Internationally there is a growing interest in evaluating experienced quality of care to better tailor care to resident’s needs. Narratives are a promising method to achieve this, because they capture experiences, identify conflicting values, and provide rich data that can be used to learn from and improve quality of care with. In the Netherlands, narratives are becoming a more substantial element within the quality improvement cycle of nursing homes. In this symposium, four Dutch research groups will present studies on how different narratives can be used and implemented in nursing homes to achieve and maintain high quality of care for residents.

The first speaker will present how micro-narratives from care staff, residents and significant others enable the evaluation of long-term care. The second speaker will present how stakeholders improve care by reflecting together on rich narrative portraits of residents’ experiences. The third speaker will present the results of a study investigating how the narrative quality evaluation method ‘Connecting Conversations’ can be implemented in nursing home organizations. And, the last speaker will present findings on how the Dutch healthcare inspectorate is currently overseeing the quality of person-centred care in long-term care facilities and discuss the potential of a more reflexive approach using narrative methods.

The narratives of care staff, residents and significant others (SOs) about their personal experiences with care offer insight into their perceived care quality. This information enables the co-creation and evaluation of good care. Therefore, we aimed to develop a method to systematically collect and reflect on micro-narratives, on multiple levels.

From January 2020 to April 2022, we conducted a participatory action study in two care home locations. By continuously following the cycle of action research, we collaboratively worked on the content development, organizational implementation, and technical realization of our method. We used a distributed ethnography software tool (SenseMaker®) as the starting point. Input from care staff, residents and SOs was obtained through participatory observations, interviews, focus groups, and informal conversations.

Together, we developed Experience Matters, a method for collecting, sharing and reflecting on micro-narratives about personal experiences with care. In Experience Matters, care staff, residents and SOs share their experiences as micro-narratives and add meaning to them by answering a number of quantitative questions. The answers to these questions are attached to the micro-narratives as metadata. Using this method, the micro-narratives and metadata can be used to co-create and evaluate care for individual residents (micro-level application) and care provided by a team (meso-level application), and to develop quality policy and accountability reports (macro-level application). Care staff indicated that using Experience Matters contributes to job satisfaction, team spirit and feelings of empowerment. Residents reported increased feelings of equality, and SOs felt more involved in the care process. Lastly, managers and directors indicated that the method leads to real-time insights into the quality of care.

Collaboratively developed with all stakeholders, Experience Matters enables collecting, sharing and reflecting on micro-narratives for the co-creation and evaluation of good care. To implement the method effectively, organizations may consider deploying Experience Matters as part of a larger transition towards being a learning organization.

Collective learning is a widespread aim in long-term care. When professionals share detailed information on their perspective regarding quality of care, they can enter each other’s perspective and create a new joint perspective which may generate a broader meaning together. Reflective spaces are helpful in learning processes as tacit and explicit knowledge is bridged when people come together to reflect on concrete care practices. This study aimed to evaluate the use of the narrative quality instrument ‘The story as a quality instrument’ as a means for collective learning to realize quality improvement.

A qualitative evaluation was performed in 2021-2022 on six field sites of four large care organizations providing long-term care to older adults in the Netherlands. On every field site. The story as a quality instrument was applied: an action plan was formulated based on narrative portraits of older adults in a quality meeting and 8-12 weeks later the progress was evaluated. The data collection concerned the transcripts of both meetings and the observation reports of the researchers. Data were analyzed using thematic analysis.

Four mechanisms became visible that stimulate learning among participants to reach quality improvement: in-depth discussion, exchange of perspectives, abstraction, and concretization. The participants reported on several outcomes regarding individual learning such as change of attitude, looking to older adults more holistically and the realization that possibilities to work on quality improvement could be small and part of everyday work. Participants learned from each other, as they gained insight into each other’s perspectives. The added value concerned getting insight into the individual perceptions of clients, the concrete areas for improvement as outcome, and the diverse people and functions represented. Time was found to be the main challenge for the application of the instrument. Furthermore, the anonymity and quality of the portraits, structural embedding of the instrument and communication were four main conditions for future execution.

The story as a quality instrument is deemed promising for practice, as it allows care professionals to learn in a structured way from narratives of older adults in order to improve the quality of care.

