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RESEARCH ARTICLE
A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes Lee-Fay Low1*, Jennifer Fletcher1, Belinda Goodenough2,3, Yun-Hee Jeon4, Christopher Etherton-Beer5, Margaret MacAndrew6, Elizabeth Beattie6
1 Faculty of Health Sciences, University of Sydney, New South Wales, Australia, 2 Dementia Collaborative Research Centre: Assessment and Better Care, University of New South Wales, New SouthWales, Australia, 3 Dementia Study Training Centre, University of Wollongong, New SouthWales, Australia, 4 Sydney Nursing School, University of Sydney, New South Wales, Australia, 5 School of Medicine and Pharmacology Royal Perth Hospital Unit, The University of Western Australia, Perth, Western Australia, Australia, 6 Dementia Collaborative Research Centre: Carers and Consumers, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
Abstract
Background
We systematically reviewed interventions that attempted to change staff practice to improve
long-term care resident outcomes.
Methods
Studies met criteria if they used a control group, included 6 or more nursing home units and
quantitatively assessed staff behavior or resident outcomes. Intervention components were
coded as including education material, training, audit and feedback, monitoring, champions,
team meetings, policy or procedures and organizational restructure.
Results
Sixty-three unique studies were broadly grouped according to clinical domain—oral health
(3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home
acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies),
reduction of physical restraints (3 studies), management of behavioral and psychological
symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality
improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single
intervention component, combination of, or increased number of components was associ-
ated with greater likelihood of positive outcomes. Studies with positive outcomes for resi-
dents also tended to change staff behavior, however changing staff behavior did not
necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 1 / 60
OPEN ACCESS
Citation: Low L-F, Fletcher J, Goodenough B, Jeon Y-H, Etherton-Beer C, MacAndrew M, et al. (2015) A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes. PLoS ONE 10(11): e0140711. doi:10.1371/journal.pone.0140711
Editor: Terence J Quinn, University of Glasgow, UNITED KINGDOM
Received: June 28, 2015
Accepted: September 28, 2015
Published: November 11, 2015
Copyright: © 2015 Low et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability Statement: All relevant data are within the paper and its Supporting Information files.
Funding: This work was supported by the Dementia Collaborative Research Centres at University of New South Wales, Queensland University of Technology, and Australian National University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
care, physical restraints) were more likely to produce positive outcomes than those requir-
ing global practice changes (e.g. care philosophy). Studies using intervention theories were
more likely to be successful. Program logic was rarely articulated, so it was often unclear
whether there was a coherent connection between the intervention components and mea-
sured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high work-
load, attitudes) or organizational factors (e.g. funding, resources, logistics).
Conclusion
Changing staff practice in nursing homes is possible but complex. Interventionists should
consider barriers and feasibility of program components to impact on each intended outcome.
Introduction There are multiple high quality trials and systematic reviews providing evidence for good prac- tice in long-term residential institutions for older people, referred to in many countries as nursing homes and, also known as long-term care homes, homes for the aged, rest homes, resi- dential aged care facilities [1–3]. However, there is often an unreasonable lag between research evidence and practice change [4]. Further, attempts at knowledge translation may not be suc- cessful. For instance, after over a decade of extensive promotion of person-centered cultures of care, culture change efforts are becoming widespread in American nursing homes, but it is not clear whether implementation efforts are changing staff and organizational practices, nor whether these practice changes are improving quality of care or resident outcomes [5].
Barriers to implementation have been identified such as cost, senior leadership resistance, low-innovation culture, low staff education, and high staff turnover [6]. Success factors for implementation include contextualizing the practice change, adequate resourcing, and demon- strating connections between practice change and outcomes [7].
Implementation science has an important role in bridging the gap between research and practice within health services [8]. There is a vast body of research that focuses on changing the practice of individual clinicians such as general practitioners [9,10], allied health profes- sionals [11] and nurses [12]. There is less information about how to change the behavior of teams of staff in organizations such as hospitals, health services, and nursing homes, despite evidence suggesting that organizational culture contributes to health care performance [7,13].
Previous systematic reviews have examined whether specific interventions can improve related resident outcomes. For example, reviews have examined the effect of training nursing home staff in dementia care and management of behavioral and psychological symptoms, and the effectiveness of quality systems in improving nursing home quality of care and culture change [14–16] [17]. These reviews described the literature as being of relatively low quality with high possibility of methodological bias. The review of staff training concluded that exten- sive interventions with ongoing support successfully demonstrated practice change, but there was little evidence for simpler training without reinforcement [15]. The review of quality sys- tems found that results were inconsistent but that there was some evidence that specific train- ing and guidelines can influence resident outcomes [14]. These reviews focused on efficacy of interventions with less emphasis on identifying which interventions or components of inter- ventions contributed to changing practice.
Implementation scientists are increasingly more interested in why practice change interven- tions succeed or fail and have called for greater use of theory in planning and understanding
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interventions [18]. Program logic models have also been used to describe how intervention components relate to each other and outcomes [19,20]. Articulating its logic to those delivering and receiving it may also help maintain its integrity during delivery [21].
This purposefully broad review aims to identify interventions or intervention components to change staff care practices in order to improve resident outcomes.
Objectives
1. To systematically identify and describe studies that have investigated the effects of interven- tions to change staff practice or care approaches in order to improve resident outcomes in nursing homes;
2. To identify interventions or intervention components which lead to successful staff practice or care approach change in nursing homes;
3. To identify potential barriers and enablers to staff practice or care approach change in nurs- ing homes.
Methods
Literature search The search strategy was developed following consultation with an information services univer- sity librarian using an iterative process of preliminary searches testing search terms and incor- porating new search terms as relevant papers were identified. In addition to our own search terms, our strategy included all relevant MeSH (Medical Subject Heading) terms. Using lan- guage (English) and date (1990–5th December, 2013) restrictions and searching titles, key- words and abstracts, we systematically searched the following electronic databases: Ovid MEDLINE, PubMED (from 2012 onwards as up to 2012 would be covered in MEDLINE), Sco- pus (Health sciences and social sciences), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, and Database of Abstracts of Reviews of Effects. Reference lists of included papers and related reviews were hand searched. The “grey literature” was not spe- cifically searched. Search results were combined using the electronic referencing system End- note, and duplicate citations were removed.
General search strategy: (“nursing home?” or “long?term care” or “residential care” or “home? for the aged” or “residential facilit�” or “residential aged care”) And (“implementation” or “knowledge translation” or “knowledge transfer�” or “culture change” or “adoption” or “quality improvement” or “dissemination” or “diffusion” or “practice change” or “training” or “champion?” or “opinion leader?” or “educational outreach” or “case conference” or “audit and feedback” or “organisational change” or “organizational change” or “”professional develop- ment” or “supervision” or “leadership” or “health plan implementation” or “traditional medical research” or “organi?ational culture” or “organi?ational innovation”) And (“staff” or “carer?” or “management” or “nurse?” or “careworker?” or “manager?” or “personal support worker?” or “personnel” or “caregivers” or “health personnel”).
Study selection Two researchers (LFL and JF) independently screened the titles and abstracts and determined whether a study met inclusion criteria. The full text of all articles classified as meeting or
Review of Staff Care Practice Interventions
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possibly meeting inclusion criteria were retrieved and evaluated. Disagreements were resolved by discussion between the two reviewers.
Inclusion criteria Setting. Studies were conducted in nursing homes, i.e. facilities catering for permanent
residential care of older people including providing housekeeping, personal care, meals, activi- ties and nursing home. This is distinct from medical facilities primarily delivering medical or palliative treatments, and retirement villages where residents attend to their own personal care and housekeeping.
Study design. Randomized controlled trials and quasi-experimental controlled trials were included as recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group [22].
Sample size. Only studies with 3 or more sites in each group were included. EPOC recom- mends only including clustered trials with at least two intervention sites and two control sites. The rationale was that in studies with only one intervention or one control site, the interven- tion is completely confounded by site characteristics making it difficult to attribute any observed differences to the intervention rather than to other site-specific variables. We extended this requirement to at least three intervention and three control sites in order to reduce the possibility of site-specific confounding and increase generalisability. A study with fewer than 6 sites is unlikely to be statistically powered to take into account site clustering in the analysis. Studies were not restricted based on the number of participants within each site.
Interventions. Aimed at changing the care practices of staff for the benefit of the residents. The intervention or components of the intervention were not delivered directly to residents by the research team or other external clinicians.
Outcome measures. Empirically assessed change in at least one of the following outcomes: change in staff behavior (but not just attitudes or knowledge), change in other staff outcomes (e.g. staff turnover, absenteeism or stress) change in resident clinical outcomes (but not just sat- isfaction with care). We did not include studies in which the only outcomes were staff attitudes or knowledge as changing knowledge does not necessitate change in behavior [23,24], or those in which the only resident outcome was satisfaction with care as these represent overly an opti- mistic view of care [25].
Data extraction Study data were extracted using standard forms that were based on forms developed by the Cochrane Effective Practice and Organisation of Care Group [22]. Extraction was conducted by one researcher (LFL or JF) and checked by a second researcher (JF, LFL or MM). Study authors were contacted for additional information as required.
Categorising of intervention components. We categorized interventions via their differ- ent components (one intervention could have many components) according to categories and definitions adapted from the Cochrane EPOC group [22]. These were:
• Educational material: written material or a DVD/video or online website
• Training: delivered in person to staff
• Reminders: e.g. postcards, posters—designed to prompt practice
• Audit and feedback: formal monitoring of the performance of staff or the organization which is fed back to them
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• Mentoring or support: supervision/consultation/mentoring of staff in teams or individually to support practice change
• Champions: individuals or teams responsible for driving change within the site
• Team meetings: Consensus/multidisciplinary team meetings to discuss issues relating to the clinical domain of practice
• Policy/procedure: a new policy or procedure introduced into the organization (e.g. reporting tool, assessment tool, guideline)
• Organizational restructure: change to the responsibilities of staff or the way care is organized
Barriers and enablers. Information on barriers and enablers were extracted either where reported as part of a process evaluation, or as part of the discussion section.
Theoretical models of behavior change. We collected information on theoretical models described as underpinning behavior change strategies. These were differentiated from theoreti- cal models guiding the hypothesized relationship between the intervention and the resident outcomes.
Program logic models. Program logic models attempt to identify key program compo- nents and outcomes and depict how these elements are expected to relate to each other [26]. Program logic models help researchers identify weaknesses in hypothesized causal relation- ships between intervention components and desired outcomes. Program logic models are also useful in planning evaluations [20].
Where the program logic was described in a figure or text, this was extracted. Otherwise researchers drew a program logic model based on their interpretation of the description of the study (see examples in Fig 1). We used the program logic model to help us categorize outcomes into staff behavior (behavior that is directly targeted by the intervention), staff indirect out- comes (staff characteristics and behaviors not directly targeted by the intervention such as turnover and stress) and resident outcomes (both directly targeted and indirectly assumed to be impacted by the intervention). We examined these models for weaknesses in the relation- ships between the intervention and outcomes, as well as staff behaviour changes, or resident outcomes that were implicit but not measured in the evaluation.
Risk of bias. One reviewer assessed the risk of bias of included studies as outlined in the Cochrane Risk of Bias for EPOC reviews tool [22] that considers selection bias, performance bias, detection bias, attrition bias, reporting bias and other bias. This risk assessment was checked by a second reviewer and disagreements were resolved through discussion.
Data analysis and synthesis The purpose of this review was not to evaluate the efficacy of interventions. Within each clini- cal domains there were no studies with similar intervention components and outcome mea- sures which could be considered for combination in meta-analysis. Hence meta-analyses were not undertaken. Results are presented in narrative form.
Studies were according to the clinical domains in which practice change was targeted. Clini- cal domains were then ordered according to our subjective judgement of the complexity and difficulty of the behavior change required and are presented in that order from Tables 1 to 12. There is no model or framework for classifying how complex or difficult a behaviour is to change, particularly in an organisational context, however this is intuitively an important factor to consider in this review. In ranking domains by difficulty of behavior change, we considered whether there were salient cues for the new behaviors with cues making change easier, whether past habitual behavior had to be relearnt as this is more difficult than learning a new behavior,
Review of Staff Care Practice Interventions
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whether the practice change required coordination and cooperation between multiple staff members which we ranked as more difficult than when cooperation was not required, and the frequency in which the behaviors occur where more frequent behaviors were harder to change [27].
Results The search produced 7572 unique articles, we obtained 211 full text articles and 77 articles were judged to meet inclusion criteria. Two articles were additionally obtained by hand search- ing reference lists, leading to a total of 79 included articles relating to 63 unique studies. (See Fig 2)
Oral health Three studies examined the effect of interventions with staff on the oral health of residents (see Table 1) [28–30]. Two of these were by the same group and tested almost identical interventions
Fig 1. Program logic drawn for Schrijnemaekers et al (2002) and Meyer (2005).Measured outcomes shown in bold.
doi:10.1371/journal.pone.0140711.g001
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Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 7 / 60
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Review of Staff Care Practice Interventions
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(C on
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T ab
le 2.
(C on
tin ue
d )
F ir st
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ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff
d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
IG 2:
92 9 re s,
33 1 st af f
+ +
+ IG
2: A s fo r IG
1 ex
ce pt
gl ov
es w er e po
w de
rle ss
an d no
sp ec
ifi c
fe ed
ba ck
.
R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;r es
,r es
id en
ts .
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 02
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 10 / 60
T ab
le 3.
N u tr iti o n .
F ir st
au th o r, ye
ar S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
W es
te rg re n,
20 09
;2 01
0 N R C T ,
va ria
bl e
du ra tio
n, 65
si te s,
C G :
10 84
re s;
IG 1:
17 5 re s;
U su
al ca
re +
+ +
+ +
IG 1 = po
lic y
do cu
m en
t. IG
1 ha
d so
m e
sh or ta
nd lo ng
te rm
po si tiv e
ef fe ct s an
d IG
2 ha
d so
m e
po si tiv e sh
or t
te rm
ef fe ct s
on nu
tr iti on
al ca
re .
N o gr ou
p by
tim e
di ffe
re nc
es be
tw ee
n IG
1, IG
2 or
C G
on un
de rn ut rit io n
ris k an
d ov
er w ei gh
t. N o
ch an
ge in
th e
nu m be
r of
re si de
nt s w ith
lo w or
hi gh
B M Ii n th e C G ,
bu ta
si gn
ifi ca
nt de
cr ea
se in
pe op
le w ith
lo w B M Ii n
IG 2.
T he
re w as
a si gn
ifi ca
nt in cr ea
se in
re si de
nt s w ith
hi gh
B M Ii n th e
IG 1.
IG 2:
46 7 re s
+ +
+ +
+ IG
2 = st ud
y ci rc le s.
S tu dy
ci rc le s
in cl ud
in g
ki tc he
n an
d nu
rs in g st af f
m et .C
irc le s
cr ea
te d a
st ru ct ur ed
ch an
ge pl an
. S tu dy
ci rc le
le ad
er tr ai ne
d.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 11 / 60
T ab
le 3.
(C on
tin ue
d )
F ir st
au th o r, ye
ar S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
G as
ki ll,
20 09
C lu st er
ra nd
om iz ed
R C T ,2
6 w ks
, 8 si te s,
IG :
13 4 re s;
C G :
14 5 re s
po st er s
+ +
+ +
T ra in -t he
- tr ai ne
r. R es
ea rc he
rs tr ai ne
d nu
tr iti on
co or di na
to rs
fo r ea
ch fa ci lit y;
nu tr iti on
co or di na
to rs
tr ai ne
d fa ci lit y
st af fu
si ng
su pp
lie d
m at er ia ls
an d
w er e
re sp
on si bl e
w ith
lia is in g
w ith
nu rs in g,
ki tc he
n an
d do
m es
tic st af f, an
d fa ci lit at in g in -
se rv ic e
se ss
io ns
ab ou
tt he
nu tr iti on
st ra te gi es
.
