Quality of care plans in long-term care facilities for the older persons-How well is information from RAI assessments utilised in care planning?

BACKGROUND: In Finland, care plans at long-term care facilities (LTCF) for the older persons should be based on information from Resident Assessment Instrument (RAI) assessments and the principles of structured data. Hence, managers are responsible for ensuring that the RAI system is used to a satisfactory extent, the provided information is used in care planning, and that staff members are competent at composing high-quality care plans. AIM: To explore the congruence between first-line managers' assessments of the extent to which care plans include RAI information and separately observed RAI-related contents of care plans. METHODS: The study was based on a descriptive, cross-sectional survey of first-line managers (n = 15) from three LTCF organisations and a randomly selected sample of care plans (n = 45) from two LTCF organisations in Finland. Manager responses and analysis of care plans were reviewed at a general level. The data were gathered in 2019 and analysed using statistical methods and content analysis. RESULTS: First-line managers' assessments of the extent to which their units' care plans included RAI information did not match the observed care plan contents. The care plan analysis revealed that managers significantly overestimated the extent to which care plans included RAI-related content. CONCLUSION: Managers at LTCF organisations need more training to be able to sufficiently support their staff in using RAI information to draft high-quality care plans. IMPLICATION FOR PRACTICE: Care plans must include a higher level of information related to RAI assessments. To develop competencies in drafting high-quality care plans, training related to RAI information utilisation on all aspects of the care plan should be emphasised and training should be provided to first-line managers and more broadly across the nursing staff.

Managers' Perspectives of Quality of Care in Service Housing and Home Care Services: A Qualitative Study.

The aim of this study was to illuminate facilitators and barriers to the quality of care in service housing and home care services, as described by managers. In total, 17 service housing and home care service front-line managers participated in this study. The interviews were conducted in Finland during October 2021 using semi-structured interviews. Qualitative content analysis was used to analyze the data. Described facilitators to the quality of care included: staff dedication and motivation, a positive psycho-social working environment, sufficient staffing, coaching management, and optimized tasks. Described barriers included: increased efficiency demands, staffing challenges, inefficient division of labor, conflicts within the working community, and disruptions due to COVID-19. The results suggest that recruiting and retaining sufficient dedicated and motivated staff is paramount to ensuring quality of care from the managerial perspective, and it seems changes in the working culture may support quality of care in a cost-efficient way.

Predictors for Unplanned Hospitalization of New Home Care Clients.

OBJECTIVES: To identify factors predicting unplanned hospitalization of new home care clients using the Resident Assessment Instrument for Home Care (RAI-HC). DESIGN: A register-based study based on RAI-HC assessments and nationwide hospital discharge records. SETTING: Municipal home care services in Finland. PARTICIPANTS: New Finnish home care clients aged 63 and older (N = 15,700). MEASUREMENTS: Information from home care clients' first RAI-HC assessment was connected to information regarding their first hospitalization over 1 year of follow-up. Multivariate regression analyses were used to evaluate the independent risk factors for hospitalization. RESULTS: Forty-three percent (n = 6,812) of participants were hospitalized at least once. The strongest independent risk factors were hospitalization during the year preceding the RAI-HC assessment (odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.87-2.16), aged 90 and older (OR = 1.69, 95% CI = 1.48-1.92), renal insufficiency (OR = 1.44, 95% CI = 1.22-1.69) and using 10 or more drugs (OR = 1.41, 95% CI = 1.26-1.58). Other independent risk factors were male sex, previous emergency department visits or other acute outpatient care use, daily urinary incontinence, fecal incontinence, history of falls, cognitive impairment, chronic skin ulcer, pain, unstable health status, housing-related problems, and poor self-rated health. Parkinson's disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and cancer were independent prognostic indicators. A body mass index of 24 kg/m2 or greater and the client's own belief that functional capacity could improve had a protective role. CONCLUSION: Assessing new home care clients using the RAI-HC reveals modifiable risk factors for unplanned hospitalization. Systematic assessment by a multidisciplinary team at the beginning of the service and targeting modifiable risk factors could reduce the risk of unplanned hospitalization.

Perceived and observed quality of long-term care for residents - Does functional ability account?

