A mixed method study of an education intervention to reduce use of restraint and implement person-centered dementia care in nursing homes.

BACKGROUND: People living with dementia in nursing homes are most likely to be restrained. The primary aim of this mixed-method education intervention study was to investigate which factors hindered or facilitated staff awareness related to confidence building initiatives based on person-centred care, as an alternative to restraint in residents with dementia in nursing homes. The education intervention, consisting of a two-day seminar and monthly coaching sessions for six months, targeted nursing staff in 24 nursing homes in Western Norway. The present article reports on staff-related data from the study. METHODS: We employed a mixed-method design combining quantitative and qualitative methods. The P-CAT (Person-centred Care Assessment Tool) and QPS-Nordic (The General Nordic questionnaire for psychological and social factors at work) instruments were used to measure staff effects in terms of person-centred care and perception of leadership. The qualitative data were collected through ethnographic fieldwork, qualitative interviews and analysis of 84 reflection notes from eight persons in the four teams who facilitated the intervention. The PARIHS (Promoting Action on Research Implementation in Health Services) theoretical framework informed the study design and the data analysis. Six nursing homes were selected for ethnographic study post-intervention. RESULTS: Qualitative data indicated increased staff awareness related to using restraint - or not- in the context of person-centered care. A slight increase in P-CAT supported these findings. Thirteen percent of the P-CAT variation was explained by institutional belonging. Qualitative data indicated that whether shared decisions of alternative measures to restraint were applied was a function of dynamic interplay between facilitation and contextual elements. In this connection, the role of the nursing home leaders appeared to be a pivotal element promoting or hindering person-centered care. However, leadership-staff relations varied substantially across individual institutions, as did staff awareness related to restraint and person-centeredness. CONCLUSIONS: Leadership, in interplay with staff culture, turned out to be the most important factor hindering or promoting staff awareness related to confidence building initiatives, based on person-centered care. While quantitative data indicated variations across institutions and the extent of this variation, qualitative data offered insight into the local processes involved. A mixed method approach enabled understanding of dynamic contextual relationships. TRIAL REGISTRATION: The trial is registered at Clinical Trials gov. reg. 2012/304 NCT01715506.

The inter-play between facilitation and context in the promoting action on research implementation in health services framework: A qualitative exploratory implementation study embedded in a cluster randomized controlled trial to reduce restraint in nursing homes.

AIM: To explore the inter-play between external facilitation and nursing home contexts relative to intervention outcomes. BACKGROUND: The Promoting Action on Research Implementation in Health Services framework is frequently used to theoretically inform implementation and research in nursing and recent reviews indicate high face validity for health services. However, the inter-play and relationship between framework sub-elements of evidence, context and facilitation and the prospective utility in non-English speaking contexts warrant further illumination. DESIGN: In an overarching single-blind cluster-randomized controlled trial, we applied participatory action research and ethnography from August 2011-June 2015 to evaluate a standardized education intervention to reduce restraint and agitation in nursing home residents living with dementia. The trial results are published elsewhere. METHODS: Prospectively informed by the PARIHS framework, a research team and eight facilitators participating in dual roles as action researchers designed, implemented, and evaluated the intervention. How contextual factors influenced the facilitation processes were explored in focus group interviews (1), reflection notes (84) written by the facilitators' after each education session, ethnographic field studies (6 homes), and co-analysis workshops (5). Directed content analysis was used to analyse data. RESULTS: Clinical leaders taking roles of internal facilitator influenced the success of implementation, while complex and fluctuating context elements determined whether restraint use was reduced- or not. The PARIHS framework was found to be relevant in a non-English nursing home setting, albeit some elements merit further conceptualization. CONCLUSIONS: Our findings confirm the prospective utility of the PARIHS framework for implementation in a non-English context, particularly the notion of implementation processes as dynamic and multifaceted.

Do organisational constraints explain the use of restraint? A comparative ethnographic study from three nursing homes in Norway.

AIMS AND OBJECTIVES: To investigate (1) what kind of restraint is used in three nursing homes in Norway and (2) how staff use restraint under what organisational conditions. BACKGROUND: Restraint use in residents living with dementia in nursing homes is controversial, and at odds with fundamental human rights. Restraint is a matter of hindering residents' free movement and will by applying either interactional, physical, medical, surveillance or environmental restraint. Previous research has identified use of restraint related to individual resident characteristics such as agitation, aggressiveness and wandering. DESIGN: This model is embedded in an overall mixed-method education intervention design study called Modelling and evaluating evidence-based continuing education program in dementia care (MEDCED), applying ethnography postintervention to examine the use of restraint in 24 nursing homes in Norway. METHOD: Based on restraint diversity measured in the trial, ethnographic investigation was carried out in three different nursing homes in Norway over a 10-month period to examine restraint use in relation to organisational constraints. RESULTS: Several forms of restraint were observed; among them, interactional restraint was used most frequently. We identified that use of restraint relates to the characteristics of individual residents, such as agitation, aggressiveness and wandering. However, restraint use should also be explained in relation to organisational conditions such as resident mix, staff culture and available human resources. CONCLUSION: A fluctuating and dynamic interplay between different individual and contextual factors determines whether restraint is used - or not in particular situations with residents living with dementia. RELEVANCE TO CLINICAL PRACTICE: Educational initiatives targeting staff to reduce restraint must be sensitive towards fluctuating organisational constraints.

