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Experiences and outcomes of systematic preventive work to reduce malnutrition, falls and pressure ulcers in nursing home residents
Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Older people living in nursing homes are at a high risk of becoming malnourished, falling and developing pressure ulcers. In Sweden the national quality registry Senior Alert was developed to support prevention in these areas. Prevention according to Senior Alert follows a preventive care process of four steps, including risk assessment, analysis of the causes of risk, to determine and perform appropriate actions, and finally, to evaluate the care given.

Aim: The overall aims of this thesis were to investigate how the preventive care process in Senior Alert functions as a tool for preventive work among older persons living in nursing homes, and to investigate the results of risk assessments and actions.

Design: The thesis is based on three longitudinal quantitative studies (I, III, and IV) and one qualitative study (II). In Studies I and III, process- and patient results were compared among different groups of nursing home residents, with a follow-up time of 6 months. In Study IV, associations between the assessment instruments and the outcomes of weight loss, falls and pressure ulcers were investigated. The qualitative study (II) was based on focus group interviews with healthcare professionals and was analyzed using content analysis.

Results: The residents included in the registry during the later years (2013-2014) had a higher proportion of registered preventive actions in the three areas, and were followed up more frequently regarding weight and new assessments than residents included during the earlier years (2010-2012). Nevertheless, regardless of risk, only 30% were reassessed, and 44% of the residents at risk for malnutrition were followed up for body weight within 6 months. No difference in weight change was found between a group of residents included in Senior Alert and a second group receiving ‘care as usual’. Generally, the mobility variables in the risk assessment instruments had the strongest associations with the tested outcomes of weight loss, fall and pressure ulcers, albeit in different ways. Healthcare professionals described that Senior Alert stimulated better teamwork while at the same time they experienced the increased documentation and time constraints as aggravating circumstances. They also described a lack of reliability of the assessment instruments in that they overrated the risks compared to their own clinical judgement. Healthcare professional’s knowledge about the evaluation part of the process was low.

Conclusion: The evaluation and follow-up step of the preventive care process was not sufficiently applied. This was expressed by the participants in the focus groups and was also reflected in registry data by the varying time to follow-up and the poor event registration. As a consequence, the sample to measure outcomes within 6 months became small. Therefore, larger samples are needed to study longitudinal outcomes, if a fixed system-mandatory time point for follow-up is not implemented. A committed leadership is important to improve the preventive work and to stimulate follow-up of results.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2018. , p. 72
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 091
Keywords [en]
Nursing homes, prevention, malnutrition, falls, pressure ulcers, patient safety, assessments, quality registers, quality of care
National Category
Gerontology, specialising in Medical and Health Sciences
Identifiers
URN: urn:nbn:se:hj:diva-39406ISBN: 978-91-85835-90-4 (print)OAI: oai:DiVA.org:hj-39406DiVA, id: diva2:1205505
Public defence
2018-06-15, Forum Humanum, chool of Health and Welfare, önköping, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2018-05-14Bibliographically approved
List of papers
1. Effects of a preventive care process for prevention of malnutrition, falls and pressure ulcers among older people living in Swedish nursing homes
Open this publication in new window or tab >>Effects of a preventive care process for prevention of malnutrition, falls and pressure ulcers among older people living in Swedish nursing homes
(English)Manuscript (preprint) (Other academic)
National Category
Gerontology, specialising in Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-39405 (URN)
Note

Included in thesis in its submitted form.

Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2018-05-14
2. Prevention of falls, malnutrition and pressure ulcers among older persons: nursing staff’s experiences of a structured preventive care process
Open this publication in new window or tab >>Prevention of falls, malnutrition and pressure ulcers among older persons: nursing staff’s experiences of a structured preventive care process
2017 (English)In: Health & Social Care in the Community, ISSN 0966-0410, E-ISSN 1365-2524, Vol. 25, no 3, p. 1011-1020Article in journal (Refereed) Published
Abstract [en]