BACKGROUND: Measuring quality in long-term residential care involves challenges concerning both the measurement method and the impaired functional ability of many older people. Ensuring quality in care is even more important for people with functional impairments, as this is a vulnerable group who may be unable to report poor quality of care for themselves. AIMS AND OBJECTIVES: The aim of this study was to analyse how perceived and observed assessments of the quality of care varied according to the residents' functional ability. DESIGN: The data (n = 278) used in the analyses included residents', family members' and staff assessments of perceived and observed quality of care combined with the Resident Assessment Instrument (RAI) scales measuring the same residents' functional abilities (physical, psychological, cognitive and social). Observations were included in the data if all four assessment types (by residents, family members, staff and the RAI) were available. The dimensions of quality of care emerging from the factor analysis were used. METHODS: Linear regression was used to explore the association between resident's functional abilities and assessed quality of care. RESULTS: Higher level of depression symptoms and higher level of dependency in activities of daily living (ADL) were significantly associated with lower level of perceived and observed quality of care. By contrast, the level of residents' cognitive functioning was not significantly associated with any quality dimensions. The social aspect was the only dimension of functional ability on which better functional ability indicated better quality of care, although differences between respondent groups were also observed. CONCLUSIONS: These analyses emphasize the importance of taking residents' functional ability into account when collecting information on and interpreting the results of perceived and observed quality of care reported separately by residents, family members and staff. IMPLICATIONS FOR PRACTICE: The information obtained can inform care professionals of how dimensions of residents' functional impairments are associated with perceived and observed quality of care and the quality of older people's care can thereby be improved.

Job demands and job strain as risk factors for employee wellbeing in elderly care: an instrumental-variables analysis.

BACKGROUND: The association between psychosocial work environment and employee wellbeing has repeatedly been shown. However, as environmental evaluations have typically been self-reported, the observed associations may be attributable to reporting bias. METHODS: Applying instrumental-variable regression, we used staffing level (the ratio of staff to residents) as an unconfounded instrument for self-reported job demands and job strain to predict various indicators of wellbeing (perceived stress, psychological distress and sleeping problems) among 1525 registered nurses, practical nurses and nursing assistants working in elderly care wards. RESULTS: In ordinary regression, higher self-reported job demands and job strain were associated with increased risk of perceived stress, psychological distress and sleeping problems. The effect estimates for the associations of these psychosocial factors with perceived stress and psychological distress were greater, but less precisely estimated, in an instrumental-variables analysis which took into account only the variation in self-reported job demands and job strain that was explained by staffing level. No association between psychosocial factors and sleeping problems was observed with the instrumental-variable analysis. CONCLUSIONS: These results support a causal interpretation of high self-reported job demands and job strain being risk factors for employee wellbeing.

Job demands and musculoskeletal symptoms among female geriatric nurses: the moderating role of psychosocial resources.

The present study examined whether job resources (job control, social support, and distributive justice) moderate the associations of high job demands induced by physical and mental workload with musculoskeletal symptoms among geriatric nurses. The data were drawn in Finland from 975 female nurses working in 152 geriatric units who responded to a survey questionnaire. Information on the objective workload in terms of resident characteristics and structural factors was also collected at the unit level. After adjusting for the objective workload, multilevel logistic regression analyses showed that self-reported physical workload was associated with higher risk of musculoskeletal symptoms (OR = 1.93, 95 % CI [1.38, 2.72]) among nurses with low social support. In addition, mental workload was associated with higher risk of musculoskeletal symptoms (OR = 1.72, 95% CI [1.12, 2.62]) for those with low distributive justice. The results suggest that social support and fair reward systems may help to buffer against the detrimental effects of heavy job demands on nurses' musculoskeletal symptoms.

Assessing prevalence of antimicrobial use and infections using the minimal data set in Finnish long-term care facilities.

Of all residents (n = 12,784) for whom a minimum data set 2.0 form was completed in long-term care facilities (n = 253) using a Resident Assessment Instrument in April and September 2011 in Finland, 16% received antimicrobials, most commonly methenamine (42%) and trimethoprim (24%). The prevalence of urinary tract infections was 8%, wound infection 2%, and pneumonia 2%. Minimum data set form provides a feasible tool for collecting data on antibiotic use and infections in long-term care facilities.

The association of ownership type with job insecurity and worry about job stability: the moderating effects of fair management, positive leadership, and employment type.