Connecting Conversations is a narrative method that assesses experienced quality of care in nursing homes from the resident’s perspective. This study aimed to identify facilitators and barriers in implementing Connecting Conversations.

In 2022, Connecting Conversations was actively implemented in a nursing home organization where the organization was in the lead. A process evaluation was performed focused on completeness (to what extent did the planned wards complete participation?), value and burden (how did respondents, care teams, ward managers and interviewers experience Connecting Conversations?), and usability of the findings (to what extent was the narrative data used for quality improvement initiatives?). Data were collected with interviews, focus groups and structured observations.

In 2022, 6 internal interviewers followed the Connecting Conversations’ interviewer training and performed 42 conversations (13 residents, 14 family, 15 caregivers) in 4 nursing homes on 5 wards within the care organization.

Findings show that vision & leadership, flexibility in performing the conversations, and clear instructions for respondents and participating wards are necessary for successful implementation. Identified barriers for implementation into the quality management cycle were the continuation of existing quality assessments, lack of resources and the administrational burden linked to research, such as randomization of participants and retrieving informed consent. In addition, it was identified as crucial to provide participating care teams ownership regarding how to use the data for learning and improvement initiatives. This process needs guidance from for example an internal facilitator.

Stories from multiple perspectives provide valuable information for quality improvement initiatives. Yet, in order to implement Connecting Conversations successfully organizational support is indispensable

The emphasis on person-centred nursing home care poses a key challenge for inspectors who regulate quality of care, because of its situated characteristics (i.e., for each client different and changing over time). This makes it difficult to assess with predetermined norms in contrast to for example requirements of medication safety. In this paper, we therefore empirically investigate how inspectors operationalize and evaluate open norms of person-centred care in the Dutch healthcare setting.

Qualitative methods were used to study the work of inspectors who assess the quality of nursing home care within the Dutch Health and Youth Care Inspectorate. The first author7it observed the inspection process of nursing home care organizations (preparation, inspection visit, consults between inspectors and team meetings) and conducted semi-structured interviews with the observed inspectors and managers of the assessed organizations. Furthermore, different versions of the quality report were analyzed.

Easy made operationalizations of person-centred care (e.g., choice for meal) received more attention than other, less easily made, operationalizations of person-centered care (e.g., group dynamics). The following three exclusion mechanisms show why certain aspects of person-centred care got less attention than others: 1) not being able to triangulate information 2) doubting the trustworthiness of a person 3) not being able to deviate from the structure of the inspection program. Furthermore, there are two exclusion mechanisms that show how the assessment of person-centred care is ignored or overruled by other values in the assessment framework: 1) downplaying person-centredness by mitigating circumstances and, 2) prioritization of safety risks over risks of lacking person-centredness.

In evaluating person-centred nursing home care using open norms, certain mechanisms are in place that exclude the assessment of quality of (certain aspects of) person-centered care. To overcome these mechanisms, a different, more reflexive approach for regulation might be needed to encourage stakeholders to engage in self-observation and self-criticism. Reflexive regulation using narrative methods can be especially helpful with complex issues, which are associated with uncertainty about standards and where different perspectives play a role. In further participative action research, we will experiment with and study the use of reflexive regulation using narrative methods in long-term care.

Around 95% of Chinese with dementia in Australia and China reside at home and are cared for by family members. The World Health Organization (WHO) iSupport program has been translated into simplified and traditional Chinese and culturally adapted to the Chinese populations in Australia, Mainland China, Taiwan, Hong Kong and Macau. The objective of this study was to explore family caregivers’ experience in a 6-month randomized controlled trial of a facilitator-enabled iSupport intervention program that includes the utilization of the online iSupport and peer support activities.

A qualitative descriptive design was applied to address the study objective. Caregivers’ interactions with peers and program facilitators in monthly online meetings were audio-recorded and transcribed verbatim for data analysis. Facilitators were required to document their support for caregivers in their monthly portfolios and submit for data analysis. Thematic analysis was used to analyse data collected from online caregiver meetings and facilitator portfolios.