C om
pa re d to
C G ,I G
w as
m or e lik el y to
re ce
iv e hi gh
en er gy
,h ig h
pr ot ei n di et
an d le ss
lik el y
to ha
ve pu
re ed
m ea
ls or
th ic ke
ne d
fl ui ds
or re qu
ire as
si st an
ce fe ed
in g.
N o
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e on
co ns
ul ta tio
ns w ith
di et ic ia n
or sp
ee ch
pa th ol og
is t.
C om
pa re d to
C G ,I G
w er e
m or e lik el y to
m ai nt ai n or
im pr ov
e th ei r
no ur is hm
en t
ra tin
g. N o
si gn
ifi ca
nt di ffe
re nc
es on
ris k of
be in g
m al no
ur is he
d.
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s;
B M I, B od
y M as
s In de
x.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 03
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 12 / 60
T ab
le 4.
N u rs in g h o m e ac
q u ir ed
p n eu
m o n ia
(N H A P )p
re ve
n ti o n an
d m an
ag em
en t.
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
H ut t, 20
10 ,
20 11
; Li nn
eb ur ,
20 11
N R C T ,1
04 w ks
,1 6
si te s,
C G :
54 9 re s;
IG :
57 4 re s
U su
al ca
re +
+ +
+ $2
00 0 pe
r an
nu m
pa ym
en tp
er ho
m e,
m ee
tin gs
w ith
D O N an
d ad
m in is tr at or
of ea
ch fa ci lit y to
pr es
en tN
H A P
gu id el in es
,a nd
di sc
us s
ba rr ie rs .N
ur se
ch am
pi on
ed in te rv en
tio n
an d
en co
ur ag
ed va
cc in at io n fo r
st af fa
nd re si de
nt s.
S ta ff
tr ai ni ng
on va
cc in at io n,
va cc
in at io ns
av ai la bl e at
in -
se rv ic es
.
N o di ffe
re nc
es in
gu id el in e
ad he
re nc
e fo r
tr ea
tin g
re si de
nt s w ith
N H A P ov
er in te rv en
tio n.
C om
pa re d to
C G ,g
re at er
im pr ov
em en
t in
IG di re ct
ca re
st af f
in fl ue
nz a
va cc
in at io n
an d re si de
nt pn
eu m oc
oc ca
l va
cc in at io n
ra te s.
N o
di ffe
re nc
es in
re si de
nt in fl ue
nz a
va cc
in at io n
ra te s.
N o di ffe
re nc
es in ho
sp ita
liz at io n
ra te s or
m or ta lit y ra te s
ov er
in te rv en
tio n
pe rio
d. N o
di ffe
re nc
e in
m or ta lit y ra te
ov er
3 ye
ar s.
N au
gh to n,
20 01
C lu st er
ra nd
om iz ed
R C T ,1
w k,
52 w ks
fo llo w -u p,
10 si te s,
35 0
ep is od
es of
N H A P
ac ro ss
gr ou
ps
P ne
um on
ia gu
id el in es
pr es
en te d
to ph ys
ic ia ns
on ly
+ +
+ +
N ur si ng
ho m e
ac qu
ire d
pn eu
m on
ia gu
id el in es
pr es
en te d to
ph ys
ic ia ns
an d
nu rs e
pr ac
tit io ne
rs .
S ta ff tr ai ne
d. N ur si ng
st af f
pr om
pt ed
to id en
tif y ba
rr ie rs
to im pl em
en ta tio
n an
d de
ve lo p
st ra te gi es
fo r
de al in g w ith
th em
. La
m in at ed
po ck
et ca
rd s
fo r al lR
N s an
d LP
N s.
N o di ffe
re nc
es be
tw ee
n IG
an d C G — bo
th in cr ea
se d on
pa re nt er al
an tib
io tic s bu
t no
to ra l
an tib
io tic
us e.
In di re ct
ou tc om
es :-
C om
pa re d to
C G ,I G
ha d no
di ffe
re nc
es in
ho sp
ita liz at io n
or 30
-d ay
m or ta lit y.
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s;
N H A P ,n
ur si ng
ho m e ac
qu ire
d pn
eu m on
ia ,R
N s,
re gi st er ed
nu rs es
;L P N s,
lic en
se d pr ac
tic al
nu rs es
.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 04
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 13 / 60
T ab
le 5.
D ep
re ss
io n .
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff
d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
Le on
tje va
s, 20
13 S te pp
ed w ed
ge cl us
te r
ra nd
om iz ed
R C T ,2
6 w ks
,f ol lo w -
up va
rie d
0– 16
m on
th s,
33 si te s,
C G
an d IG
nu m be
r va
rie d
U su
al ca
re +
+ +
M ul ti-
di sc ip lin ar y ca
re pr og
ra m
th at
pr es
cr ib ed
pa th w ay
s fo r
co lla bo
ra tiv e
tr ea
tm en
t: st ru ct ur ed
as se
ss m en
t, 2
st ep
sc re en
in g
an d di ag
no st ic
pr oc
ed ur e.
M ul tid
is ci pl in ar y
tr ea
tm en
t. M on
ito rin
g of
tr ea
tm en
t ef fe ct s.
In fo rm
at io n an
d pr ac
tic al
to ol s
w er e pr ov
id ed
, st af ft ra in ed
on de
pr es
si on
an d
th e pr og
ra m ,
ps yc ho
lo gi st s
tr ai ne
d on
lif e-
re vi ew
th er ap
y tr ai ni ng
, m ed
ic at io n
pr ot oc
ol to
th e
un it ph
ys ic ia n,
ta ilo re d
co m m un
ic at io n
w ith
ps yc ho
lo gi st s
an d ph
ys ic ia ns
ab ou
ti nd
iv id ua
l de
pr es
si on
sc or es
.
D em
en tia
an d so
m at ic
un its ’
re su
lts tr ea
te d
se pa
ra te ly .
N o
in te rv en
tio n
ef fe ct s on
de pr es
si on
in de
m en
tia un
its ,b
ut cl in ic al
de pr es
si on
de cr ea
se d
(o n th e
m ai n
m ea
su re )
af te r
cr os
si ng
to th e
in te rv en
tio n
in so
m at ic
un its .
In di re ct
ou tc om
es :
qu al ity
of lif e
im pr ov
ed af te r
in te rv en
tio n
in bo
th so
m at ic
an d
de m en
tia un
its .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 14 / 60
T ab
le 5.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff
d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
S m ith
,2 01
3 N R C T ,6
w ks
,8 ,1
2 an
d 16
w ks
po st -t ra in in g
fo llo w -u ps
, 13
si te s,
C G :
13 re s;
IG 1:
16 re s;
IG 2:
30 re s
U su
al ca
re +
+ IG
1: C D -b as
ed tr ai ni ng
(s el f-
di re ct ed
) on
la te -li fe
de pr es
si on
an d
co m or bi d
co nd
iti on
s, ra tin
g sc al es
, in te rv en
tio ns
(p sy ch
os oc
ia l,
be ha
vi or al
ac tiv at io n,
m ed
ic at io n us
e) ,
co m m un
ic at io n
an d te am
w or k
am on
g he
al th
pr ov
id er s.
Le ar ne
rs im
pl em
en te d
ex er ci se
s w ith
an ol de
r ad
ul t
w ith
de pr es
si on
IG re su
lts re po
rt ed
to ge
th er ,
no t
in di vi du
al ly .
N o gr ou
p by
tim e
ef fe ct s on
de pr es
si on
. In di re ct
ou tc om
es :
N o
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e fo r
an xi et y or
qu al ity
of lif e or
pa in .
+ +
+ IG
2: C D -b as
ed tr ai ni ng
w ith
ps yc hi at ric
nu rs e su
pp or t
in vo
lv in g w ee
kl y
ph on
e ca
lls ,o
n- si te
vi si ts .
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 05
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 15 / 60
T ab
le 6.
A p p ro p ri at e p re sc
ri b in g .
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
A vo
rn ,
19 92
P ai re d,
cl us
te re d
ra nd
om iz ed
R C T ,2
2 w ks ,1
2 si te s,
C G :
39 2 re s;
IG :
43 1 re s
U su
al ca
re +
+ +
E du
ca tio
n m at er ia ls en
tt o
ph ys ic ia ns
fo llo w ed
by ed
uc at io na
lv is its
w ith
ea ch
ph ys ic ia n w ith
hi gh
ps yc ho
ac tiv e
dr ug
pr es
cr ib in g
ra te .T
ra in in g fo r
al ld
ire ct
ca re
an d
nu rs in g st af f.
C om
pa re d to
C G ,
in IG
th er e w as
gr ea
te r re du
ct io n
of m ea
n ps
yc ho
ac tiv e
dr ug
us e an
d nu
m be
r of
da ys
of an
tip sy ch
ot ic
th er ap
y pe
r m on
th ,a
nd m or e
di sc on
tin ua
tio n of
an tip
sy ch
ot ic s
In di re ct
ou tc om
es :
co m pa
re d to
C G ,
IG re si de
nt s on
ba se
lin e
an tip
sy ch
ot ic s
ha d gr ea
te r
m ai nt en
an ce
of m em
or y bu
t w or se
ne d
de pr es
si ve
sy m pt om
s. N o
di ffe
re nc
es on
m en
ta ls ta te ,
an xi et y,
ot he
r be
ha vi or
or sl ee
p. C om
pa re d
to C G ,I G
re si de
nt s on
ba se
lin e
be nz
od ia ze
pi ne
s or
hy pn
ot ic s
de cr ea
se d in
an xi et y an
d im
pr ov
ed in
fu nc
tio n,
de te rio
ra te d
m or e in
m em
or y.
N o di ffe
re nc
es be
tw ee
n gr ou
ps in
ra te s of
ho sp
ita liz at io n,
m or ta lit y or
ch an
ge in
le ve
lo f
ca re .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 16 / 60
T ab
le 6.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
M ea
do r,
19 97
P ai re d,
cl us
te re d
ra nd
om iz ed
R C T ,5
w ks ,
5 m on
th fo llo w -u p,
12 si te s.
C G :
63 1 re s;
IG :
68 0 re s.
U su
al ca
re +
+ +
+ +
P hy
si ci an
vi si te d,
gi ve
n pr es
cr ip tio
n re co
m m en
da tio
ns an
d fl ow
ch ar t.
S ta ff tr ai ne
d in
st ru ct ur ed
gu id el in es
: m ed
ic al
ev al ua
tio n;
m in im
iz in g th e
oc cu
rr en
ce an
d se
ve rit y of
be ha
vi or al
pr ob
le m s;
w rit te n
pl an
s to
m an
ag e
be ha
vi or al
pr ob
le m s;
lo w
do se
an tip
sy ch
ot ic
th er ap
y fo r
be ha
vi or s th at
w er e da
ng er ou
s, in te rf er ed
w ith
ca re
or se
rio us
ly di st re ss ed
th e
re si de
nt ;t ria
ls of
gr ad
ua l
w ith
dr aw
al
R ed
uc ed
us e of
an tip
sy ch
ot ic s in
in te rv en
tio n
co m pa
re d to
co nt ro l; no
in cr ea
se in
be nz
od ia ze
pi ne
us e.
R ed
uc ed
us e of
an tip
sy ch
ot ic s in
in te rv en
tio n
co m pa
re d to
co nt ro l; no
in cr ea
se in
be nz
od ia ze
pi ne
us e. (C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 17 / 60
T ab
le 6.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
S ch
m id t,
19 98
P ai re d,
cl us
te re d
R C T ,5
2 w ks ,3
3 si te s,
C G :
12 28
re s;
IG :
62 6 re s
U su
al ca
re +
+ +
T ra in ed
ph ar m ac
is ts
sp en
t 1 da
y ou
tr ea
ch pe
r m on
th at
ea ch
ho m e.
P ha
rm ac
is ts
or ga
ni ze
d re gu
la r
m ul ti- di sc ip lin ar y
dr ug
us e
m ee
tin gs
fo r st af f
in vo
lv ed
in dr ug
ad m in is tr at io n
an d/ or
di re ct
re si de
nt ca
re .
In C G s,
th er e
w er e si gn
ifi ca
nt in cr ea
se s in
nu m be
r of
dr ug
s pr es
cr ib ed
an d
pr op
or tio
n of
re si de
nt s w ith
th er ap
eu tic
du pl ic at io n;
th es
e w er e st ab
le in
IG .
In IG
,u se
of re co
m m en
de d
hy pn
ot ic s
in cr ea
se d an
d no
n- re co
m m en
de d
hy pn
ot ic s
de cr ea
se d an
d ov
er al lr at e
de cl in ed
,n o
si gn
ifi ca
nt ch
an ge
s in
C G .
N o ch
an ge
in ei th er
gr ou
p in
us e of
no n-
re co
m m en
de d
an xi ol yt ic s.
In cr ea
se in
IG in
th e pr om
ot io n of
re si de
nt s w ith
ac ce
pt ab
le an
xi ol yt ic s.
B ot h
gr ou
ps de
cr ea
se d
in th e us
e of
tr ic yc lic
an tid
ep re ss an
ts (n on
-p re fe rr ed
tr ea
tm en
t) an
d bo
th gr ou
ps in cr ea
se d in
th e
us e of
se le ct iv e
se ro to ni n re -
up ta ke
in hi bi to rs
(a pr ef er re d
tr ea
tm en
t) .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 18 / 60
T ab
le 6.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
C ro tty
, 20
04 C lu st er
ra nd
om iz ed
R C T ,1
2 w ks ,1
0 si te s,
C G :
10 4 re s;
IG :
50 re s.
½ da
y tr ai ni ng
an d a
to ol ki to
n m an
ag em
en t
of ch al le ng
in g
be ha
vi or
+ +
+ M ed
ic al
ou tr ea
ch te am
tr ai ne
d on
to ol ki ti n
m an
ag em
en to
f ch
al le ng
in g
be ha
vi or s.
A pr ob
le m
lis ta
nd m ed
ic at io n re vi ew
w as
co nd
uc te d by
G P s an
d ca
re st af fa
nd pr es
en te d at
2 ca
se co
nf er en
ce s
w hi ch
al so
in cl ud
ed a
ge ria
tr ic ia n,
ph ar m ac
is t, an
d re pr es
en ta tiv e of
th e A lz he
im er ’s
A ss oc
ia tio
n.
C om
pa re d to
th e
C G ,t he
ch an
ge sc or es
fo r
m ed
ic at io n
ap pr op
ria te ne
ss in de
x (M
A I)
im pr ov
ed .
C om
pa re d to
th e
C G ,t he
M A I
sc or es
fo r
be nz
od ia ze
pi ne
s (c on
si de
re d
in ap
pr op
ria te )
w er e si gn
ifi ca
nt ly
re du
ce d.
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
be ha
vi or .N
o ca
rr y- ov
er ef fe ct s
to ot he
r re si de
nt s
in th e fa ci lit y.
F os
se y,
20 06
S tr at ifi ed
bl oc
k cl us
te r
ra nd
om iz ed
R C T ,4
2 w ks ,f ol lo w -
up at
52 w ks ,
12 si te s,
C G :
16 8 re s;
IG :
18 1 re s
P sy ch
ia tr ic
dr ug
re vi ew
, le tte
rs an
d ph
on e ca
lls to
G P s
+ +
N ur si ng
st af f
tr ai ne
d in
pe rs on
ce nt er ed
ca re ,
po si tiv e ca
re pl an
ni ng
, en
vi ro nm
en ta l
de si gn
, in di vi du
al iz ed
in te rv en
tio ns
, al te rn at iv es
to dr ug
s, in vo
lv in g
fa m ily
ca re rs .
G ro up
an d
in di vi du
al su
pe rv is io n
in cl ud
in g
ad dr es
si ng
or ga
ni za
tio na
l ch
an ge
.P hy
si ci an
co ns
ul te d ab
ou t
re co
m m en
da tio
ns
C om
pa re d to
C G ,
pr op
or tio
n of
IG pa
rt ic ip an
ts ta ki ng
ne ur ol ep
tic s w as
si gn
ifi ca
nt ly
lo w er .