This study examined whether the ownership type is associated with job insecurity and worry about job stability and whether the type of employment contract, positive leadership, and fair management moderated these associations. Survey data from 1249 Finnish female elderly care staff aged 18 to 69 years were used. Job insecurity and worry about job stability were highest in not-for-profit sheltered homes. However, positive leadership and fair management were able to mitigate this insecurity and worry. Job insecurity was highest among fixed-term employees in public sheltered homes or not-for-profit nursing homes. Thus, promoting good leadership and fair management would be of importance.

Ownership type and team climate in elderly care facilities: the moderating effect of stress factors.

AIMS: This paper is a report of a study examining the association between ownership type and perceived team climate among older people care staff. In addition, we examined whether work stress factors (time pressure, resident-related stress, role conflicts and role ambiguity) mediated or moderated the above mentioned association. BACKGROUND: There has been a trend towards contracting out in older people care facilities in Finland and the number of private for-profit firms has increased. Studies suggest that there may be differences in employee well-being and quality of care according to the ownership type of older people care. METHODS: Cross-sectional survey data was collected during the autumn of 2007 from 1084 Finnish female older people care staff aged 18-69 years were used. Team Climate Inventory was used to measure team climate. Ownership type was divided into four categories: for-profit sheltered homes, not-for-profit sheltered homes, public sheltered homes and not-for-profit nursing homes. Analyses of covariance were used to examine the associations. RESULTS: Team climate dimensions participative safety, vision and support for innovation were higher in not-for-profit organizations (both sheltered homes and nursing homes) compared to for-profit sheltered homes and public sheltered homes. Stress factors did not account for these associations but acted as moderators in a way that in terms of task orientation and participative safety employees working in for-profit organizations seemed to be slightly more sensitive to work-related stress than others. CONCLUSION: Our results suggest that for-profit organizations and public organizations may have difficulties in maintaining their team climate. In consequence, these organizations should focus more effort on improving their team climate.

The effects of ownership, staffing level and organisational justice on nurse commitment, involvement, and satisfaction: a questionnaire study.

BACKGROUND: Elderly care systems have undergone a lot of changes in many European countries, including Finland. Most notably, the number of private for-profit firms has increased. Previous studies suggest that employee well-being and the quality of care might differ according to the ownership type. OBJECTIVE: The present study examined whether the ownership type and the staffing level were associated with organisational commitment, job involvement, and job satisfaction. In addition, we examined the potential moderating effect of organisational justice on these associations. DESIGN: Cross-sectional questionnaire study. PARTICIPANTS AND SETTING: 1047 Finnish female staff members aged 18-69 years working in sheltered housing or nursing homes (units n=179). METHODS: The relationships were studied with analyses of covariance (ANCOVA), adjusting for the effects of age and case-mix. RESULTS: Organisational commitment and job satisfaction levels were low in for-profit sheltered homes when justice levels were low, but when justice levels were high, for-profit sheltered homes did not differ from other ownership types. Similarly, organisational justice acted as a buffer against low commitment resulting from low staffing levels. Staffing levels were lowest in public sheltered homes and highest in not-for-profit sheltered homes. CONCLUSION: The results show that organisational justice can act as a buffer against low organisational commitment that results from low staffing levels and working in for-profit sheltered homes. Increasing justice in regard to the management, outcomes, and procedures in the organisation would thus be important.

Method for Assigning Priority Levels in Acute Care (MAPLe-AC) predicts outcomes of acute hospital care of older persons--a cross-national validation.

BACKGROUND: Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been : identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning. METHODS: Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses. RESULTS: Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models. CONCLUSION: MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.

Recent visual decline-a health hazard with consequences for social life: a study of home care clients in 12 countries.

Information about recent visual decline (RVD) and its consequences is limited. The aim was to investigate this in an observational, prospective study. Participants were recipients of community home services, >/=65 years, from Ontario (Canada, n = 101618), Finland (the-RAI-database, STAKES, n = 1103), and 10 other European countries (the-Aged-in-HOmeCarestudy (AdHOC), n = 3793). The instrument RAI-HC version 2.0 was used in all sites. RVD was assessed by the item "Worsening of vision compared to status 90 days ago" and was present in 6-49% in various sites, more common among persons living alone, and in females. In the AdHOC sample, RVD was independently associated with declining social activity and limited outdoors activities due to fear of falling. The combination of stable vision impairment (SVI) and RVD was independently associated with IADL loss. RVD is common and has greater impact than SVI on social life and function. Caregivers should be particularly aware of RVD, its consequences, and help patients to seek assessments, treatment, and rehabilitation.