Five main themes were identified from data. First, caregivers were able to follow the group learning goal to complete their monthly learning activities using the online iSupport. They were also capable of selecting additional learning units from iSupport to meet their individual learning needs. Second, caregivers perceived that iSupport enabled them to change their responses to changed behaviours their care recipients had by which they reduced the sources of stressor in their daily care. Third, caregivers were willing and felt safe to share their stressors and seek help from peers and facilitators in group meetings. Fourth, caregivers demonstrated their enthusiasm to help their peers reduce their stressors and social isolation by searching and sharing various electronic resources via Wechat or Whatsapp platform throughout the trial. In addition, facilitators were able to assess caregivers’ learning needs and link them with relevant care services and resources accordingly.

Facilitator-enabled iSupport intervention in our study demonstrated advantages of engaging caregivers in learning iSupport, applying knowledge into daily care activities, sharing experiences with and supporting other caregivers.

Informal caregivers of people with dementia are at high risk of developing mental and physical distress because of the intensity of the care provided. iSupport is an evidence-based online program developed by the World Health Organization (WHO) to provide education and support to informal everyday care. The study aims to describe the process and results of iSupport cultural adaptation in Switzerland.

We used a mixed-methods design, with a community based participatory research approach. The adaptation of iSupport followed WHO adaptation guidelines and developed into five steps: content translation, linguistic and cultural revision by the members of the Community Advisory Board, validation with health professions faculty, validation with formal and informal caregivers, and fidelity check appraisal by members of the WHO.

Findings from each phase showed and consolidated the adjustments needed for a culturally adapted Swiss version of iSupport. We collected feedback and implemented changes related to the following areas: language register and expressions (e.g., from lesson to chapter; from suffering from dementia to affected by dementia); graphics and illustrations (e.g. from generalized objects’ illustrations to featured humans’ illustrations); exercises and case studies (e.g., from general, non-familiar scenarios to local and verisimilar examples); and extra features to add to the online version (e.g., short tailoring assessment questionnaire, interactive forum section, glossary). Additionally, based on the suggestions from the interviews with health professions faculty, we also created a training of trainers (ToT) version of iSupport for health care professionals.

Our results show that adopting a community based participatory approach and collecting lived experiences from the final users and stakeholders is essential to meet local needs and to inform the further development, testing and implementation of an online evidence-based intervention to a specific cultural context.

More than 1.5 million people have been diagnosed with dementia in Russia. Although we have all the necessary doctors and medicines, there is no clear, expert-approved special care system for people with dementia: caregivers do not have a manual for working with people with cognitive impairments. Our adapted web-guide and mobile application aim to educate professional and informal caregivers, and society about the principles of taking care for people with dementia, it’s any age prevention, creating an environment of equality.

The objective of this study is to explore the level of raising awareness of the Russian society about dementia after the implementation of our digital technologies.

Conducting an in-depth expert interview and a focus group with caregivers who got acquainted with the adapted ISupport guide were applied in order to evaluate the appropriateness of care practice for people with dementia in terms of medical standards and to uncover practical infelicities and improve them. Collected data and respondent’s replies analyses, content-analysis that we made became the basic principles of our new application. The quantitative method allows us to track user activity and assess the level of social involvement in dementia issues. Moreover, we have collected caregivers' opinions after they used our application and web-version for the first time by virtue of a qualitative method.

We have reached various aims during our ISupport implementation and working on the research project. First, the number of users of our mobile application is steadily growing (+ 4 people per day at the launch stage). Second, we have received a lot of feedback about our ISupport web version: “it is easy to use; it has a good design, sipid content and a logical structure, which in turn facilitates the process of caring for a person with dementia. Third, medical experts approved our adaptation, web-version and mobile application and recommended it for use in Russian-speaking countries.

we have come to both theoretical and practical results of ISupport implementation in Russia and successfully launched two digital projects. Thanks to the work we have done the dementia issue in Russia will become more popular among society and will prevent the disease of thousands of people.

Why should you pay attention to personality pathology in geriatric psychiatry? To what extent is mental well-being determined by this? How does that relate to the influence of mental disorders? Does the Alternative Dimensional Model of Personality pathology (AMPD) as proposed by the DSM-5 provide more insight into this than the DSM-IV and DSM-5 categorical diagnoses of personality disorders?