N o di ffe
re nc
es be
tw ee
n gr ou
ps fo r ag
ita tio
n. In di re ct
ou tc om
es :n
o di ffe
re nc
es be
tw ee
n gr ou
ps on
fa lls
or w el lb ei ng
.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 19 / 60
T ab
le 6.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
W es
tb ur y,
20 10
, 20
11
N R C T ,2
6 w ks ,7
8 w ks
fo llo w -u p,
25 si te s,
C G :
69 3 re s;
IG :
89 8 re s
U su
al ca
re +
+ +
+ +
+ D ru g us
e ev
al ua
tio n da
ta pr ov
id ed
.S ta ff
tr ai ni ng
. In di vi du
al iz ed
ac ad
em ic
de ta ili ng
fo r
ph ys ic ia ns
. E du
ca tio
na l
pa m ph
le tf or
re si de
nt s an
d re la tiv es
. “S ed
at iv e re vi ew
”
fo rm
ge ne
ra te d—
to be
di sc us
se d
by st af f, G P ,c
ar er
an d ph
ar m ac
is t.
O ve
r th e 6
m on
th s
in te rv en
tio n,
co m pa
re d to
C G ,
IG ha
d re du
ce d
us e an
d do
se of
be nz
od ia ze
pi ne
s, an
tip sy ch
ot ic s,
ov er al l
ps yc ho
tr op
ic us
e, an
d m ul tip
le ps
yc ho
tr op
ic us
e. N o di ffe
re nc
es be
tw ee
n gr ou
ps on
an tid
ep re ss an
t us
e. A tf ol lo w -u p:
D ec
re as
e in
be nz
od ia ze
pi ne
s an
d di az
ep am
us e an
d do
sa ge
ca rr ie d ou
tt o 18
m on
th s bu
tt he
pr es
cr ip tio
n an
d do
sa ge
s of
an tip
sy ch
ot ic s
re tu rn ed
to ba
se lin e in
IG ho
m es
at 18
m on
th s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 20 / 60
T ab
le 6.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
S te in ,
20 01
P ai re d,
cl us
te re d,
R C T ,1
3 w ks ,2
0 si te s,
C G :7
1 re s;
IG :7
6 re s
U su
al ca
re +
+ +
T ra in er s in
an ed
uc at io na
l pr og
ra m
fo r
op tim
al tr ea
tm en
t of m us
cu lo sk el et al
pa in
fo r al ln
ur si ng
ho m e st af f:
al te rn at iv e
ap pr oa
ch es
to N S A ID S .M
ee tin
g w ith
ad m in is tr at or
an d D O N .
M ee
tin g w ith
th e
nu rs in g ho
m e
ap po
in te d st ud
y co
or di na
to r.
V is ite
d or
te le ph
on ed
al l
pr im
ar y ca
re ph
ys ic ia ns
of pa
rt ic ip an
ts in
in te rv en
tio n
ho m es
.A lg or ith
m fo r st op
pi ng
N S A ID S in
hi gh
ris k pe
rs on
s. E du
ca tio
na l
m at er ia ls
fo r
ph ys ic ia ns
an d
ap po
in te d nu
rs e
co or di na
to r.
E ffe
ct iv el y
de cr ea
se d no
n- st er oi da
la nt i-
in fl am
m at or y
dr ug
s (N
S A ID s)
us e an
d in cr ea
se d
ac et am
in op
he n
us e.
M ea
n nu
m be
r of
da ys
of N S A ID
us e
dr op
pe d ov
er 3
m on
th s an
d in cr ea
se d fo r
ac et am
in op
he n.
P ai n di d no
t ch
an ge
ov er
tim e.
N o
m ea
su re
of fu nc
tio na
lit y w as
si gn
ifi ca
nt ly
di ffe
re nt .T
he re
w er e no
si gn
ifi ca
nt ly
di ffe
re nt
m ea
n ch
an ge
s fr om
ba se
lin e to
fo llo w -u p
be tw ee
n IG
an d
C G
in ill ne
ss im
pa ct s,
co gn
iti on
, ga
st ro in te st in al
sy m pt om
s or
di ffi cu
lty w ith
ac tiv iti es
of da
ily liv in g.
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s;
G P s,
ge ne
ra lp
ra ct iti on
er s;
N S A ID S ,n
on -s te ro id al
an ti- in fl am
m at or y dr ug
s; D O N ,D
ire ct or
of nu
rs in g.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 06
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 21 / 60
T ab
le 7.
P h ys
ic al
re st ra in tu
se .
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
H ui zi ng
, 20
09 R C T ,2
6 w ks
, 15
w ar ds
in 7
nu rs in g
ho m es
,C G :
16 3 re s;
IG :
20 8 re s
U su
al ca
re +
+ T ra in in g fo r al l
st af fo
n ph
ys ic al
re st ra in ts —
ef fe ct iv en
es s,
co ns
eq ue
nc es
, de
ci si on
m ak
in g
pr oc
es se
s, st ra te gi es
fo r
an al yz
in g an
d re sp
on di ng
to re si de
nt s’ ris
k be
ha vi or .
E xt en
si ve
tr ai ni ng
fo r nu
rs in g st af f
w ith
ke y ro le s on
w ar d.
C on
su lta
nt vi si te d w ee
kl y,
ad vi se
d nu
rs in g
st af f, at te nd
ed m ul tid
is ci pl in ar y
m ee
tin gs
, ev
al ua
te d th e us
e of
ph ys
ic al
re st ra in ts
an d
di sc
us se
d di ffi cu
lti es
.
In bo
th gr ou
ps us
e of
re st ra in ts
an d
in te ns
ity of
re st ra in ts
in cr ea
se d ov
er tim
e. C om
pa re d to
th e C G ,o
ve r
tim e IG
ha d
de cr ea
se d us
e of
sl ee
p su
its ,
us e of
be lts
in be
d, bi la te ra l
be dr ai ls ,a
nd in cr ea
se d us
e of
de ep
/ti pp
ed ch
ai rs ,
in cr ea
se d us
e of
be lts
an d
in cr ea
se d us
e of
in fr ar ed
sy st em
s.
G ul pe
rs ,
20 11
, 20
13
N R C T ,3
5 w ks ,1
3 nu
rs in g
ho m es
,2 6
w ar ds
,C G :
20 1 re s;
IG :
31 7 re s
U su
al ca
re ;
co nt ro l
re ce
iv ed
tr ea
tm en
t af te r 35
w ks
+ +
+ P ol ic y ch
an ge
by m an
ag em
en t
pr oh
ib iti ng
ne w
us e of
be lts
an d
fo r re du
ct io n of
cu rr en
tu se
. E du
ca tio
n fo r
st af f. C on
su lta
tio n
to w ar d nu
rs es
by nu
rs e sp
ec ia lis ts
re ga
rd in g
ch al le ng
es in
re du
ci ng
re st ra in ts
an d
sp ec
ifi c re si de
nt is su
es .P
ro vi si on
of al te rn at iv e
in te rv en
tio ns
e. g.
se ns
or m at s,
ba la nc
e tr ai ni ng
, ex
er ci se
s, lo w —
he ig ht
ad ju st ab
le be
ds .
C om
pa re d to
C G ,I G
si gn
ifi ca
nt ly
de cr ea
se d
ov er
tim e on
be lt us
e an
d on
an y ty pe
of ph
ys ic al
re st ra in ts .N
o di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e in
ps yc
ho tr op
ic us
e. D ec
re as
e in
re st ra in tu
se co
nt in ue
d th ro ug
h to
24 m on
th s.
In di re ct
ou tc om
es :
N o
di ffe
re nc
es be
tw ee
n gr ou
ps on
fa lls
or in ju rie
s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 22 / 60
T ab
le 7.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
K op
ke ,
20 12
S tr at ifi ed
, bl oc
k ra nd
om iz ed
R C T ,2
6 w ks
, 36
si te s,
C G :
18 19
re s;
IG :
19 52
re s
P rin
t in fo rm
at io n
an d sh
or t
pr es
en ta tio
n
+ +
+ T ra in in g on
gu id el in es
on ph
ys ic al
re st ra in ts
an d
al te rn at iv e
ap pr oa
ch es
. G ui da
nc e
pr ov
id ed
on po
st er s,
pe ns
, m ug
s, an
d no
te pa
ds .
N om
in at ed
nu rs e
fr om
ea ch
cl us
te r
ho m e tr ai ne
d on
im pl em
en ta tio
n pr oc
es s.
E nd
or se
m en
tb y
nu rs in g ho
m e
le ad
er s.
C om
pa re d to
C G ,I G
re du
ce d in
pr ev
al en
ce of
ph ys
ic al
re st ra in ts .N
o di ffe
re nc
es be
tw ee
n gr ou
ps in
ps yc
ho tr op
ic us
e.
In di re ct
ou tc om
es :
no di ffe
re nc
es be
tw ee
n gr ou
ps on
fa lls
or fa ll-
re la te d
fr ac
tu re s.
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; w ks ,w
ee ks ;r es
,r es
id en
ts .
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 07
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 23 / 60
T ab
le 8.
M an
ag em
en to
fb eh
av io ra la
n d p sy
ch o lo g ic al
sy m p to m s o fd
em en
ti a.
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
P ro ct or ,
19 98
,1 99
9 P ai re d,
cl us
te re d
R C T ,2
6 w ks ,1
2 si te s,
C G :6
0 re s,
IG :6
0 re s
U su
al ca
re +
+ T ra in in g on
or ga
ni c an
d fu nc
tio na
l di so
rd er s in
ol d
ag e,
ap pr oa
ch es
to ca
re ,a
ct iv iti es
. S up
er vi si on
in in di vi du
al pr og
ra m
pl an
ni ng
in cl ud
in g
ob se
rv at io n an
d as
se ss m en
t, pe
rc ei ve
d ne
ed s
an d go
al pl an
ni ng
, br ea
ki ng
do w n th e
go al
in to
st ep
s an
d sm
al lt ar ge
ts ,
m on
ito rin
g an
d re co
rd in g
pr og
re ss .
A tf ol lo w -u p a
la rg er
pr op
or tio
n of
C G
st af fm
et cr ite
ria fo r
ca se
ne ss
on th e
G en
er al
H ea
lth Q ue
st io nn
ai re
co m pa
re d w ith
IG st af f. N o
di ffe
re nc
es ov
er tim
e be
tw ee
n gr ou
ps on
so ur ce
s of
w or k
re la te d pr es
su re .
C om
pa re d to
C G ,o
ve r tim
e IG
ha d le ss
co gn
iti ve
de cl in e
an d m or e
im pr ov
em en
ti n
de pr es
si on
.N o
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e on
le ve
lo fb
eh av
io r
or ph
ys ic al
di sa
bi lit y.
D eu
do n,
20 09
C lu st er ,
ra nd
om iz ed
R C T ,8
w ks ,
fo llo w -u p at
12 w ks ,1
6 si te s,
C G :
13 2 re s;
IG :
17 4 re s
U su
al ca
re +
+ +
+ +
T ra in in g on
be ha
vi or al
an d
ps yc ho
lo gi ca
l sy m pt om
s of
de m en
tia (B P S D ),
“h ow
to ” st af f
in st ru ct io n ca
rd s
on m an
ag in g
B P S D ,w
ha tt o do
an d w ha
tt o av
oi d
in ca
re ,n
on -
ph ar m ac
ol og
ic al
in te rv en
tio ns
. P er so
na liz ed
st af f
co ns
ul ta tio
n.
C om
pa re d to
C G ,o
ve r tim
e th e IG
ha d
si gn
ifi ca
nt ly
lo w er
gl ob
al ag
ita tio
n, ph
ys ic al ly no
n- ag
gr es
si ve
, ve
rb al ly
no n-
ag gr es
si ve
be ha
vi or s,
an d
ob se
rv ed
be ha
vi or al
di st ur ba
nc es
.
Z im
m er m an
, 20
10 N es
te d
co ho
rt R C T ,
6 w ks ,3
m on
th s
fo llo w -u p,
16 si te s,
C G :
37 1 st af f; IG
: 29
1 st af f
U su
al ca
re +
T ra in in g fo r
su pe
rv is or s an
d di re ct
ca re
st af fo
n de
m en
tia ca
re an
d pa
in re du
ct io n.
S up
er vi so
rs tr ai ne
d on
le ad
er sh
ip sk ill s.
Im m ed
ia te
im pr ov
em en
ti n
co m m un
ic at io n
an d in
pa in
aw ar en
es s an
d af te r 3 m on
th s,
co m m un
ic at io n
im pr ov
em en
ts pe
rs is te d.
C om
pa re d to
th e
C G ,t he
IG w or k
st re ss
in cr ea
se d
an d su
pe rv is or y
su pp
or tr ec
ei ve
d de
cr ea
se d fo r
di re ct
ca re
st af f
an d su
pe rv is or s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 24 / 60
T ab
le 8.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
V an
de ve
n, 20
13 M in im
iz at io n
on cl us
te r
ra nd
om iz ed
R C T ,3
5 w ks ,3
4 si te s,
C G :
19 8 st af f,
16 6 re s;
IG :
17 8 st af f,
10 2 re s
+ 2 st af fm
em be
rs tr ai ne
d in
D em
en tia
C ar e
M ap
pi ng
(D C M ).
D C M
br ie fi ng
da y
fo r or ga
ni za
tio n.
C om
pa re d to
C G ,o
ve r tim
e th e IG
re po
rt ed
fe w er
ne ga
tiv e
em ot io na
l re ac
tio ns
an d
m or e po
si tiv e
em ot io na
l re ac
tio ns
, gr ea
te r
au to no
m y an
d w or k pl ea
su re .
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
ge ne
ra l
he al th
or jo b
sa tis fa ct io n.
C om
pa re d to
C G ,I G
de te rio
ra te d on
to ta l
ne ur op
sy ch
ia tr ic
sy m pt om
s. N o
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e on
ag ita
tio n.
In di re ct
ou tc om
es :n
o di ffe
re nc
es be
tw ee
n gr ou
ps on
qu al ity
of lif e.
Le on
e, 20
13 C lu st er ,
ra nd
om iz ed
R C T ,4
w ks ,
13 w ks
fo llo w -u p,
16 si te s,
C G :
11 1 re s;
IG :
11 9 re s
+ +
T ra in in g fo r st af f
on ap
at hy
in de
m en
tia ,
de pr es
si on
, de
fi ci ts
in fu nc
tio n,
st ru ct ur ed
ac tiv iti es
; in fo rm
at io n
in cl ud
in g
re co
m m en
da tio
ns fo r no
n- ph
ar m ac
ol og
ic al
in te rv en
tio ns
su m m ar iz ed
on D os
an d D on
’ts ca
rd .
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
pr es
cr ip tio
ns of
ps yc ho
tr op
ic s,
an tid
ep re ss an
ts ,
an xi ol yt ic s or
an tip
sy ch
ot ic s.
C om
pa re d to
C G ,I G
im pr ov
ed on
em ot io na
l bl un
tin g,
bu tn
ot an
in iti at iv e or
in te re st ,a
nd ha
d gr ea
te r
de te rio
ra tio
n on
af fe ct iv e an
d ps
yc ho
tic sy m pt om
s. IG
ha d
im pr ov
em en
ts on
so m e
ac tiv iti es
of da
ily liv in g (d re ss in g
an d
tr an
sf er rin
g) ,
an d de
te rio
ra tio
n on
ot he
rs (t oi le tin
g an
d co
nt in en
ce ).
E is se
s, 20
05 P ai re d,
cl us
te r
ra nd
om iz ed
R C T ,2
w ks ,
26 w ks
fo llo w -u p,
10 si te s,
C G :
22 8 re s;
IG :
19 8 re s
+ +
+ T ra in in g fo r st af f
on di ffe
re nc
es be
tw ee
n de
m en
tia an
d de
pr es
si on
be ha
vi or s.