Pain in European long-term care facilities: cross-national study in Finland, Italy and The Netherlands.

There have been very few and limited cross-national comparisons concerning pain among residents of long-term care facilities in Europe. The aim of the present cross-sectional study has been to document the prevalence of pain, its frequency and severity as well as its correlates in three European countries: Finland (north), Italy (south) and the Netherlands (western central). Patients (aged 65years or above) were assessed with the Minimum Data Set 2.0 (MDS).The final sample comprised 5761 patients from 64 facilities in Finland, 2295 patients from 8 facilities in the Netherlands and 1959 patients from 31 facilities in Italy. The prevalence of pain - defined as any type of pain - varied between 32% in Italy, 43% in the Netherlands and 57% in Finland. In nearly 50% of cases, pain was present daily; there were no significant differences in pain prevalence between patients with cancer diagnosis and those with non-cancer diagnosis. Regardless of the different prevalence estimates, pain was moderate-to-severe in over 50% of cases in all the countries. In multivariate logistic regression models, clinical correlates of pain were substantially similar across countries: pain was positively correlated with more severe physical disability (ADL impairment), clinical depression and a diagnosis of osteoporosis. Pain was negatively correlated with a diagnosis of dementia and more severe degrees of cognitive deterioration. We conclude that pain is frequently encountered in long-term care facilities in Europe and that, despite cultural and case-mix differences, pain speaks one language.

Gender, living arrangements, and social circumstances as determinants of entry into and exit from long-term institutional care at older ages: a 6-year follow-up study of older Finns.

PURPOSE: Due to population aging, the need for long-term institutional care is increasing. We study the potentially modifiable sociodemographic factors that affect the rate of entry into and exit from long-term care. DESIGN AND METHODS: A 40% sample from the population registration data of Finns aged 65 and older living in private households at the end of 1997 (n = 280,722) was followed for first entry into (n = 35,926) and subsequent exit -- due to death or return to the community -- from long-term institutional care until the end of 2003. RESULTS: Being female, old, living alone, and of low socioeconomic status increased the risk for entering long-term care. Exit was affected by the same factors, but the associations were weaker and, with the exception of age, in the opposite direction. Women's higher risk for entry was due to older age and greater likelihood of living alone. The effects of living arrangements and socioeconomic factors on entry were stronger among men and were attenuated after adjustment for each other and for health status. The mean duration of care was 1,064 days among women and 686 among men. IMPLICATIONS: Gender, age, living arrangements, and socioeconomic status are major determinants of institutional residence. Women and certain other population groups, e.g., those living alone, are likely to spend a longer time in institutional care because of higher rates of entry and lower rates of exit. These results have implications for the financing of long-term care and for targeting of interventions aimed at delaying it.

Vision and hearing impairments and their associations with falling and loss of instrumental activities in daily living in acute hospitalized older persons in five Nordic hospitals.

BACKGROUND: Many older people believe sensory problems are inevitably, a part of growing old, and avoid assessment and help. Such problems are often also overlooked by health professionals. The aim of this study was to find the prevalence of hearing and vision impairment and their associations with loss of instrumental activities in daily living (IADL) and risk of falling in patients aged 75 years or older, admitted to a medical ward in an acute hospital in each of the five Nordic countries. METHOD: The Minimum Data Set for Acute Care was used for data collection in 770 patients. Premorbid data, admission data and history of falls over 3 months were obtained on admission by interview and observation. Hearing impairment was present if the patient required a quiet setting to be able to hear normal speech. Vision impairment was defined as unable to read regular print in a newspaper. RESULTS: Bivariate and logistic regression analyses were performed. Forty-eight per cent of the patients had a hearing impairment, 32.3% had vision impairment and 20.1% had both. Hearing impairment was associated with falling but not in the logistic regression model. Hearing and vision impairment were associated with loss of IADL but only combined impairment was independently. CONCLUSION: Hearing and vision impairments were frequent among older patients in the medical wards. Falling was associated with hearing loss and IADL loss with hearing, vision and combined impairments. Sensory loss was also associated with fear of falling. It is recommended routinely to screen sensory functions in older patients in a medical setting. Intervention studies are needed to determine whether improvements in hearing and vision can prevent falls and further loss of function in this patient population.

