Elisabeth Gjerberg

Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials.

BackgroundStudies have shown that residents in nursing homes often are exposed to inappropriate medication. Particular concern has been raised about the consumption of psychoactive drugs, which are commonly prescribed for nursing home residents suffering from dementia. This review is an update of a Norwegian systematic review commissioned by the Norwegian Directorate of Health. The purpose of the review was to identify and summarise the effect of interventions aimed at reducing potentially inappropriate use or prescribing of drugs in nursing homes.MethodsWe searched for systematic reviews and randomised controlled trials in the Cochrane Library, MEDLINE, EMBASE, ISI Web of Knowledge, DARE and HTA, with the last update in April 2010. Two of the authors independently screened titles and abstracts for inclusion or exclusion. Data on interventions, participants, comparison intervention, and outcomes were extracted from the included studies. Risk of bias and quality of evidence were assessed using the Cochrane Risk of Bias Table and GRADE, respectively. Outcomes assessed were use of or prescribing of drugs (primary) and the health-related outcomes falls, physical limitation, hospitalisation and mortality (secondary).ResultsDue to heterogeneity in interventions and outcomes, we employed a narrative approach. Twenty randomised controlled trials were included from 1631 evaluated references. Ten studies tested different kinds of educational interventions while seven studies tested medication reviews by pharmacists. Only one study was found for each of the interventions geriatric care teams, early psychiatric intervening or activities for the residents combined with education of health care personnel. Several reviews were identified, but these either concerned elderly in general or did not satisfy all the requirements for systematic reviews.ConclusionsInterventions using educational outreach, on-site education given alone or as part of an intervention package and pharmacist medication review may under certain circumstances reduce inappropriate drug use, but the evidence is of low quality. Due to poor quality of the evidence, no conclusions may be drawn about the effect of the other three interventions on drug use, or of either intervention on health-related outcomes.

Women doctors in Norway: the challenging balance between career and family life.

In most Western countries, women doctors are still underrepresented in the higher positions in the medical hierarchy and in the most prestigious specialities. A crucial question is whether family responsibilities affect female and male career differently. The article examines how Norwegian physicians balance their work and family responsibilities and demonstrates differences in the way doctors combine work and family obligations, between women and compared with men. Among women doctors, the probability of becoming a specialist decreased with an increasing number of children. Moreover, postponing the birth of the first child increased the probability of completing hospital specialities. Although more women than men work part-time, this was the case only for a small proportion of women doctors. Transition from full-time to part-time work is primarily an accommodating strategy to family responsibilities, however strongly influenced by variations in the opportunity structure of different specialities. The findings further demonstrate that being married to another doctor had a positive impact on the career, especially for women doctors.

Staff and family relationships in end-of-life nursing home care:

This article examines the involvement of residents and their relatives in end-of-life decisions and care in Norwegian nursing homes. It also explores challenges in these staff—family relationships. The article is based on a nationwide survey examining Norwegian nursing homes’ end-of-life care at ward level. Only a minority of the participant Norwegian nursing home wards ‘usually’ explore residents’ preferences for care and treatment at the end of their life, and few have written procedures on the involvement of family caregivers when their relative is in the terminal phase. According to the respondents, most staff seem to comfort relatives well. However, several challenges were described. The study revealed a need for better procedures in the involvement of residents and relatives in nursing home end-of-life care. The findings emphasize a need to strengthen both the involvement of nursing home physicians and staff communication skills.

A review of the implementation and research strategies of advance care planning in nursing homes.

BackgroundNursing home (NH) patients have complex health problems, disabilities and needs for Advance Care Planning (ACP). The implementation of ACP in NHs is a neglected research topic, yet it may optimize the intervention efficacy, or provide explanations for low efficacy. This scoping review investigates methods, design and outcomes and the implementation of ACP (i.e., themes and guiding questions, setting, facilitators, implementers, and promoters/barriers).MethodsA systematic search using ACP MESH terms and keywords was conducted in CINAHL, Medline, PsychINFO, Embase and Cochrane libraries. We excluded studies on home-dwelling and hospital patients, including only specific diagnoses and/or chart-based interventions without conversations.ResultsSixteen papers were included. There were large variations in definitions and content of ACP, study design, implementation strategies and outcomes. Often, the ACP intervention or implementation processes were not described in detail. Few studies included patients lacking decision-making capacity, despite the fact that this group is significantly present in most NHs. The chief ACP implementation strategy was education of staff. Among others, ACP improved documentation of and adherence to preferences. Important implementation barriers were non-attending NH physicians, legal challenges and reluctance to participate among personnel and relatives.ConclusionACP intervention studies in NHs are few and heterogeneous. Variation in ACP definitions may be related to cultural and legal differences. This variation, along with sparse information about procedures, makes it difficult to collate and compare research results. Essential implementation considerations relate to the involvement and education of nurses, physicians and leaders.