V id eo
m at er ia l. U se
of st an
da rd iz ed
sc re en
in g
in st ru m en
tf or
de pr es
si on
, re vi ew
s at
st af f
m ee
tin gs
.
Im pr ov
em en
ti n
se ns
iti vi ty ,b
ut no
ts pe
ci fi ci ty ,
in re co
gn iti on
of de
pr es
si on
sy m pt om
s. N o
im pr ov
em en
ts in
tr ea
tm en
to f
de pr es
si on
.
Im pr ov
em en
ti n
de pr es
si ve
sy m pt om
s. N o
di ffe
re nc
e fo r
pr ev
al en
ce an
d in ci de
nc e of
de pr es
si on
.
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; w ks ,w
ee ks ;r es
,r es
id en
ts .
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 08
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 25 / 60
T ab
le 9.
F al ls
re d u ct io n an
d p re ve
n tio
n .
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
M ey
er ,
20 03
,2 00
5 C lu st er ,
ra nd
om iz ed
R C T ,7
8 w ks ,
49 si te s,
C G :
48 3 re s;
IG :
45 9 re s
In fo rm
at io n
on fa lls
+ +
T ra in in g fo r st af f
on ris
k of
hi p
fr ac
tu re
an d
re la te d m or bi di ty ,
st ra te gi es
to pr ev
en tf al ls an
d fr ac
tu re s,
ef fe ct iv en
es s of
hi p pr ot ec
to rs ,
pr ot ec
to r us
e an
d im
pl em
en ta tio
n. S ta ff as
ke d to
ed uc
at e re si de
nt s.
P ro vi de
d hi p
pr ot ec
to rs ,fl
ip ch
ar ts
an d le afl
et s
fo r re si de
nt s,
in fo rm
at io n fo r
re la tiv es
an d
ph ys ic ia ns
.
C om
pa re d to
C G ,
gr ea
te r pr op
or tio
n of
IG re si de
nt s
us ed
hi p
pr ot ec
to rs .
C om
pa re d to
C G ,I G
ha d
fe w er
ho sp
ita l
ad m is si on
s re la te d to
fa lls .N
o di ffe
re nc
es be
tw ee
n gr ou
ps in
ris k
of ha
vi ng
on e
fa ll, m ea
n nu
m be
r of
fa lls
or ris
k of
hi p fr ac
tu re s
or ot he
r fr ac
tu re s,
or in
nu m be
r of
fa lls -r el at ed
m ed
ic al
co ns
ul ta tio
ns .
O ’H al lo ra n,
20 04
S tr at ifi ed
bl oc
k ra nd
om iz ed
R C T ,7
2 w ks ,
12 7 si te s,
C G :
27 61
re s;
IG :
13 66
re s
U su
al ca
re +
+ +
+ +
S up
po rt ob
ta in ed
fr om
an d pr ot oc
ol pr ov
id ed
to m an
ag er s an
d or ga
ni za
tio ns
. S up
po rt to
ho m es
to pr om
ot e an
d m on
ito r pr og
re ss .
T ra in in g on
us e of
hi p pr ot ec
to rs ,
ris ks
an d
co ns
eq ue
nc es
of fr ac
tu re s.
R em
in de
r po
st er s
an d st ic ke
rs .V
id eo
pr ov
id ed
to be
us ed
by st af f.
In fo rm
at io n
se ss io ns
fo r
re si de
nt s an
d fa m ili es
m ad
e av
ai la bl e.
F ou
r pa
irs of
hi p
pr ot ec
to rs
pr ov
id ed
fo r ev
er y
re si de
nt ag
re ei ng
to w ea
r th em
.
In iti al
ac ce
pt an
ce of
hi p pr ot ec
to rs
w as
37 .2 %
in th e
in te rv en
tio n
gr ou
p w ith
ad he
re nc
e fa lli ng
to 19
.9 %
at 72
w ee
ks .
C om
pa re d to
C G ,I G
in cr ea
se d in
pe lv ic
fr ac
tu re
ra te
an d no
di ffe
re nc
e in
ov er al lm
ea n
fr ac
tu re
ra te
or in ju rio
us fa lls .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 26 / 60
T ab
le 9.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
K er se
, 20
04 S tr at ifi ed
bl oc
k ra nd
om iz ed
R C T ,2
6 w ks ,
fo llo w -u p at
52 w ks ,1
4 si te s,
C G :3
09 re s;
IG :2
38 re s
U su
al ca
re +
+ +
+ F al ls co
or di na
to r
ap po
in te d an
d tr ai ne
d. T ra in in g
fo r st af fo
n fa lls
ris k as
se ss m en
t an
d m an
ag em
en t,
lo go
to id en
tif y
hi gh
ris k re si de
nt s,
co lo r- co
di ng
fo r
re si de
nt s’ pl an
s. F al ls pr ev
en tio
n m an
ua lc on
ta in in g
ris k as
se ss m en
t fo rm
s, fa ll
pr ev
en tio
n st ra te gi es
,l og
os pr ov
id ed
.A ud
it an
d fe ed
ba ck
of fa lls .
C om
pa re d to
C G ,I G
ha d a
hi gh
er in ci de
nc e ra te
of fa lls .T
he re
w er e no
di ffe
re nc
es be
tw ee
n gr ou
ps on
in ju rio
us fa ll
in ci de
nc e or
se rio
us in ju rie
s.
R ay
,2 00
5 S tr at ifi ed
bl oc
k cl us
te r
ra nd
om iz ed
R C T ,1
w k,
fo llo w -u p at
52 w ks ,1
12 si te s,
C G :5
62 6 re s;
IG :4
93 2 re s
U su
al ca
re +
+ +
+ P ro gr am
te am
s tr ai ne
d co
m pr is in g:
nu rs e to
se le ct ,
as se
ss an
d de
ve lo p ca
re pl an
s fo r re si de
nt s at
hi gh
ris k fo r fa lls ,
m on
ito r st af f
pe rf or m an
ce an
d co
nd uc
ti n- se
rv ic e
tr ai ni ng
;n ur si ng
as si st an
ts to
in sp
ec tr es
id en
t liv in g sp
ac e an
d eq
ui pm
en t;
oc cu
pa tio
na la
nd ph
ys ic al
th er ap
y as
si st an
ts to
as se
ss tr an
sf er rin
g an
d m ob
ili ty
to re co
m m en
d w he
el ch
ai r se
at in g
m od
ifi ca
tio ns
; en
gi ne
er to
in sp
ec t
an d re pa
ir w he
el ch
ai rs .
M an
ua l, vi de
o, m at er ia ls fo r st af f
in -s er vi ce
, as
se ss m en
ts an
d to
tr ac
k tr ea
tm en
t pl an
im pl em
en ta tio
n pr ov
id ed
.R eg
ul ar
ph on
e su
pp or t.
N o
di ffe
re nc
es be
tw ee
n gr ou
ps on
hi p
fr ac
tu re s,
ot he
r fr ac
tu re s,
so ft
tis su
e in ju rie
s or
to ta l
in ju rie
s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 27 / 60
T ab
le 9.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
W ag
ne r,
20 05
N R C T ,1
7 w ks ,6
si te s,
91 0 re s
U su
al ca
re +
+ +
F al ls m en
u- dr iv en
in ci de
nt -r ep
or tin
g sy st em
(M D IR S )
re pl ac
ed ex
is tin
g na
rr at iv e re po
rt in g.
T ra in in g m an
ua l
pr ov
id ed
.
C om
pa re d to
C G ,
in IG
hi gh
er pr op
or tio
ns do
cu m en
te d of
ne ar
fa lls ,t yp
e of
fo ot w ea
r, fa ll
ty pe
s, ci rc um
st an
ce s
an d si de
ra il
st at us
.N o
di ffe
re nc
es be
tw ee
n gr ou
ps fo r
do cu
m en
ta tio
n of
un kn
ow n fa ll
ou tc om
es or
pa in .
N o
di ffe
re nc
es be
tw ee
n gr ou
ps on
in ci de
nc e of
fa lls .
R as
k, 20
07 N R C T ,5
2 w ks ,4
2 si te s,
C G :1
9 si te s;
IG :2
3 si te s
U su
al ca
re +
+ +
+ +
O rg an
iz at io na
l su
pp or td
ev el op
ed an
d fa ci lit y
pr ep
ar ed
.F al ls
te am
tr ai ne
d an
d qu
al ity
im pr ov
em en
tt oo
ls pr ov
id ed
.F al ls
nu rs e co
or di na
to r
ap po
in te d to
ch am
pi on
th e
pr og
ra m .S
up po
rt gi ve
n du
rin g
im pl em
en ta tio
n.
R ed
uc tio
n in
ph ys ic al
re st ra in t
us e in
bo th
C G
an d IG
.I G
ha d
im pr ov
em en
ts ac
ro ss
tim e in
ca re
pr oc
es s
do cu
m en
ta tio
n as
so ci at ed
w ith
fa lls
m an
ag em
en t.
IG di d no
t ch
an ge
in fa ll
ra te ,b
ut C G
in cr ea
se d.
N o
si gn
ifi ca
nt ch
an ge
s in
se rio
us in ju rie
s re su
lti ng
fr om
fa lls
in C G
or IG
.
C ox
,2 00
8 S tr at ifi ed
, cl us
te r
ra nd
om iz ed
R C T ,5
2 w ks ,
23 0 si te s,
C G :
27 53
re s;
IG :
34 76
re s
U su
al ca
re ,
de la ye
d tr ea
tm en
t
+ +
+ M an
ag er s,
R N an
d N A s tr ai ne
d on
fa ll
ris k as
se ss m en
t an
d fr ac
tu re
pr ev
en tio
n. S ta ff
as se
ss ed
re si de
nt s,
ca lc ul at ed
fa ll an
d fr ac
tu re
ris k,
re po
rt ed
re su
lts to
ca re
ho m e an
d G P
w ith
re co
m m en
da tio
n
C om
pa re d to
C G ,
in IG
th er e w as
a si gn
ifi ca
nt in cr ea
se in
bi sp
ho sp
ho na
te ,
ca lc iu m ,a
nd V ita
m in
D pr es
cr ip tio
ns .N
o di ffe
re nc
es in
hi p
pr ot ec
to r us
e.
N o
di ffe
re nc
es be
tw ee
n gr ou
ps fo r
fa lls ,t ot al
fr ac
tu re s or
hi p fr ac
tu re s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 28 / 60
T ab
le 9.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
B ou
w en
, 20
08 P ai re d (a nd
so m e
un pa
ire d)
cl us
te r
ra nd
om iz ed
R C T ,6
w ks ,
26 w ks
fo llo w -
up ,1
0 si te s,
C G :1
69 re s;
IG :2
10 re s
U su
al ca
re +
+ +
T ra in in g fo r st af f
on ris
k fa ct or s fo r
fa lls
an d
en vi ro nm
en ta la
nd be
ha vi or al
m od
ifi ca
tio ns
. R ei nf or ce
m en
t w ith
re m in de
rs .
N ur se
s ke
pt di ar y
of fa lls
to lis tr is k
fa ct or s an
d po
ss ib le
pr ev
en tiv e
in te rv en
tio ns
. In fo rm
at io n
co lle ct ed
on m ed
ic at io ns
an d
co m or bi di tie
s fo r
re si de
nt s w ith
ris k
fa ct or s fo r fa lls .
C om
pa re d to
C G ,i n IG
th er e w as
a si gn
ifi ca
nt re du
ct io n of
re si de
nt s w ith
on e or
m or e
fa lls .F
or re si de
nt s w ith
1+ fa ll, no
di ffe
re nc
e in
av er ag
e nu
m be
r of
fa lls
be tw ee
n gr ou
ps .
R ap
p, 20
10 N R C T ,5
2 w ks ,1
04 w ks
fo llo w -u p,
13 59
si te s,
C G 1:
23 ,2 50
re s;
C G 2:
20 ,3 33
re s;
IG :
9, 07
7 re s
U su
al ca
re ,
C G 1:
fr om
w ith
in sa
m e
st at e;
C G 2:
fr om
ot he
r st at e
+ +
+ A ud
it an
d fe ed
ba ck
re ga
rd in g a
nu m be
r of
fa lls .
M an
ua lp
ro vi de
d. T ra in in g fo r
ph ys io th er ap
is ts /
ex er ci se
in st ru ct or s in
co nd
uc tin
g ex
er ci se
gr ou
ps .
W ee
kl y gr ou
p ex
er ci se
pr og
ra m s.
F al lp
re ve
nt io n
nu rs es
tr ai ne
d w ho
w er e re sp
on si bl e
fo r in -h ou
se te ac
hi ng
se ss io ns
an d
im pl em
en ta tio
n. W eb
-t ra in in g
m at er ia ls pr ov
id ed
. M ed
ic at io n re vi ew
fo r re si de
nt s
fo cu
si ng
on re du
ci ng
ps yc ho
tr op
ic s an
d ad
m in is tr at io n of
vi ta m in
D .
E nv
iro nm
en ta l
ha za
rd s id en
tifi ed
. H ip
pr ot ec
to rs
re co
m m en
de d.
F al lr is k to ol
us ed
. R eg
ul ar
su pp
or t
vi si ts .
N o si gn
ifi ca
nt di ffe
re nc
es be
tw ee
n C G s
an d IG
on in ci de
nc e of
fe m or al
fr ac
tu re s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 29 / 60
T ab
le 9.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
B ec
ke r,
20 11
N R C T ,5
2 w ks ,1
14 9
si te s,
C G :
31 ,6 68
re s;
IG :
13 ,6 53
re s
U su
al ca
re +
+ +
+ +
H om
es si gn
ed pa
rt ic ip at io n
co nt ra ct .T
ra in in g
fo r ch
an ge
ag en
ts an
d ex
er ci se
in st ru ct or s.
M an
ua l
pr ov
id ed
an d
m at er ia ls fo r in -
ho us
e ed
uc at io n,
w eb
pa ge
w ith
ad di tio
na l
in fo rm
at io n.
G ro up
pr og
re ss iv e
st re ng
th an
d ba
la nc
e tr ai ni ng
ex er ci se
s de
liv er ed
bi w ee
kl y
by ex
er ci se
in st ru ct or s an
d st af f.
D oc
um en
ta tio
n of
fa lls .
E nv
iro nm
en ta l
ch ec
kl is tt o id en
tif y
pe rs on
- en
vi ro nm
en t
m is m at ch
. M ed
ic at io n re vi ew
an d V ita
m in
D di sc us
se d w ith
ph ys ic ia ns
.H ip
pr ot ec
to rs
pr ov
id ed
fo r
de m on
st ra tio
n an
d re co
m m en
da tio
ns .
C om
pa re d to
C G ,I G
ha d
si gn
ifi ca
nt ly
lo w er
ra te s of
fe m or al
fr ac
tu re s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 30 / 60
T ab
le 9.
(C on
tin ue
d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
T er es
i, 20
13 R eg
io n- ba
se d
ra nd
om iz at io n
R C T ,1
w k,
12 w ks
fo llo w -u p,
10 si te s,
C G :
21 79
re s;
IG 1:
22 55
re s;
IG 2:
29 26
U su
al ca
re +
+ IG
1: tr ai n th e
tr ai ne
r se
ss io ns
fo r
1– 2 hi gh
le ve
ls ta ff
in ea
ch N H .S
ta ff
tr ai ni ng
fo r al l
fr on
tli ne
st af fa
nd ad
di tio
na ls ta ff.
B as
ic kn
ow le dg
e ab
ou tv
is io n an
d vi su
al im
pa irm
en t
an d po
ss ib le
in te rv en
tio ns
fo r
N H s.