Drug use and pressure ulcers in long-term care units: do nurse time pressure and unfair management increase the prevalence?

AIMS: This study examined the associations between nurse working conditions (time pressure and perceived unfair management) and quality indicators (prevalence of antianxiety or hypnotic drug use and pressure ulcers) in long-term care units. BACKGROUND: Differences persist across long-term care facilities in their care processes and resident outcomes even after adjusting for residents' clinical conditions. Little is known about how nurses' working conditions influence the quality of care. DESIGN: Survey. METHODS: Data on working conditions were drawn in 2002 from 724 nurses in 66 long-term care units that reported quality indicators based on the Resident Assessment Instrument system as measured by Minimum Data Set. Percentage change in the quality indicators from 2002 were estimated using hierarchical multiple regression analyses with adjustments made for the baseline quality indicators (2001) and unit structural factors (unit size and staffing level). RESULTS: Unit time pressure increased the prevalence of both quality problems (p-values <0.05). Perceived unfair management was related to increased drug use (p = 0.038). CONCLUSIONS: The findings of this research suggest that quality of care can be improved by enhancing nurse working conditions. RELEVANCE TO CLINICAL PRACTICE: Organisational initiatives should be aimed at reducing time pressures and promoting fair managerial procedures that engage all nursing staff in the decision-making in long-term care settings.

Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment.

AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. METHOD: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. FINDINGS: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases. CONCLUSIONS: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.

Aging, health expenditure, proximity to death, and income in Finland.

This study revisits the debate on the 'red herring', i.e. the claim that population aging will not have a significant impact on health care expenditure (HCE), using a Finnish data set. We decompose HCE into several components and include both survivors and deceased individuals into the analyses. We also compare the predictions of health expenditure based on a model that takes into account the proximity to death with the predictions of a naïve model, which includes only age and gender and their interactions. We extend our analysis to include income as an explanatory variable. According to our results, total expenditure on health care and care of elderly people increases with age but the relationship is not as clear as is usually assumed when a naïve model is used in health expenditure projections. Among individuals not in long-term care, we found a clear positive relationship between expenditure and age only for health centre and psychiatric inpatient care. In somatic care and prescribed drugs, the expenditure clearly decreased with age among deceased individuals. Our results emphasize that even in the future, health care expenditure might be driven more by changes in the propensity to move into long-term care and medical technology than age and gender alone, as often claimed in public discussion. We do not find any strong positive associations between income and expenditure for most non-LTC categories of health care utilization. Income was positively related to expenditure on prescribed medicines, in which cost-sharing between the state and the individual is relatively high. Overall, our results indicate that the future expenditure is more likely to be determined by health policy actions than inevitable trends in the demographic composition of the population.

Comparing psychogeriatric units to ordinary long-term care units - are there differences in case-mix or clinical symptoms?

This study is a comparative analysis of long-term psychogeriatric and mixed-care unit patient characteristics in nursing homes and hospitals in Helsinki. The role of the so-called psychogeriatric nursing homes is still under question and not well developed. The aims of the study were to identify and survey psychogeriatric wards and analyze whether these units differ from the rest of the long-term units/wards in terms of patients' characteristics. Participants studied were a total of 2828 elderly long-term care residents, of which 372 were living in long-term psychogeriatric and 2456 in ordinary long-term care units. Data were drawn from the Resident Assessment Instrument (RAI) database and had been collected in the project "Benchmarking and implementation of RAI in Elderly Care in Finland". Scales and items based on Minimum Data Set were used for the comparisons. Resident groups in psychogeriatric units and in ordinary, mixed-client settings were clearly distinguishable. The psychogeriatric residents were younger, had more comorbidity as to psychiatric diseases, and had more often psychiatric symptoms and psychotropic medications. The residents in psychogeriatric units did not differ in cognitive and functional status from those in mixed-client units and had similar comorbidity as to somatic diseases. This study shows that psychiatric symptoms that need to be addressed are common in long-care facilities. The results emphasize the importance of recognition of the multiple care needs of elderly with severe mental symptoms or illness.