A structured and systematic care process for preventive work, aimed to reduce falls, pressure ulcers and malnutrition among older people, has been developed in Sweden. The process involves risk assessment, teambased interventions and evaluation of results. Since development, this structured work process has become web-based and has been implemented in a national quality registry called ‘Senior Alert’ and used countrywide. The aim of this study was to describe nursing staff’s experience of preventive work by using the structured preventive care process as outlined by Senior Alert. Eight focus group interviews were conducted during 2015 including staff from nursing homes and homebased nursing care in three municipalities. The interview material was subjected to qualitative content analysis. In this study, both positive and negative opinions were expressed about the process. The systematic and structured work flow seemed to only partly facilitate care providers to improve care quality by making better clinical assessments, performing team-based planned interventions and learning from results. Participants described lack of reliability in the assessments and varying opinions about the structure. Furthermore, organisational structures limited the preventive work.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keywords
falls prevention, home care, nursing care of older people, nursing homes, nutrition, risk assessment
National Category
Gerontology, specialising in Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-32100 (URN)10.1111/hsc.12400 (DOI)000400367700019 ()27730698 (PubMedID)2-s2.0-84995426811 (Scopus ID)
Available from: 2016-10-27 Created: 2016-10-27 Last updated: 2018-05-14Bibliographically approved
3. The effect of a structured nutritional care programme in Swedish nursing homes
Open this publication in new window or tab >>The effect of a structured nutritional care programme in Swedish nursing homes
2017 (English)In: The Journal of Nursing Home Research Sciences, ISSN 2496-0799, no 3, p. 64-70Article in journal (Refereed) Published
Abstract [en]

Objective: Malnutrition with consequent weight loss is a well-known problem among older frail persons living in nursing homes. The objective of this study was to examine the effect of a structured preventive care programme including an individualized nutrition plan. Design: A retrospective study, based on already collected data from two different nursing home populations. One population constituted a group of nursing home residents receiving the nutritional care programme (ncp-group), including individually performed nutritions actions. The ncp-group (N=135) was registered in the national quality registry Senior Alert (SA), a platform for following of this preventive care process. The other population constituted a group of nursing home residents receiving “care as usual” (n=186), ie not using the nutritional care programme, collected from the study SHADES. The two populations was compared by a quasi-experimental pre-posttest design with a follow-up time of 5–7 months.

Settings: Nursing homes in Sweden.

Participants: Two populations of nursing home residents assessed to be at risk for malnutrition, or to be already malnourished, according to the short form of the Mini Nutritional Assessment (MNA-SF).

Intervention: The ncp-group received a structured, individually targeted care programme including risk assessments, team-based decisions on actions, and evaluation of results.

Measurements: Body weight and weight changes were monitored over time. Additionally, nutritional status was described using the MNA-SF scores and body mass index (BMI).

Results: No statistically significant differences in body weight, MNA-SF or BMI between the groups were found at follow-up. However, within-group analyses in the group followed in SA showed improved outcomes.

Conclusion: This suggest small differences in nutritional care provided at nursing homes working with SA and “care as usual” in nursing homes, not working with SA.

Place, publisher, year, edition, pages
Serdi, 2017
National Category
Gerontology, specialising in Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-35612 (URN)10.14283/jnhrs.2017.11 (DOI)
Available from: 2017-05-29 Created: 2017-05-29 Last updated: 2018-05-14Bibliographically approved
4. Factors related to falls, weight-loss and pressure ulcers – more insight in risk assessment among nursing home residents
Open this publication in new window or tab >>Factors related to falls, weight-loss and pressure ulcers – more insight in risk assessment among nursing home residents
Show others...
2016 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 25, no 7-8, p. 940-950Article in journal (Refereed) Published
Abstract [en]

Aims and objectives

To describe how the included items in three different scales, Downton Fall Risk Index, the short form of Mini Nutritional Assessment and the Modified Norton Scale are associated to severe outcomes as falls, weight loss and pressure ulcers.

Background

Falls, malnutrition and pressure ulcers are common adverse events among nursing home residents and risk scoring are common preventive activities, mainly focusing on single risks. In Sweden the three scales are routinely used together with the purpose to improve the quality of prevention.

Design

Longitudinal quantitative study.

Methods

Descriptive analyses and Cox regression analyses.

Results

Only 4% scored no risk for any of these serious events. Longitudinal risk scoring showed significant impaired mean scores indicating increased risks. This confirms the complexity of this population's status of general condition. There were no statistical significant differences between residents categorised at risk or not regarding events. Physical activity increased falls, but decreased pressure ulcers. For weight loss, cognitive decline and the status of general health were most important.

Conclusions

Risk tendencies for falls, malnutrition and pressure ulcers are high in nursing homes, and when measure them at the same time the majority will have several of these risks. Items assessing mobility or items affecting mobility were of most importance. Care processes can always be improved and this study can add to the topic.

Relevance to clinical practice

A more comprehensive view is needed and prevention can not only be based on total scores. Mobility is an important factor for falls and pressure ulcers, both as a risk factor and a protective factor. This involves a challenge for care – to keep the inmates physical active and at the same time prevent falls.

Keywords
falls; frail older; malnutrition; nursing homes; pressure ulcers; risk assessment
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-28666 (URN)10.1111/jocn.13154 (DOI)000372928900006 ()26813994 (PubMedID)2-s2.0-84958225443 (Scopus ID)
Available from: 2015-12-17 Created: 2015-12-17 Last updated: 2018-05-14Bibliographically approved

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