IG 2:
sa m e as
IG 1 pl us
in sp
ec to rs
(s ur ve
yo rs
w ho
ar e
em pl oy
ed by
st at e
le ve
ld ep
ar tm
en ts
of he
al th ) w er e
tr ai ne
d us
in g sa
m e
m at er ia ls as
st af f.
R ed
uc tio
n in
fa lls
fo r IG
1 bu
tn ot
IG 2
co m pa
re d to
co nt ro ls .N
o ch
an ge
s in
be ha
vi or al
sy m pt om
s of
de m en
tia .
R ed
uc tio
n in
de pr es
si on
fo r
IG 2 bu
tn ot
IG 1 co
m pa
re d
to co
nt ro ls .
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; C G 1,
co nt ro lg
ro up
1; C G 2,
co nt ro lg
ro up
2; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n
gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;r es
,r es
id en
ts ;R
N ,r eg
is te re d nu
rs e;
N A ,n
ur si ng
as si st an
t; G P ,g
en er al
pr ac
tit io ne
r; N H ,n
ur si ng
ho m e
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 09
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 31 / 60
T ab
le 10
. Q u al it y im
p ro ve
m en
t.
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
R an
tz ,2
00 1
C lu st er ,
ra nd
om iz ed
R C T ,5
2 w ks ,
87 si te s,
C G :
32 fa ci lit ie s;
IG 1:
27 fa ci lit ie s
U su
al ca
re +
+ IG
1: M an
ag em
en t
an d nu
rs e
tr ai ni ng
on qu
al ity
im pr ov
em en
t (Q
I) an
d ho
w to
us e th ei r “S ho
w -
M e Q IR
ep or ts ”.
Q ua
rt er ly
co m pa
ra tiv e
“S ho
w -M
e Q I
R ep
or ts ”. Q ua
lit y
In di ca
to r m an
ua l
an d m on
ito rin
g pl an
s fo r ea
ch M in um
um D at as
et Q ua
lit y
In di ca
to r.
R ef er en
ce lis to
f cl in ic al
st an
da rd s.
C om
pa re d to
C G ,I G s bo
th de
cl in ed
on pr es
en ce
of lit tle
or no
ac tiv ity .N
o di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e on
us e
of 9 or
m or e
di ffe
re nt
m ed
ic at io ns
, an
d pr ev
al en
ce of
oc ca
si on
al or
fr eq
ue nt
bl ad
de r
or bo
w el
in co
nt in en
ce w ith
ou ta
to ile tin
g pl an
, in dw
el lin g
ca th et er s,
da ily
ph ys ic al
re st ra in ts .
N o
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e on
in ci de
nc e of
ne w fr ac
tu re s,
an d
pr ev
al en
ce of
fa lls ,
be ha
vi or al
sy m pt om
s af fe ct in g
ot he
rs ,f ec
al im
pa ct io n,
w ei gh
tl os
s, be
df as
t re si de
nt s,
st ag
e 1–
4 pr es
su re
ul ce
rs .
IG 2:
28 fa ci lit ie s
+ +
+ IG
2: as
fo r IG
1 pl us
te le ph
on e
an d on
-s ite
cl in ic al
co ns
ul ta tio
n fr om
a ge
ro nt ol og
ic al
cl in ic al
nu rs e
sp ec
ia lis to
n in te rp re tin
g re po
rt s an
d de
ci di ng
ab ou
t cl in ic al
is su
es th at
re qu
ire re vi ew
.
A ch
te rb er g,
20 01
N R C T ,3
5 w ks ,1
6 si te s,
C G :1
35 re s,
16 :1
43 re s
U su
al ca
re +
+ T he
R es
id en
t A ss es
sm en
t In st ru m en
t( R A I)
st ru ct ur ed
as se
ss m en
tt oo
l im
pl em
en te d.
P ro je ct
te am
fr om
ea ch
si te
tr ai ne
d in
th e
R A Im
et ho
d. T ra in ed
pr oj ec
t te am
s th en
tr ai ne
d ca
re gi ve
rs in
th e
im pl em
en ta tio
n of
R A I.
A ss es
sm en
t: C om
pa re d to
C G
in IG
th er e
w as
si gn
ifi ca
nt im
pr ov
em en
ti n
ta ki ng
ca se
hi st or y.
M an
ag em
en t:
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
ca re
pl an
s, en
d of
sh ift
re po
rt s,
co m m un
ic at io n,
pa tie
nt al lo ca
tio n,
pa tie
nt re po
rt ,
to ta lc
ar e
co or di na
tio n.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 32 / 60
T ab
le 10
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
C ro tty
,2 00
4 P ai re d,
cl us
te r
ra nd
om iz ed
R C T ,3
0 w ks ,
20 si te s,
C G :
33 4 re s;
IG :
38 1 re s
U su
al ca
re +
+ +
+ +
A ca
de m ic
de ta ili ng
fo r
ph ys ic ia ns
on ev
id en
ce -b as
ed gu
id el in es
on fa lls
pr ev
en tio
n, ca
se au
di t,
st ro ke
pr ev
en tio
n. Li nk
nu rs e fo r ea
ch fa ci lit y ap
po in te d
an d tr ai ne
d ch
an ge
m an
ag em
en t,
m an
ag em
en to
f be
ha vi or al
sy m pt om
s of
de m en
tia ,
m ed
ic at io n
m an
ag em
en t
an d fa lls
pr ev
en tio
n te ch
ni qu
es .S
ta ff
tr ai ni ng
on re du
ci ng
th e us
e of
ps yc ho
tr op
ic m ed
ic at io ns
.A ll
gr ou
ps re ce
iv ed
to ol ki ti n
m an
ag in g
ch al le ng
in g
be ha
vi or s.
N o di ffe
re nc
e be
tw ee
n gr ou
ps ov
er tim
e on
ps yc ho
tr op
ic dr ug
us e (e xc ep
t fo r gr ea
te r us
e of
as re qu
ire d
an tip
sy ch
ot ic s) ,
or on
re co
rd in g
of bl oo
d pr es
su re ,o
r pr op
or tio
n of
pa tie
nt s on
as pi rin
or w ar fa rin
.
N o di ffe
re nc
e be
tw ee
n gr ou
ps ov
er tim
e on
fa lls ,
re si de
nt s w ith
hi gh
bl oo
d pr es
su re ,o
r pe
rc en
ta ge
of re si de
nt s w ith
at ria
l fi br ill at io n.
B ra vo
,2 00
5 P ai re d
cl us
te r
ra nd
om iz ed
R C T ,2
6 w ks ,
40 si te s,
C G :
99 re s;
IG :
10 2 re s
+ +
A re as
fo r
im pr ov
em en
t id en
tifi ed
an d
go al s de
ve lo pe
d us
in g go
al at ta in m en
t sc al in g.
M on
th ly
vi si ts
to fa ci lit y
an d fr eq
ue nt
te le ph
on e ca
lls to
as si st
m an
ag er
an d
st af ft o
im pl em
en t
pe rm
an en
t ch
an ge
s in
th e
ar ea
s of
ca re
ta rg et ed
fo r
im pr ov
em en
t.
A ss es
sm en
t: C om
pa re d to
th e
C G ,t he
IG si gn
ifi ca
nt ly
in cr ea
se d go
al at ta in m en
t sc al in g.
M an
ag em
en t:
T he
re w er e no
di ffe
re nc
es be
tw ee
n gr ou
ps on
ov er al l
qu al ity
of ca
re or
an y su
b- di m en
si on
s of
ca re .
N o
di ffe
re nc
es on
ov er al lq
ua lit y
of ca
re be
tw ee
n gr ou
ps .
S ig ni fi ca
nt de
cr ea
se in
co gn
iti on
in th e IG
ov er
tim e,
bu tn
ot in
th e C G .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 33 / 60
T ab
le 10
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
B ai er ,2
00 8
N R C T ,5
2 w ks ,1
6, 75
6 si te s,
C G :
9, 66
5 si te s;
IG :7
,0 91
si te s,
N no
t sp
ec ifi ed
U su
al ca
re +
+ IG
1: H om
es se
t ta rg et s us
in g th e
N ur si ng
H om
e S et tin
g T ar ge
ts — A ch
ie vi ng
R es
ul ts
(S T A R )
si te
fo r ph
ys ic al
re st ra in ts
an d
pr es
su re
ul ce
rs .
IG 2:
S om
e ho
m es
re ce
iv ed
ad di tio
na l
su pp
or tf ro m
th e
N ur si ng
H om
e Q ua
lit y
Im pr ov
em en
t O rg an
iz at io n.
C om
pa re
to C G ,
IG s ha
d gr ea
te r
im pr ov
em en
tf or
ph ys ic al
re st ra in ts .N
o di ffe
re nc
es be
tw ee
n in te rv en
tio n
ho m es
th at
re ce
iv ed
or di d
no tr ec
ei ve
ad di tio
na l
su pp
or to
n ph
ys ic al
re st ra in ts .
C om
pa re d to
C G ,I G s ha
d gr ea
te r
im pr ov
em en
t fo r pr es
su re
ul ce
rs .N
o di ffe
re nc
es be
tw ee
n in te rv en
tio n
ho m es
th at
re ce
iv ed
or di d no
t re ce
iv e
ad di tio
na l
su pp
or to
n pr es
su re
ul ce
rs .
R an
tz ,2
01 0
N R C T ,1
04 w ks ,1
8 si te s,
C G :8
90 re s;
IG 1:
66 8 re s
U su
al ca
re +
+ +
IG 1:
Im pl em
en te d
O pt im
us E le ct ro ni c
M ed
ic al
R ec
or d
(O E M R )
in cl ud
in g
tr ai ni ng
.O n- si te
nu rs e cl in ic al
co ns
ul ta tio
n se
rv ic es
.Q ua
lit y
Im pr ov
em en
tf or
M is so
ur i
(Q IM
P O ) sy st em
us ed
.
A ll gr ou
ps in cl ud
in g
co nt ro ls
re du
ce d
us e of
ph ys ic al
re st ra in ts .I G 1
sh ow
ed re du
ct io n in
sy m pt om
s of
de pr es
si on
w ith
no tr ea
tm en
t.
N o ch
an ge
s in
st af fr et en
tio n
ov er
tim e.
IG 1,
IG 2 an
d IG
3 im
pr ov
ed on
hi gh
ris k
pr es
su re
so re s an
d be
ha vi or al
sy m pt om
s. IG
1 an
d IG
2 im
pr ov
ed on
de cl in e in
la te -lo
ss ac
tiv iti es
of da
ily liv in g,
de cl in ed
in ra ng
e of
m ot io n,
de cl in ed
in ur in ar y tr ac
t in fe ct io ns
.I G 1
an d IG
3 im
pr ov
ed on
sh or ts
ta y
de lir iu m .
IG 2:
63 5 re s
IG 2 –
im pl em
en te d
O E M R on
ly in cl ud
in g
tr ai ni ng
.
IG 3:
54 3 re s
IG 3 – U se
d Q IM
P O
on ly
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 34 / 60
T ab
le 10
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
R an
tz ,2
01 2
C lu st er
ra nd
om iz ed
R C T ,1
04 w ks ,5
8 si te s,
C G :2
9 fa ci lit ie s;
IG :
29 fa ci lit ie s;
N o re si de
nt n
sp ec
ifi ed
V id eo
ta pe
d in se
rv ic es
an d
ed uc
at io na
l m at er ia l
pr ov
id ed
+ +
+ D et ai le d
in te rv en
tio n
m an
ua la
nd te xt
bo ok
s pr ov
id ed
. R es
ea rc he
rs ob
se rv ed
di re ct
ca re
st af f
w or ki ng
an d
pr ov
id ed
fe ed
ba ck .
Q ua
lit y
im pr ov
em en
t te am
s id en
tifi ed
, co
lle ct ed
ba se
lin e an
d fo llo w -u p da
ta ,
m ad
e an
d pr io rit iz ed
pl an
s an
d im
pl em
en te d
ch an
ge s fo r an
ar ea
fo r
im pr ov
em en
t. R es
ea rc he
rs vi si te d m on
th ly
to re in fo rc e.
C om
pa re d to
C G ,I G
im pr ov
ed on
th e
ca re
su bs
ca le
of th e qu
al ity
of ca
re m ea
su re ,
bu tn
ot on
th e
su bs
ca le s fo r
co m m un
ic at io n,
gr oo
m in g,
en vi ro nm
en t-
ac ce
ss ,
ho m el ik e,
od or
or en
vi ro nm
en t
ba si cs .
N o di ffe
re nc
es be
tw ee
n gr ou
p ov
er tim
e on
st af f
re te nt io n,
tu rn ov
er ,
or ga
ni za
tio na
l w or ki ng
co nd
iti on
s, st af fi ng
an d
st af fm
ix .
N o
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e on
pr es
su re
ul ce
rs ,
bl ad
de r an
d bo
w el
in co
nt in en
ce ,
w ei gh
tl os
s or
de cl in e in
ac tiv iti es
of da
ily liv in g.
V an
G aa
l, 20
10 ,2
01 1
C lu st er
ra nd
om iz ed
R C T ,5
8 w ks ,
10 0 w ks
fo llo w -u p,
10 si te s,
C G :
12 7 re s;
IG :
11 4 re s
U su
al ca
re +
+ +
+ +
W ar d m an
ag er
an d 2 ke
y nu
rs es
re sp
on si bl e fo r
pr og
ra m
im pl em
en ta tio
n. T ra in in g fo r al l
nu rs es
in cl ud
in g
ed uc
at io n,
kn ow
le dg
e te st
an d ca
se di sc us
si on
. In fo rm
at io n
co lle ct ed
ab ou
t pr es
su re
ul ce
rs ,
fa lls
an d ur in ar y
tr ac
ti nf ec
tio ns
. C om
pu te riz
ed re gi st ra tio
n sy st em
fo r
do cu
m en
ta tio
n of
da ily
ca re
an d
th e pr es
en ce
/ ab
se nc
e of
ad ve
rs e ev
en ts .
F ee
db ac
k gi ve
n on
in di ca
to rs .
C om
pa re d to
th e
C G ,t he
IG re si de
nt s at
ris k
of fa lls
w er e
m or e lik el y to
ha ve
a pr ev
en tiv e pl an
. N o di ffe
re nc
es be
tw ee
n gr ou
ps on
re si de
nt s at
ris k of
pr es
su re
ul ce
rs re ce
iv in g
ad eq
ua te
pr ev
en tiv e ca
re .
F ew
er pa
tie nt s
at ris
k of
ur in ar y
tr ac
ti nf ec
tio ns
in th e IG
re ce
iv ed
ad eq
ua te
pr ev
en tiv e ca
re .
C om
pa re d to
C G ,I G
im pr ov
ed on
ad ve
rs e
ev en
ts (f al ls ,
ur in ar y tr ac
t in fe ct io ns
, pr es
su re
ul ce
rs ),
di ffe
re nc
e w as
m ai nl y
du e to
re du
ct io ns
in pr es
su re
ul ce
rs an
d fa lls .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 35 / 60
T ab
le 10
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
tio n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
B oo
rs m a,
20 11
P ai re d,
cl us
te r
ra nd
om iz ed
R C T ,2
6 w ks ,
10 si te s,
C G :
13 9 re s;
IG :
20 1 re s
U su
al ca
re +
+ +
R es
id en
t A ss es
sm en
t In st ru m en
t( R A I)
us ed
w ith
al l
re si de
nt s ev
er y
3 m on
th s.
R A I
re su
lts co
m pa
re d w ith
be nc
hm ar ks .
C ar e pl an
ni ng
in cl ud
ed di sc us
se d w ith
re si de
nt ,f am
ily an
d ph
ys ic ia n
an d co
or di na
te d
by nu
rs e he
lp er .
R es
id en
ts w ith
co m pl ex
ne ed
s sc he
du le d at
le as
tt w ic e a
ye ar
fo r
m ul tid
is ci pl in ar y
m ee
tin g.
C on
su lta
tio n
w ith
a ge
ria tr ic ia n or
ps yc ho
lo gi st
fo r
fr ai le st
re si de
nt s.
