (e.g. knowledge, experience and skills, attitude towards the intervention), and person with dementia/family (e.g. nature and stage of dementia, response of persons with dementia and their families). CONCLUSIONS: Besides general influencing factors for implementing nursing interventions, we identified dementia-specific factors reaching beyond already known barriers and facilitators. A pre-existing person-centred culture of care as well as consistent team cultures and attitudes have a facilitating effect on implementation processes. Furthermore, there is a need for interventions that are highly flexible and sensitive to patients' condition, needs and behaviour.

Toxicity of carbon dioxide: a review.

The toxicity of carbon dioxide has been established for close to a century. A number of animal experiments have explored both acute and long-term toxicity with respect to the lungs, the cardiovascular system, and the bladder, showing inflammatory and possible carcinogenic effects. Carbon dioxide also induces multiple fetal malformations and probably reduces fertility in animals. The aim of the review is to recapitulate the physiological and metabolic mechanisms resulting from CO(2) inhalation. As smokers are exposed to a high level of carbon dioxide (13%) that is about 350 times the level in normal air, we propose the hypothesis that carbon dioxide plays a major role in the long term toxicity of tobacco smoke.

Effects of CO2 inhalation exposure on mice vomeronasal epithelium.

Nasal epitheliums are the first sites of the respiratory tract in contact with the external environment and may therefore be susceptible to damage from exposure to many toxic volatile substances (i.e., volatile organic components, vapors, and gases). In the field of inhalation toxicology, a number of studies have considered the main olfactory epithelium, but few have dealt with the epithelium of the vomeronasal organ (VNO). However, in several species such as in rodents, the VNO (an organ of pheromone detection) plays an important role in social interactions, and alterations of this organ are known to induce adaptative behavioral disturbances. Among volatile toxicants, health effects of inhaled gases have been thoroughly investigated, especially during CO(2) inhalation because of its increasing atmospheric concentration. Therefore, this work was designed to examine the effects of 3% CO(2) inhalation on VNO in two different exposure conditions (5 h/day and 12 h/day) in mice. Behavioral sensitivity tests to urine of congener and histological measurements of VNO were conducted before, during (weeks 1-4), and after (weeks 5-8) CO(2) inhalation exposures. Results showed no significant modifications of behavioral responses to urine, but there were significant changes of both cell number and thickness of the VNO epithelium. Moreover, the findings indicated a selectively dose-dependent effect of CO(2), and further research could use other gases in the same manner for comparison.