Facilitating change from a distance - a story of success? A discussion on leaders' styles in facilitating change in four nursing homes in Norway.

AIM: To examine the influence of leadership when facilitating change in nursing homes. BACKGROUND: The study is a part of an education intervention for care staff to prevent the use of restraint in nursing home residents with dementia in 24 nursing homes (NHs) in Norway. Leadership is known to be a fundamental factor for success of evidence-based practice (EBP) implementation in health services. However, the type of leadership that strengthens the processes of change remains to be clarified. METHOD: A multi-site comparative ethnography was performed in four nursing homes to investigate how contextual factors influenced the implementation. The analysis was informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and in particular the sub-element of leadership. RESULTS: Different leadership styles to facilitate change were identified. Paradoxically, a strong collective and collaborative leadership style was found to hamper change in one particular home, whereas a remote leadership style combined with almost no cooperation with staff proved successful in another setting. CONCLUSIONS: The study indicates that leadership cannot be understood on a low-high continuum as suggested by the PARIHS framework, but rather as a factor characterised by diversity. IMPLICATION FOR NURSING MANAGEMENT: Our study indicates, as a minimum, that a leader's presence is necessary to facilitate the internal processes in order more successfully to implement EBP.

Modeling and evaluating evidence-based continuing education program in nursing home dementia care (MEDCED)--training of care home staff to reduce use of restraint in care home residents with dementia. A cluster randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a tailored 7-month training intervention "Trust Before Restraint," in reducing use of restraint, agitation, and antipsychotic medications in care home residents with dementia. METHODS: This is a single-blind cluster randomized controlled trial in 24 care homes within the Western Norway Regional Health Authority 2011-2013. RESULTS: From 24 care homes, 274 residents were included in the study, with 118 in the intervention group and 156 in the control group. Use of restraint was significantly reduced in both the intervention group and the control group despite unexpected low baseline, with a tendency to a greater reduction in the control group. There was a significant reduction in Cohen-Mansfield Agitation Inventory score in both the intervention group and the follow-up group with a slightly higher reduction in the control group, although this did not reach significance and a small nonsignificant increase in use of antipsychotics (14.1-17.7%) and antidepressants (35.9-38.4%) in both groups. CONCLUSIONS: This study reports on the statistically significant reduction in use of restraint in care homes, both prior and during the 7-month intervention periods, in both intervention and control groups. When interpreted within the context of the current climate of educational initiatives to reduce restraint and a greater focus on the importance of person-centered care, the study also highlights the potential success achieved with national training programs for care staff and should be further evaluated to inform future training initiatives both in Norway and internationally.

Nursing education in Norway.

AIM: The aim of this paper is to describe nursing education in Norway and some essential questions and challenges regarding the undergraduate and newly graduated nurses' competencies and functionally preparedness. BACKGROUND: The first formal training of nurses in Norway started in Oslo in 1886. Since then the education has changed considerably. As long as society is changing, and nurses are going to meet and adapt to societies needs, the education of nurses will also have to change continuously. The present general plan of nursing education has gone through a long process. The discussions have concerned the content of medical and natural science subjects, the practical part of the training and the relation between theory and practice. CHALLENGES: There are challenges in nursing education in Norway today. We have seen that recruitment has decreased, and that nurses seek jobs where they are better paid. To increase the accessibility distance and part-time education has been established. The theory-practice gap will always exist. Therefore we should aim to prepare the students to minimize this gap in a way that they can combine training of nursing with training in improvement. The demand of a masters degree to be a nursing teacher has reduced the teachers' ability to keep up their practical skills. The government pays nursing teachers who want to practice as nurses for several months to maintain their salary level during that period. CONCLUSIONS: There are many possibilities to improve nursing education in Norway. We are on our way with highly qualified teachers and students, and we still have enough good applicants. The new general plan and new law for universities and university colleges offer great opportunities. However, the shortage of nurses is a great challenge for further quality improvement both in clinical practice and in education.