C om
pa re d to
C G ,I G
ha d
lo w er
pe rc en
ta ge
of re si de
nt s w ith
ne w in -d w el lin g
ca th et er s,
us e of
ph ys ic al
re st ra in ts ,u
se of
an tip
sy ch
ot ic
ag en
ts ,b
ut hi gh
er pe
rc en
ta ge
of re si de
nt s w ith
in ad
eq ua
te pa
in m an
ag em
en t.
N o
di ffe
re nc
es be
tw ee
n gr ou
ps on
re si de
nt ra te d
qu al ity
of ca
re ,q
ua lit y
of lif e or
ac tiv iti es
of da
ily liv in g,
ho sp
ita l
ad m is si on
s or
m or ta lit y.
C om
pa re d to
C G ,q
ua lit y of
ca re
w as
hi gh
er fo r th e
IG us
in g th e
su m
sc or e of
32 ris
k- ad
ju st ed
qu al ity
ca re
in di ca
to rs
w hi ch
w er e
m os
tly re si de
nt ou
tc om
es .
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s,
Q I, qu
al ity
im pr ov
em en
t.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 10
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 36 / 60
T ab
le 11
. P h ilo
so p h y o fc
ar e an
d as
p ec
ts o fc
u lt u re
o fc
ar e.
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
B ur gi o,
20 01
P ai re d
re cr ui tm
en t,
cl us
te r
ra nd
om iz ed
R C T ,5
w ks
,8 w ks
fo llo w -u p,
5 si te s,
C G :
33 re s;
25 st af f; IG
:3 4
re s,
37 st af f
U su
al ca
re +
+ +
+ A ll nu
rs in g st af f
tr ai ne
d in
th e
us e of
m em
or y
bo ok
s an
d ge
ne ra l
co m m un
ic at io n
sk ill s.
S ta ff
m ot iv at io na
l sy
st em
w ith
w ee
kl y
re co
gn iti on
of st af f
pe rf or m an
ce .
O bs
er va
tio n an
d fe ed
ba ck
to st af f
on th ei r
co m m un
ic at io n
sk ill s.
C om
pa re d to
C G ,o
ve r tim
e IG
st af f
im pr ov
ed on
ov er al l
co m m un
ic at io n
sk ill s,
st af f
po si tiv e
st at em
en ts ,
am ou
nt of
st af f
sp ee
ch an
d ra te
of po
si tiv e
ve rb al
in te ra ct io ns
be tw ee
n st af f
an d re si de
nt s
du rin
g ca
re .
T he
re w er e no
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e fo r
us in g fe w er
m ul tis te p
in st ru ct io ns
,u se
of bi og
ra ph
ic al
st at em
en ts ,o
r tim
e sp
en ti n
da ily
ca re .
A tt he
2 m on
th fo llo w -u p,
IG re si de
nt s w er e
m or e
in de
pe nd
en ti n
se lf- ca
re th an
C G .
S ch
rij ne
m ae
ke rs ,
20 02
,2 00
2, 20
03 P ai re d,
cl us
te r
ra nd
om iz ed
R C T ,3
5 w ks
, 52
w ks
fo llo w -
up ,1
6 si te s (8
si te s pe
r gr ou
p) ,C
G :
74 re s,
13 9
st af f; IG
:7 7
re s,
15 4 st af f
U su
al ca
re ,
w ai tli st
co nt ro l
+ +
C lin ic al
le ss
on s
fo r al l
em pl oy
ee s
ab ou
te m ot io n
or ie nt ed
ca re .
T ra in in g fo r 8
ca re rs
pe r
ho m e,
su pe
rv is io n
m ee
tin gs
.
T he
re w er e no
di ffe
re nc
es be
tw ee
n gr ou
ps in co
m m un
ic at io n
an d in te ra ct io n
w ith
th e
re si de
nt s.
T he
IG gr ou
p ha
d so
m e
im pr ov
em en
ts in
jo b sa
tis fa ct io n
an d bu
rn ou
to ve
r tim
e co
m pa
re d to
th e C G .
N o in te rv en
tio n
ef fe ct s on
be ha
vi or al
ou tc om
e m ea
su re s ov
er tim
e.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 37 / 60
T ab
le 11
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
S lo an
e, 20
04 ;
H oe
ffe r, 20
06 C lu st er ,c
ro ss
- ov
er R C T
(c ro ss
ov er
fo r
2 ty pe
s of
ba th in g) ,6
w ks
/6 w ks
cr os
so ve
r, 15
si te s (5
si te s
pe r gr ou
p) ,
C G :2
3 re s,
13 st af f; IG
1: 24
re s;
IG 2:
22 re s;
IG 1 an
d IG
2 co
m bi ne
d: 24
st af f
U su
al ca
re +
+ +
T hr ee
ce rt ifi ed
nu rs in g
as si st an
ts pe
r si te
tr ai ne
d to
id en
tif y
be ha
vi or al
sy m pt om
s an
d th ei r
an te ce
de nt s,
in cl ud
in g ha
nd s-
on su
pe rv is io n
to te ac
h: 1)
to w el
ba th
an d
2) pe
rs on
- ce
nt er ed
sh ow
er in g.
T ra in in g on
de m en
tia an
d be
ha vi or al
sy m pt om
s, pe
rs on
-c en
te re d
ap pr oa
ch es
to ba
th ,b
eh av
io ra l
as se
ss m en
ta nd
pr ob
le m
so lv in g.
R ev
ie w
w ith
st af f
of at
le as
t1 vi de
o pe
r re si de
nt w ho
m th ey
as si st ed
w ith
ba th in g.
B at h
co m pl et en
es s
di d no
td iff er
fr om
ba se
lin e
fo r to w el
ba th
or pe
rs on
-c en
te re d
sh ow
er in g (b ut
pe rs on
-c en
te re d
sh ow
er in g to ok
si gn
ifi ca
nt ly
m or e tim
e th an
to w el
ba th ).
C om
pa re d to
C G ,b
ot h IG
im pr ov
ed m or e
on ge
nt le ne
ss an
d ea
se ,b
ut no
tv er ba
l su
pp or t,
co nfi
de nc
e an
d ha
ss le s.
C om
pa re d to
C G ,b
ot h IG
s im
pr ov
ed in
sk in
co nd
iti on
,a nd
de cr ea
se d in
di sc
om fo rt
ra tin
gs ,o
ve ra ll
ag ita
tio n an
d ag
gr es
si on
.N o
di ffe
re nc
es be
tw ee
n tw o
IG s on
ve rb al
ag ita
tio n,
or co
lo ni za
tio n
w ith
po te nt ia lly
pa th og
en ic
ba ct er ia .
D is co
m fo rt w as
le ss
fo r th e
to w el -b at h
in te rv en
tio n
th an
th e pe
rs on
- ce
nt er ed
sh ow
er in g.
Jo hn
so n,
20 05
N R C T ,5
w ks
, 17
w ks
fo llo w -
up ,1
2 si te s,
C G :4
2 re s,
18 st af f; IG
:4 2
re s,
21 st af f
U su
al ca
re +
+ T ra in in g fo r
se le ct
st af fo
n re st or at iv e ca
re :
ph ys
ic al
ac tiv ity ,
po si tio
ni ng
, m ob
ili ty
an d
tr an
sf er s;
co m m un
ic at io n;
fe ed
in g/ ea
tin g;
as se
ss m en
ta nd
ev al ua
tio n.
T ea
m bu
ild in g,
st ra te gi es
fo r
m ot iv at in g
re si de
nt s an
d de
cr ea
si ng
le ar ne
d he
lp le ss
ne ss
em ph
as iz ed
. R es
ou rc e
m an
ua l
pr ov
id ed
.
C om
pa re d to
C G ,I G
im pr ov
ed si gn
ifi ca
nt ly
m or e in
G oa
l A tta
in m en
t S ca
lin g
(e va
lu at in g
co m pl ex
ne ed
s of
ge ria
tr ic
cl ie nt s) .
C om
pa re d to
C G ,I G
im pr ov
ed on
fu nc
tio na
l in de
pe nd
en ce
, se
lf- ca
re an
d pr og
re ss
io n an
d re co
ve ry
in a
ra ng
e of
ba la nc
e an
d m ob
ili ty
ab ili tie
s.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 38 / 60
T ab
le 11
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
F in ne
m a,
20 05
M at ch
ed th en
cl us
te r
ra nd
om iz ed
R C T ,3
9 w ks
, 16
si te s (1 6
w ar ds
fr om
14 nu
rs in g
ho m es
), C G :
79 re s,
53 st af f; IG
:6 7
re s,
46 st af f
T ra in in g
an d
su pp
or ti n
us ua
l nu
rs in g
ho m e
qu al ity
ca re
+ +
+ B as
ic tr ai ni ng
in em
ot io n or ie nt ed
ca re
fo r al ls
ta ff
an d ad
va nc
ed co
ur se
in em
ot io n- or ie nt ed
ca re
fo r fi ve
st af f
m em
be rs
on ea
ch w ar d.
O ne
st af fm
em be
r tr ai ne
d as
em ot io n- or ie nt ed
ca re
ad vi so
r w ho
w as
re sp
on si bl e fo r
im pl em
en tin
g em
ot io n- or ie nt ed
ca re .
S up
er vi si on
w ith
fe ed
ba ck
gi ve
n.
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
ge ne
ra lh
ea lth
, pe
rc ei ve
d w or k
re la te d st re ss
, st re ss
re ac
tio ns
, fe el in gs
of co
m pe
te nc
e an
d nu
m be
r of
da ys
to ab
se nt ee
is m
du e
to ill ne
ss .
C om
pa re d to
C G ,I G
ha d le ss
de cl in e in
m ai nt ai ni ng
a po
si tiv e se
lf- im
ag e an
d ba
la nc
e am
on g
re si de
nt s w ith
m ild -m
od er at e
de m en
tia .N
o di ffe
re nc
es be
tw ee
n gr ou
ps on
re si de
nt be
ha vi or ,
de pr es
si on
an d
ag ita
tio n.
B er kh
ou t, 20
03 ,
20 04
;B ou
m an
s, 20
05
N R C T ,9
5 w ks
,1 2 si te s
(1 2 w ar ds
fr om
3 nu
rs in g
ho m es
), C G :
10 9 st af f; IG
: 10
1 st af f
U su
al ca
re +
+ +
+ R es
id en
t- or ie nt ed
, pr of es
si on
- or ie nt ed
,a nd
or ga
ni za
tio n-
or ie nt ed
m ee
tin gs
w er e
he ld .R
es id en
ts w er e as
si gn
ed to
pr im
ar y
nu rs in g ca
re rs
(P N C s) ,w
ho w er e
re sp
on si bl e fo r
as se
ss m en
t, ca
re pl an
ni ng
, ex
ec ut io n,
an d
ev al ua
tio n of
ca re .P
N C s
w er e de
le ga
te d
re sp
on si bi lit y
an d
ac co
un ta bi lit y fo r
to ta ln
ur si ng
ca re
of as
si gn
ed re si de
nt s.
S up
er vi so
rs co
ac he
d an
d su
pp or to
f P N C s.
W ar d
si st er s tr ai ne
d on
th e jo b an
d st im
ul at ed
P N C s.
C om
pa re d to
C G ,I G
w ar ds
in cr ea
se d m or e
in re si de
nt as
si gn
m en
t, ‘u se
of nu
rs in g
ca re
pl an
s/ ev
al ua
tio n’ ,
‘ta ki ng
nu rs in g
hi st or y’ ,‘ nu
rs in g
pr ob
le m s an
d go
al s ac
tio ns
’, an
d (f or
th e
ps yc
ho ge
ria tr ic
w ar ds
on ly )
re si de
nt -
or ie nt ed
ta sk
s. IG
de cr ea
se d in
qu al ity
fo rm
s of
co m m un
ic at io n
co m pa
re d to
C G .N
o di ffe
re nc
es be
tw ee
n gr ou
ps on
w ar d
or ie nt ed
ta sk
s, va
rie ty
of re si de
nt -
or ie nt ed
an d
w ar d- or ie nt ed
fo rm
s of
co m m un
ic at io n.
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
jo b au
to no
m y,
jo b re sp
on si bi lit y
or so
ci al
su pp
or t.
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
re si de
nt w el lb ei ng
or re si de
nt sa
tis fa ct io n or
fa m ily
sa tis fa ct io n w ith
ca re .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 39 / 60
T ab
le 11
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
V an
W ee
rt ,2
00 5,
20 06
N R C T ,7
8 w ks
,1 2 si te s,
C G :6
4 re s,
60 st af f; IG
:6 5
re s,
60 st af f
U su
al ca
re +
+ +
+ C N A s tr ai ne
d in
sn oe
ze le n fo r
pe rs on
s w ith
de m en
tia in cl ud
in g
aw ar en
es s of
re si de
nt s’
ne ed
s; m ak
in g
co nt ac
ta nd
sh ow
in g
af fe ct io n an
d em
pa th y;
su pp
or tin
g re si de
nt s in
re sp
on si ve
ne ss
; av
oi di ng
co rr ec
tin g th e
re si de
nt s’
su bj ec
tiv e
re al ity ;a
vo id in g
sp re ad
in g
us el es
s in fo rm
at io n an
d te st in g
kn ow
le dg
e an
d; in -h ou
se su
pe rv is io n
of fe re d.
M ee
tin gs
w ith
nu rs in g ho
m e
re pr es
en ta tiv es
to su
pp or t
or ga
ni za
tio na
l le ve
l im
pl em
en ta tio
n.
C om
pa re d to
C G ,o
ve r tim
e IG
in cr ea
se d
tim e sp
en ti n
m or ni ng
ca re ,
du ra tio
n an
d pe
rc en
ta ge
of ey
e- co
nt ac
t, af fe ct iv e to uc
h, m ea
n nu
m be
r of
sm ile s,
po si tiv e
af fe ct iv e an
d in st ru m en
ta l
co m m un
ic at io n,
an d nu
m be
r of
ve rb al
ut te ra nc
es .
T he
re w as
de cr ea
se d
ne ga
tiv e
af fe ct iv e an
d in st ru m en
ta l
be ha
vi or .
In cr ea
se d
nu m be
r of
ex pl ic itl y of fe re d
se ns
or y st im
ul i.
In st ru m en
ta l
to uc
h di d no
t di ffe
r.
Im pr ov
em en
to n
P os
iti ve
W or k
S ca
le an
d M al ig na
nt S oc
ia l
P sy
ch ol og
y sc
al e.
C om
pa re d to
C G ,t he
IG im
pr ov
ed in
du ra tio
n of
re si de
nt ga
ze di re ct ed
at st af f,
an d fr eq
ue nc
y of
sm ili ng
an d
di sp
la ye
d le ss
di sa
pp ro va
la nd
an ge
r, an
d m or e au
to no
m y.
T he
re w er e no
di ffe
re nc
es be
tw ee
n gr ou
ps ov
er tim
e fo r
re si de
nt s’
po si tiv e
af fe ct iv e
co m m un
ic at io n,
ne ga
tiv e
in st ru m en
ta l
co m m un
ic at io n
or to ta lv
er ba
l ut te ra nc
es .
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 40 / 60
T ab
le 11
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
C he
no w et h,
20 09
;J eo
n, 20
12 B lo ck
cl us
te r
ra nd
om iz at io n
R C T ,1
7 w ks
, 15
si te s (3
si te s pe
r gr ou
p) ,C
G :
82 re s,
23 st af f; IG
1: 10
9 re s,
56 st af f;
U su
al ca
re +
+ +
+ IG
1: tw o st af f
fr om
ea ch
ho m e
tr ai ne
d on
pe rs on
-c en
te re d
ca re
ph ilo so
ph y
an d to
de ve
lo p
an d im
pl em
en t
in di vi du
al iz ed
ca re
pr ac
tic es
fo r re si de
nt s,
su pp
or tv
is its
an d ph
on e ca
lls .