End-of-life care communications and shared decision-making in Norwegian nursing homes - experiences and perspectives of patients and relatives

BackgroundInvolving nursing home patients and their relatives in end-of-life care conversations and treatment decisions has recently gained increased importance in several Western countries. However, there is little knowledge about how the patients themselves and their next-of-kin look upon involvement in end-of-life care decisions. The purpose of this paper is to explore nursing home patients’ and next-of-kin’s experiences with- and perspectives on end-of-life care conversations, information and shared decision-making.MethodsThe study has a qualitative and explorative design, based on a combination of individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 33 relatives. The data was analysed applying a “bricolage” approach”. Participation was based on informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics.ResultsFew patients and relatives had participated in conversations about end-of-life care. Most relatives wanted such conversations, while the patients’ opinions varied. With some exceptions, patients and relatives wanted to be informed about the patient’s health condition. The majority wanted to be involved in the decision-making process, but leave the final decisions to the health professionals. Among the patients, the opinion varied; some patients wanted to leave the decisions more or less completely to the nursing home staff. Conversations about end-of-life care issues are emotionally challenging, and very few patients had discussed these questions with their family. The relatives’ opinions of the patient’s preferences were mainly based on assumptions; they had seldom talked about this explicitly. Both patients and relatives wanted the staff to raise these questions.ConclusionNursing home staff should initiate conversations about preferences for end-of-life care, assisting patients and relatives in talking about these issues, while at the same time being sensitive to the diversity in opinions and the timing for such conversations. As the popularity of advance care planning increases in many Western countries, discussions of patients’ and relatives’ perspectives will be of great interest to a broader audience.

How to avoid and prevent coercion in nursing homes: A qualitative study

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence.

Unitary management, multiple practices?

PURPOSE The purpose of this paper is to explore whether unitary managers with different professional backgrounds carry out and reflect differently upon their roles as unitary managers. DESIGN/METHODOLOGY/APPROACH This paper presents findings from two different studies, comprising both data from qualitative interviews and a nationwide survey. FINDINGS Doctors and nurses in many respects perform their roles as unitary managers differently. They hold the same position but carry out their roles differently. Doctors are very committed to clinical tasks and stress to a great extent that clinical tasks should be integrated in management at the department level. The opposite is true for the nurses, where leadership first and foremost should be understood as management. PRACTICAL IMPLICATIONS Even though doctors and nurses are in the same position they manage differently, being committed to different tasks within the unit. This is not the intention of the reform. However, the question is thus, will this have (severe) consequences for the organization? Or does it represent a healthy diversity in the health organisation? ORIGINALITY/VALUE This paper explores whether different professions carry out their managerial tasks differently and what practical implications this could have. It brings to the fore substantial empirical data on how one of the major reforms in Norwegian (and international) health care has been adopted and carried out by major professional groups.

Ethical challenges when using coercion in mental healthcare A systematic literature review

Background: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. Methods: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver Protocol. Results: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. Conclusion: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress.

Ethics support in community care makes a difference for practice.

Background: Through the Norwegian ethics project, ethics activities have been implemented in the health and care sector in more than 200 municipalities. Objectives: To study outcomes of the ethics activities and examine which factors promote and inhibit significance and sustainability of the activities. Research design: Two online questionnaires about the municipal ethics activities. Participants and research context: A total of 137 municipal contact persons for the ethics project answered the first survey (55% response rate), whereas 217 ethics facilitators responded to the second survey (33% response rate). Ethical considerations: Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services. Findings: Around half of the respondents found the ethics project to have been highly significant for daily professional practice. Outcomes include better handling of ethical challenges, better employee cooperation, better service quality, and better relations to patients and next of kin. Factors associated with sustainability and/or significance of the activities were sufficient support from stakeholders, sufficient available time, and ethics facilitators having sufficient knowledge and skills in ethics and access to supervision. Discussion: This study shows that ethics initiatives can be both sustainable and significant for practice. There is a need to create regional or national structures for follow-up and develop more comprehensive ethics training for ethics facilitators. Conclusion: It is both possible and potentially important to implement clinical ethics support activities in community health and care services systematically on a large scale. Future ethics initiatives in the community sector should be designed in light of documented promoting and inhibiting factors.

Forberedende samtaler i norske sykehjem

BACKGROUND Nursing home patients are often frail and have a number of chronic conditions. Increased risk of critical events, hospitalisations and death indicates the need for dialogue with patients and their next of kin about the future, how to agree on sound decisions and what should happen if the patient’s health condition deteriorates. Previous studies have shown that only a minority of nursing homes practise this type of advance care planning. MATERIAL AND METHOD In early summer 2014, a questionnaire was sent to all Norwegian nursing homes, containing questions about the prevalence and content of advance care planning. RESULTS A total of 57 % (486 nursing homes) responded to the survey. Approximately two-thirds reported that they «always’ or «usually’ undertook advance care planning and around one-third of them had written guidelines. The conversations primarily took place when the patient’s health condition deteriorated, when the patient entered the last phase of life, or in connection with the admission interview. Hospitalisation, pain relief and cardiopulmonary resuscitation (CPR) were the most frequent topics. Next of kin and the nursing home doctor participated most often in the interviews, while the patients participated more seldom. INTERPRETATION There were large variations between the nursing homes with regard to advance care planning. This may partly be explained by the lack of national guidelines, and partly by the fact that this is a relatively recent discussion in Norway. The infrequent participation by patients in the conversations is probably associated with the fact that among them a high proportion are cognitively impaired, the availability of medical resources is low, and a culture of patient participation is insufficiently developed.