N ei th er
in te rv en
tio n
re su
lte d in
si gn
ifi ca
nt lo w er in g of
ps yc
ho tr op
ic dr ug
s. IG
2 ha
d de
cl in e in
th e
em ot io na
l ex
ha us
tio n,
bu t
no t
de pe
rs on
al iz at io n
or pe
rs on
ac co
m pl is hm
en t,
as pe
ct s of
bu rn ou
t. N ei th er
in te rv en
tio n
re su
lte d in
be tte
r ge
ne ra lh
ea lth
, st af fa
tti tu de
s or
re ac
tio ns
to be
ha vi or al
di st ur ba
nc es
,s ta ff
pe rc ep
tio n of
su pp
or tf ro m
m an
ag em
en t.
C om
pa re d to
C G ,o
ve r tim
e IG
1 an
d IG
2 re du
ce d in
ag ita
tio n.
C om
pa re d to
C G ,i nc
re as
e in
fa lls
in IG
1 an
d re du
ct io n in
fa lls
in IG
2. N o
di ffe
re nc
es be
tw ee
n gr ou
ps on
ps yc
hi at ric
sy m pt om
s, ra te
of ac
ci de
nt s or
ho sp
ita liz at io ns
.
IG 2:
98 re s,
45 st af f
+ +
IG 2:
st af ft ra in ed
in de
m en
tia ca
re m ap
pi ng
,p ee
r su
pp or tg
ro up
s di sc
us si ng
ch al le ng
in g
be ha
vi or s,
em ot io na
l re ac
tio ns
an d
ho w to
co pe
w ith
w or k- re la te d
st re ss
.R eg
ul ar
te le ph
on e
su pp
or t.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 41 / 60
T ab
le 11
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d it io n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
B ur ac
k, 20
12 ,
20 12
N R C T ,1
04 w ks
,2 60
w ks
fo llo w -u p,
13 si te s,
C G :5
1 re s;
IG :5
0 re s
w ai tli st
+ +
+ +
C om
m un
ity co
or di na
to rs
ac te d as
ch an
ge ch
am pi on
s an
d pr om
ot ed
st af fi ng
co ns
is te nc
y. T ra in in g fo r al l
st af fo
n cu
ltu re
ch an
ge .S
ta ff
re st ru ct ur ed
to w or k as
co m m un
ity te am
s. S ta ff to
do pl an
ne d
ac tiv iti es
w ith
el de
rs .E
ld er s
gi ve
n m or e
ch oi ce
ov er
th ei r
da ily
sc he
du le s.
F am
ily in vi te d to
be m or e
in vo
lv ed
in ca
re pl an
ni ng
, co
m m un
ity m ee
tin gs
an d
so ci al
ev en
ts .
E nv
iro nm
en ta l
ch an
ge s m ad
e.
C om
pa re d to
C G ,o
ve ra ll
ch oi ce
im pr ov
ed fo r th e
IG ov
er tim
e. O ve
ra ll ch
oi ce
fo r el de
rs in cr ea
se d in
th e
IG co
m pa
re d to
C G
on ly
fr om
ba se
lin e to
2 ye
ar s,
bu tt he
n de
cr ea
se d fr om
2 ye
ar s to
5 ye
ar fo llo w -u p.
In di re ct
ou tc om
es :
co m pa
re d to
C G ,t he
IG de
cr ea
se d in
th e fr eq
ue nc
y of
fo rc ef ul
an d
ph ys
ic al
ag ita
tio n.
T he
fr eq
ue nc
y of
ve rb al
ag ita
tio n
di d no
t si gn
ifi ca
nt ly
de cr ea
se .
C la re ,2
01 3
P ai re d,
cl us
te r
ra nd
om iz ed
R C T ,8
w ks
,8 si te s,
C G :3
3 st af f, 33
re s;
IG :3
2 st af f, 32
re s
U su
al ca
re .
W ai tli st
co nt ro l
+ +
+ T ra in in g on
be in g m or e
aw ar e du
rin g
ca re
an d
ob se
rv at io na
l m ea
su re
of aw
ar en
es s,
co m m un
ic at io n.
S ta ff sc
he du
le d
to ob
se rv e a
sm al ln
um be
r of
re si de
nt s.
S up
po rt of fe re d
be tw ee
n w ee
kl y
tr ai ni ng
.
N o si gn
ifi ca
nt di ffe
re nc
es in
st af f
w el lb ei ng
, ps
yc ho
lo gi ca
l di st re ss
,a tti tu de
s or
qu al ity
of ca
re .
In di re ct
ou tc om
es :
co m pa
re d to
C G ,I G
si gn
ifi ca
nt ly
im pr ov
ed in
fa m ily -r at ed
bu t
no ts
ta ff—
ra te d
re si de
nt qu
al ity
of lif e.
N o
di ffe
re nc
es on
re si de
nt w el l-
be in g,
co gn
iti ve
fu nc
tio ni ng
or be
ha vi or .
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 11
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 42 / 60
T ab
le 12
. O th er
st u d ie s.
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
M ol lo y,
20 00
P ai re d,
cl us
te r
ra nd
om iz ed
R C T ,1
w k,
78 w ks ,6
si te s,
C G :
65 6 re s;
IG :
63 6 re s
+ +
+ T ra in in g fo r
nu rs es
on ad
va nc
e di re ct iv es
,a s
he al th
ca re
fa ci lit at or s,
ap pr oa
ch es
to ed
uc at in g st af f,
re si de
nt s an
d fa m ili es
,a nd
as se
ss in g
ca pa
ci ty
to co
m pl et e
di re ct iv es
. N ur se
s tr ai ne
d st af fa
nd em
er ge
nc y
w or ke
rs .V
id eo
s de
sc rib
in g
pr og
ra m
pr ov
id ed
. R ef re sh
er se
ss io ns
fo r
ne w st af fa
nd to
m ai nt ai n
aw ar en
es s of
al re ad
y tr ai ne
d st af f.
C om
pa re d to
C G ,I G
ha d
hi gh
er pr op
or tio
n of
A dv
an ce
d C ar e
D ire
ct iv es
co m pl et ed
.
C om
pa re d to
C G ,o
ve r tim
e IG
ho m es
re po
rt ed
fe w er
ho sp
ita liz at io ns
pe r re si de
nt an
d th ey
ha d a
lo w er
m ea
n nu
m be
r of
ho sp
ita ld
ay s.
In di re ct
ou tc om
es :
di ffe
re nc
es be
tw ee
n gr ou
ps on
sa tis fa ct io n
w ith
he al th
ca re
in co
m pe
te nt
or in co
m pe
te nt
re si de
nt s or
in th e pr op
or tio
n of
de at hs
.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 43 / 60
T ab
le 12
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
Jo ne
s, 20
04 N R C T ,2
6 w ks ,1
2 ho
m es
,1 89
9 re s to ta l( IG
an d C G
n no
t sp
ec ifi ed
)
U su
al ca
re +
+ +
+ +
+ T ra in in g fo r al l
st af f,
pa rt ic ul ar ly
nu rs es
.3 m em
be r in te rn al
pa in
te am
s (I P T s)
fo rm
ed w ho
de ve
lo pe
d pa
in vi ta ls ig n
as se
ss m en
t an
d do
cu m en
ta tio
n. F ee
db ac
k re po
rt s
pr ov
id ed
. R es
id en
t ed
uc at io na
l vi de
o pr ov
id ed
on ad
m is si on
. P hy
si ci an
s of fe re d vi de
o an
d pa
m ph
le t,
C M E cr ed
its m al pr ac
tic e
in su
ra nc
e pr em
iu m
di sc ou
nt .P
ai n
ex pe
rt av
ai la bl e,
do cu
m en
ta tio
n de
ve lo pe
d by
st af ff or
th ei r
fa ci lit y.
N o di ffe
re nc
es be
tw ee
n gr ou
ps on
no n- M D S
pa in
as se
ss m en
ts an
d pa
in re as
se ss m en
ts .
N o re du
ct io n in
pe rc en
ta ge
of re si de
nt s
re po
rt in g pa
in or
re po
rt in g
m od
er at e/
se ve
re pa
in in
IG ho
m es
. Im
pr ov
em en
ti n
pe rc en
ta ge
of re si de
nt s
re po
rt in g
co ns
ta nt
pa in
in in te rv en
tio n
ho m es
.
Ir vi ne
,2 01
2 C lu st er
ra nd
om iz ed
R C T ,2
w ks ,
14 w ks
fo llo w -u p,
6 si te s,
C G :4
5 st af f; IG
:5 8
st af f
D el ay
ed tr ea
tm en
t +
In te rn et
ba se
d tr ai ni ng
in cl ud
in g vi de
os on
fu nd
am en
ta l
de -e sc al at io n
sk ill s w ith
re si de
nt s
ex hi bi tin
g ag
gr es
si ve
be ha
vi or ,a
bo ut
hi ts ,h
its w ith
fi st s or
ar m s,
ha ir gr ab
s, w ris
t gr ab
s.
N o
di ffe
re nc
es in
se lf-
ef fi ca
cy or
em pa
th y.
C om
pa re d to
C G ,t he
IG de
cr ea
se d ov
er tim
e in
nu m be
r of
as sa
ul ts
re po
rt ed
.
(C on
tin ue
d )
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 44 / 60
T ab
le 12
. (C
on tin
ue d )
F ir st
au th o r,
ye ar
S tu d y
d es
ig n ,
in te rv en
ti o n
le n g th ,
n u m b er
o f
si te s,
b as
el in e
sa m p le
si ze
C o n tr o l
co n d iti o n
E d u ca
ti o n
m at er ia l
T ra in in g
R em
in d er s
A u d it
an d
fe ed
b ac
k
M en
to ri n g
o r su
p p o rt
C h am
p io n /
s T ea
m m ee
ti n g s
P o lic
y/ p ro ce
d u re
ch an
g es
O rg an
iz at io n al
re st ru ct u re
In te rv en
ti o n
d es
cr ip ti o n
S ta ff d ir ec
t b eh
av io r
o u tc o m es
S ta ff
in d ir ec
t o u tc o m es
R es
id en
t o u tc o m es
T er es
i, 20
13 C lu st er
ra nd
om iz ed
(r eg
io n-
ba se
d) R C T ,
4 w ks ,5
2 w ks
fo llo w -
up ,4
7 si te s,
C G :5
00 st af f, 68
5 re s;
IG :5
25 st af f, 72
0 re s
T ra in in g in
fi lli ng
ou t
be ha
vi or
re co
gn iti on
an d
do cu
m en
ta tio
n sh
ee ts
+ S ta ff tr ai ne
d in
id en
tifi ca
tio n
an d in te rv en
tio n
(a nd
re po
rt in g)
w ith
re sp
ec tt o
re si de
nt to
re si de
nt el de
r m is tr ea
tm en
t.
C om
pa re d to
C G ,I G
ha d
hi gh
er le ve
ls of
re co
gn iti on
an d
do cu
m en
ta tio
n of
re si de
nt to
re si de
nt m is tr ea
tm en
t ov
er tim
e.
B ee
ck m an
, 20
13 C lu st er
ra nd
om iz ed
R C T ,1
6 w ks ,
11 si te s,
C G :
23 9 re s,
53 st af f; IG
:2 25
re s,
65 st af f
P re ss ur e ul ce
r pr ev
en tio
n pr ot oc
ol ha
rd co
py an
d le ct ur e fo r al l
st af f
+ +
+ +
+ +
E le ct ro ni c
de ci si on
su pp
or ts
ys te m ,
P re vP
la n.
T ra in in g ab
ou t
pr es
su re
ul ce
r pr ev
en tio
n. M on
ito rin
g an
d fe ed
ba ck
on ad
eq ua
cy of
pr es
su re
ul ce
r pr ev
en tio
n, kn
ow le dg
e, at tit ud
es .
R em
in de
rs .K
ey nu
rs e
in tr od
uc ed
, in ve
nt or y an
d fe ed
ba ck
on qu
al ity
an d
av ai la bi lit y of
cu rr en
tm at er ia l
fo r pr es
su re
ul ce
rs ,s
up po
rt th e ac
qu is iti on
of ne
w pr es
su re
ul ce
r pr ev
en tiv e
m at er ia ls .
C om
pa re d to
C G ,I G
m or e
lik el y to
pr ov
id e
fu lly
ad eq
ua te
pr ev
en tio
n w he
n in
a ch
ai r,
an d in
th e
pr op
or tio
n of
re si de
nt s w ith
so m e
pr ev
en tio
n, bu
t no
di ffe
re nc
e be
tw ee
n gr ou
ps ov
er tim
e fo r
fu lly
ad eq
ua te
pr ev
en tio
n in
be d.
C om
pa re d to
C G ,I G
ha d
si gn
ifi ca
nt ly
lo w er
pr es
su re
ul ce
r pr ev
al en
ce (c at eg
or ie s I–
IV ). N o
di ffe
re nc
e w he
n on
ly co
ns id er in g
ca te go
rie s II- IV .
N R C T ,n
on -r an
do m iz ed
co nt ro lle d tr ia l; R C T ,r an
do m iz ed
co nt ro lle d tr ia l; C G ,c
on tr ol
gr ou
p; IG
,i nt er ve
nt io n gr ou
p; IG
1, in te rv en
tio n gr ou
p 1;
IG 2.
In te rv en
tio n gr ou
p 2;
w ks ,w
ee ks ;
re s,
re si de
nt s.
do i:1 0. 13 71 /jo ur na l.p on e. 01 40 71 1. t0 12
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 45 / 60
Fig 2. Flow chart indicating inclusion of articles in the study.
doi:10.1371/journal.pone.0140711.g002
Review of Staff Care Practice Interventions
PLOS ONE | DOI:10.1371/journal.pone.0140711 November 11, 2015 46 / 60
in different countries (Belgium and Netherlands) [29,30]. One provided training and tooth- brushes [28], the other two provided a more complex multifactorial intervention (De Visschere et al., 2012, van der Putten et al., 2013).
None of the studies measured whether staff behavior changed. All three reported improve- ments in residents’ denture plaque, and two also improved dental plaque [28,30]. One study also reported improvements on other oral health conditions [28]. See Table 1.
Hygiene and infection control Two studies examined the impact of interventions to improve hygiene [31,32] and one focused on infection control [33] (see Table 2). All provided training supported by additional strategies [31–33].
The two studies that reported staff behavior found improvements regarding infection con- trol and hand hygiene. This change in staff behavior resulted in improved outcomes for resi- dents in terms of reducing hospitalization relating to meticillin resistant staphylococcus aureus (MRSA) or respiratory outbreaks [32] but not on prevalence of MRSA [31]. One study reported no impact of the infection control program on resident infections [33]. Staff levels of MRSA were also not shown to be improved in the one study that measured this [31].
Nutrition There were two studies that focused on improving residents’ nutrition [34–36] (see Table 3). Both provided training, education materials and supported a change champion. Both studies showed some positive impacts on the nutritional care provided and improvements in some nutritional indicators in residents [35,36] [34].
Nursing home acquired pneumonia Two studies used a guideline implementation approach to prevention and management of nursing home acquired pneumonia [37,38] (see Table 4). Both these studies involved staff training, and one supported a nurse to champion the program and materials and reminders [37]. One of the studies also offered staff vaccinations [37]; this showed improvement in staff influenza vaccination rates, and resident pneumococcal vaccination but no differences between groups on antibiotic use [39]. Neither study found differences in the indirect outcomes for resi- dents of hospitalization or short-term mortality [38,40].
Depression There were two studies with a focus on reducing nursing home residents’ depression (see Table 5) [41,42]. Both provided staff training. Neither study reported staff outcomes. One study found an the intervention improved depression in somatic but not dementia units and indirect effects of improvement in quality of life for both units [41], however the other study found no impact on depression [42] nor improvements on the more distal resident outcomes of anxiety, quality of life or pain.
Appropriate prescribing Seven studies focused on appropriate medication use [43–50](see Table 6), most relating to antipsychotic medications. With the exception of [50], all these studies educated physicians and staff on appropriate medication use and on non-pharmacological strategies to manage clinical conditions. Most studies included other methods in their intervention such as audit and feedback [43,51] and team meetings (i.e. case conferences [44,50,51].
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All studies showed improvements in the use of some or all the target medications, and two studies reported no resultant deterioration in resident behavior [44,52]. One study reported both improvements and deteriorations in some resident clinical domains [43]. No studies mea- sured the indirect effects of the programs on staff (i.e. whether they experienced greater stress or perceived workload). Two studies measured effects on indirect resident outcomes and found no effects on falls and wellbeing [52], or on rates of hospitalization, mortality or change in level of care [43].
Physical restraint reduction Three studies examined the impact of interventions to reduce physical restraints [53–56] (see Table 7). All included training, and two included consultations [53,56] and one a champion [55].
All these studies measured the impact of training on staff behavior. Two studies reported reductions in physical restraint use by staff without concurrent increase in chemical restraints, or increased falls or injuries in residents [54,55], however one study did not demonstrate over- all improvements relative to the control group [53].
Management of behavioral and psychological symptoms of dementia There were six studies which attempted to change staff behavior in relation to the management of behavior and psychological symptoms of dementia [57–62](see Table 8). All these involved training and additional intervention components such as mentoring and support [58,59] and reminders [59,62].
Only two of the studies measured whether there was a change in staff behavior in regards to care of people with dementia [58,60]. One study found no changes in the treatment of depres- sion [58] and one improved communication in pain awareness [60]. One study showed that the intervention had negative impacts on staff stress and perception of supervisory support [60]. However, another study that measured indirect staff outcomes and found benefits for emotional reactions, autonomy and work pleasure, but not for the more distal outcomes of general health and job satisfaction [61]. The effects of the interventions on resident behavior were mixed, with some studies suggesting behavioral improvements [58,59], some studies find- ing worsening of behaviors [61,62]. One study which measured the indirect resident outcome of quality of life found no impact [61].
Falls reduction and prevention Eleven studies examined interventions to change staff care practices with regards to falls reduc- tion and prevention [63–74] (see Table 9). Compared with other clinical domains the studies in this domain tended to be larger in terms of number of sites and participants. With one exception which introduced a computerized measure of fall reporting [67], all the studies offered training and additional intervention components such as education materials [63,65,66,72,74] hip protectors [63,74], reminder materials [63,70], assessment tools [64,68,71], supported behavior change [66,68], audit and feedback [64,71], champions [64,71,72], and one trained regulatory inspectors [73]. Two studies also encouraged staff to run exercise groups [71,72].
Five of the studies examined whether staff changed their practices though none examined fall prevention activities comprehensively—one reported increases in hips protector use [65] and two did not [63,69], one found some improvement in documentation relating to falls [67], one reported reductions in physical restraint use and better care process documentation for falls [68], and one found increased prescriptions of biphosphonate, calcium and Vitamin D
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[69]. Of the seven studies which investigated the impact of the intervention on rates of falls [64,65,67–70] three reported a reduction [64,70,73]. Only one of eight studies which looked at rates of fractures or other injuries [63–66,68,69,71,72] found a reduction in at least one type of injury [72]. One study found a reduction in hospitalization related to falls [65].
Quality improvement Nine studies investigated the impact of interventions to improve care quality [75–83] (see Table 10). With one exception [79], all studies utilized multi-component interventions which encouraged nursing homes to examine their existing care performance and processes and included other methods to support facilities to change their practices.
All studies included and reported improvements in at least one measure of staff behavior related to quality improvement [75–77,79–82,84,85]. The studies which measured the impact of quality improvement on indirect staff outcomes such as retention rates found no effect [82,83]. Five studies which measured outcomes for residents reported improvements on at least one of these [78,79,81,83,85]. The two which did not improve resident outcomes pro- duced minimal changes in staff behavior [76,77]. There did not appear to be a pattern in type or number of components of interventions and outcomes.
Philosophy of care Ten studies focused on changing the philosophy or aspects of care culture, such as person-cen- tered care, emotion-oriented care, awareness oriented care and restorative care [86–103](see Table 11). One study offered training only [91], and one changed staff responsibilities and care procedures [93]. The remaining studies combined training with other intervention compo- nents such as mentoring or support [86,87,89,92,97,99,100,102] and audit and feedback [86,89].
Seven out of eight studies that measured whether staff changed their behavior showed at least some improvements [86,90,91,94,96,98,101]. There did not appear to be a pattern in the intervention components that produced successful interventions. Studies that measured indi- rect staff outcomes reported improvements relating to feelings related to some aspects of work [88,96,101,102], but not on more distal outcomes of health, stress, absenteeism or turnover [92,93,100,101]. Some studies reported benefits on resident behavior [87,89,97,98] functional ability and self-care [91] and quality of life [100], however others found no change or a negative effect on behavior [92,100], wellbeing and satisfaction with care [95,100] and resident commu- nication [102]. Generally, studies which had positive outcomes for residents also achieved staff care practice change, however changing staff behavior did not necessitate improved resident outcomes.
Other clinical domains Single studies were identified which addressed use of advance care directives [104], pain man- agement [30], assault reduction [105], resident to resident mistreatment [106], and pressure ulcer reduction [107](see Table 12). Three of these studies had some positive effects for chang- ing staff practices [104,106,107] and the three studies which reported resident outcomes showed some positive results [104,105,107].
Theoretical orientation of practice change component of program Nine of the eleven studies that reported using a theory in planning the intervention successfully changed at least one aspect of staff care practices. The theories were: Kotter’s eight-step change
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model [82], Kitson implementation of evidence based practice framework [35,36,63], precede/ proceed model [60], Roger’s diffusion theory of innovation [37,39,40,108], Bandura’s social learning theory [65,74], adult learning theory [106], Grol and Wensing’s stepwise approach to implementation [107], the disease management model [81], and the theory of planned behav- ior [55].
Program logic Only three studies explicitly described or presented their program logic or how the intervention was intended to impact the outcomes measured. Zimmerman [60] provided a clear causal chain (and means of testing it) from staff training through to resident quality of life. Teresi [73] provided a risk factor model indicating risk factors, process outcomes and distal outcomes. Smith [42] outlined the components of nursing home staff participation and resident participa- tion in the program and the evaluation methods for each level of participation.
The program logic models that we drew based on the intervention description show that tar- geted staff practices were often not evaluated (for example in Fig 1 in the Meyer study, staff falls prevention practices were not measured), or only some aspects of practice change were evaluated. The logical link was not always apparent or strong between the intervention ele- ments and some of the indirect staff outcomes, particularly turnover and absenteeism, and resi- dent outcomes such as quality of life.
Translating research-demonstrated programs Three studies reported implementing with staff a program which had previously been shown to be effective when delivered by expert clinicians [38,61,66]. These were in the areas of NHAP guideline adherence, fall-related injury prevention and dementia care. There were also two studies which were larger implementation projects of a fracture prevention program which was originally shown to be effectively delivered by staff [71,72,109].
Potential barriers and enablers to change Some studies reported barriers and enablers as part of a formal process evaluation [e.g.s 54,105,110] and others reported barriers as part of the discussion [e.g.s 53,92,107]. Many barri- ers and enablers related to staff—these appeared to be factors that impact on staff practices in general as well as in the implementation of new practices (e.g. high turnover, absenteeism, high workload, low education, and communication/support from senior staff). Organizational and system issues cited seemed to be more specific to the implementation of the new practices e.g. insufficient funding, logistical issues and infrastructure difficulties associated with implementa- tion. Finally, there were several studies that mentioned barriers and enablers that were related to the resident’s high care needs or attitudes of residents and/or families (see Table 13).
Risk of bias (see data in S1 Appendix and Tables 1–12) Given the nature of staff behavior change interventions, the allocation to control and interven- tion groups were not blinded from almost all staff participant groups. Some studies did not use a randomized design, and randomized trials often did not report on their randomization method. Other common biases were incomplete outcome data not being adequately addressed and assessors not being blinded to group allocation. Most studies took some care to protect against contamination and we were unable to detect selective outcome reporting. Baseline characteristics and outcomes were usually similar or controlled for to the intervention group.
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However, studies which were rated as having multiple risks of bias were not more likely to report a positive outcome.
Discussion There are no “magic bullets” to change staff care practices in order to improve resident out- comes. We did not find that any single intervention component (e.g. champions, or audit and feedback), or combination of components consistently resulted in improvements in staff practices within each clinical domain, nor did increasing the number of intervention components.
Table 13. Barriers and enablers to change.
Barrier First author, year
Staff
High turnover or absenteeism Hutt, 2010; Kerse, 2004; Wagner, 2005; Rask, 2007; Rantz, 2001; Achterberg, 2001; Crotty, 2004; Rantz, 2012; Teresi, 2013a; Bravo, 2005; Teresi 2013b.
High workload Ho, 2012; Rantz, 2001; Schrijnemaekers, 2003; Johnson, 2005; Boumans, 2005; Teresi 2013a; Bravo, 2005; Teresi, 2013b; van Weert, 2004.
Insufficient support from senior staff
Kerse, 2004; Boumans, 2005; van Weert, 2004; Huizing, 2009.
Opposing attitudes and lack of commitment
De Visschere, 2012; Rask, 2007; Rantz, 2001; Baier, 2008.
Low education Ho, 2012.
Not all staff trained in intervention
Leone, 2013; Crotty, 2004; Huizing, 2009.
Communication/ cooperation between staff/ physicians
Kerse, 2004; Becker, 2011; Johnson, 2005; van Weert, 2004.
Organisation/ systems issues
Funding and resources lacking Ho, 2012; Avorn, 1992; Ray, 2005; Rask, 2007; Johnson, 2005; Beeckman, 2013.
Infrastructure/ software difficulties
Wagner, 2005; Achterberg, 2001; Irvine, 2012.
Difficulties with logistics (e.g. time schedules, organization)
Crotty, 2004; Zimmerman, 2010; Schrijnemaekers, 2003; Berkhout, 2003.
Does not align with other guidelines/ framework/ policies
Avorn, 1992; Ray, 2005; Schrijnemaekers, 2003.
Competing priorities Teresi, 2013b; van Weert, 2004.
Traditional culture Fossey, 2006; Berkhout, 2003; Irvine, 2012.
Resident/ family
Residents’ high level of care needs
Stein, 2001; Eisses, 2005; Kerse, 2004; Boumans, 2005.
Resident/ family attitudes De Visschere, 2012; Hutt, 2010; Schrijnemaekers, 2003.
Other
Complexity in establishing best practice
Crotty, 2004.
Insufficient length of intervention Finnema, 2005.
External opinion leaders Hutt, 2011; Gulpers, 2013; Becker, 2011.
doi:10.1371/journal.pone.0140711.t013
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Studies that did not change the targeted staff behavior tended to also not improve resident outcomes, and indirect staff outcomes were rarely improved as a result of interventions aimed at improving care of residents.
Studies in clinical domains involving more specific care practices (i.e. hygiene, oral care, appropriate prescribing, and physical restraint reduction) tended to have a higher proportion of “successful” studies compared to domains requiring more global practice changes (i.e. dementia care, falls, quality improvement, philosophy of care). Possible reasons for these differences are:
• The staff behaviors were relatively easier to target and easier to change, such as those which require the changes during specific care practices by individual staff, rather than more coor- dinated changes between staff across multiple care practices
• The target outcomes were easier to measure (and therefore successes and failures were easier to observe)
• The primary outcome of the intervention was staff behavior which is more directly influ- enced by the intervention components, rather than resident outcomes
• There was a better established evidence base between specific care practices and resident out- comes (e.g. fracture prevention program by [109], or between implementation strategies and changing that behavior in another setting (e.g. hygiene in hospitals [111])
In many studies the logical relationships between interventions and measured staff and resi- dent outcomes were not clear. Using a program logic model may help better match interven- tion components and outcomes in designing the intervention and measurements, as well as assisting with maintaining program integrity during delivery. The program logic model also can guide choice of outcome measures, measuring resident outcomes address questions of effectiveness, and may help researchers and services wanting replicate the intervention in their own setting understand the how practice changes were achieved [112]. When staff behavior is not measured, it is not clear whether the program has been unsuccessful because of implemen- tation error or because the staff behavior has changed, but has not brought about the desired improvement in residents [113].
These results support the notion that using theory to plan implementation strategies will increase the success of translating research into practice change [114]. Theories are seldom used, possibly because of the proliferation of theories, models and frameworks, many with lim- ited empirical validation [115]. Nilsen has suggested that since implementation is multifaceted and complex it is unlikely that a single theory can guide all endeavors in the field, however those of us attempting to change practice are left with little guidance on how to choose a theory to guide our implementation.
Barriers and enablers for staff behavior change were often discussed in the context of failed or suboptimal interventions; addressing these proactively as part of the intervention design may increase the chances of success [116]. Common barriers at the staff level were high turn- over or absenteeism and high workload, and at the organizational level, were lack of resources and funding, infrastructure and software difficulties and other logistic difficulties such as time scheduling and organization. Barriers were consistent with other research relating to practice change in nursing homes [117,118]. Researchers should consider barriers from staff, organiza- tional and resident and family perspectives, as well as the external context.
Strengths and limitations The inclusion criteria were designed to include higher quality studies; however we may have inadvertently missed a high quality study because of how we operationalized inclusion criteria.
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There may be a risk of publication bias towards reporting of studies with positive effects within the literature and also of selective reporting within studies—we were unable to assess publica- tion bias statistically as the range of outcomes within each group of studies meant that it did not make sense to combine them in a forest plot. The patterns of results described in this review should be considered with this limitation in mind.
We included a broad range of staff behavior changes so that we could observe the common ingredients for successful practice change across interventions. This was challenging because of the large number of studies included. We decided to present the studies grouped according to clinical domains, we examined groupings according to intervention components, however these were difficult to interpret and not very meaningful. The review team ranked difficulty and complexity of behavior change of clinical domains subjectively.
This review did not look at the ‘dose’ of training or other components, just whether these were provided. This was not examined because the length and frequency of training were usu- ally described however other aspects such as the number of staff trained and style of training (e.g. didactic, interactive) were not routinely reported and may also be important in influencing the impact of training. We attempted to examine fidelity of implementation of the interven- tions, however this was poorly described or not described at all in many studies, such that is it not known whether the interventions were delivered as described in many studies.
Practice change and research implications Researchers, clinicians and service providers contemplating programs requiring staff behavior change in nursing homes should consider: a multifactorial program rather than training alone, investigating and addressing barriers and enablers for their program, using a theory and program logic to design the intervention to ensure that components that target the specific behaviors they want to change and considering motivation as well as knowledge and skills, con- ducting a process evaluation based on the theory and program logic so as to understand how and why the program succeeds or fails, and planning their statistical analyses to take into account clustering and incomplete datasets.
Future research could consider staff motivations in achieving and sustaining behavior change, distinct from delivery of the knowledge and skills required for the change. It would also be useful to develop of a list of common barriers and possible solutions in nursing home practice change, as well as a framework for categorizing the difficulty or complexity of behavior change, for individuals and in an organizational context. The methodology for systematic reviews of efficacy (examining the relationship between a single intervention and single out- come) is well developed, similar methodological development is required for systematic reviews of complex interventions [119] and when outcomes relate to implementation success.
Supporting Information S1 Appendix. Risk of bias ratings. (PDF)
S1 PRISMA Checklist. PRISMA Checklist. (PDF)
Acknowledgments We thank Monica O’Brien, information services librarian at University of New South Wales library for advice on the search strategies for online databases.
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Author Contributions Conceived and designed the experiments: LFL JF. Performed the experiments: LFL JF. Ana- lyzed the data: LFL JF MM. Wrote the paper: LFL JF BG Y-HJ CE-B MM EB.
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