These questions were examined in baseline data of 145 patients included in our randomized controlled trial (RCT) into group Schema therapy enriched with psychomotor therapy in older patients with a personality disorder (see Oude Voshaar in this symposium). Mental well-being was measured by a combination of psychological distress (53-item Brief Symptom Inventory), positive mental health (Warwick-Edinburgh Mental Well-being Scale), assessment of own health (RAND-36), and satisfaction with life (Cantrill’s ladder). Personality pathology was assessed according to the categorical personality model using the Structured Clincal Interview for Personality Disorder (SCID-II) as well as the AMDP DSM-5 model using the Severity Indices of Personality Problems (SIPP-short form) and the Personality Iventory for DSM-5 (PID-25). The relationship between personality pathology and mental well-being was investigated using multivariate regression analysis.

Three quarters of the included people with a personality disorder also had another psychiatric disorder (beyond personality pathology). However, personality pathology was found to be responsible for the bulk of the mental health burden and outweighed the influence of these psychiatric disorders. Personality dimensions were highly predictive of mental well-being. This contrasted with the absence of any influence from categorical personality disorders. Although dimensions of personality functioning – and in particular Identity Integration – were the primary predictors of mental well-being, pathological traits added significant predictive value (particularly Disinhibition and Negative Affectivity).

Personality pathology seriously affects the mental well-being of patients and exceeds the impact of comorbid psychiatric disorders. Contrary to the assumption in the alternative DSM-5 and ICD-10 model, both personality functioning and pathological traits contribute to this impact on mental well-being. Screening and systematic assessment of personality pathology in geriatric psychiatry seems warranted.

Different types of psychotherapy have been shown to be successful in treating personality disorders in younger age groups. Nevertheless, well-powered, randomized controlled trials evaluating effectiveness of these therapies in older are lacking. That is why we set up the first randomized controlled trial worldwide into the effect and cost-effectiveness of psychotherapy in older patients with a personality disorder.

We randomized 145 patients (mean age 68 years, range 60 – 80, 65% females) with a cluster B and/or C personality disorder to either group schema therapy enriched with psychomotor therapy (GST+PMT) or to usual care (UC) in specialized geriatric mental health care. The effects were measured after 6 months (end of therapy) and 12 and 18 months (one-year follow-up). Primary outcome measure was psychological distress, as measured with the 53-item Brief Symptom Inventory (BSI-53). Secondary outcome measures were mental well-being, assessed with the Warwick-Edinburgh Mental Well-being Scale, and personality functioning assessed with the Severity Indices of Personality Problems – Short Form (SIPP-SF). Intention to treat analyses using linear mixed models were applied to compare GST+PMT with UC.

Group schema therapy significantly outperformed usual care with an medium effect-size of 0.4 post-treatment, which faded out to a small effect-size of 0.2 at the end of follow-up on the primary outcome parameter. Interestingly, the lower effect-size during follow-up could be explained by a slower treatment response in the usual care condition as post-treatment results of schema therapy were fully maintained during follow-up. Similar results were found with respect to improvement of mental well-being and improvement of personality functioning, although effect-sizes of the latter were a little bit smaller. Age, sex, level of education, and/or cognitive functioning had no impact of these outcomes.

Schema therapy enriched with psychomotor therapy is more effective for the treatment of personality disorder in later life than usual care (which often consists of drug treatment combined with supportive nurse-led care and/or individual psychotherapy).

Approximately one third of older adults (≥ 60 years) with a posttraumatic stress disorder (PTSD) also suffer from a comorbid personality disorder. Emerging evidence shows that in Eye Movement Desensitization and Reprocessing (EMDR) therapy can be beneficial for personality disorders. Since personality disorders are associated with several adverse events, the present study aims to investigate whether EMDR in older adults with PTSD will improve personality functioning.

A multi-center feasibility study was conducted with 24 older PTSD-patients (60-83 years). PTSD was assessed with the Clinician-Administered PTSD Scale-5 (CAPS-5). All participants received weekly 1-hour sessions of EMDR therapy for PTSD up to a maximum of 9 months. The primary outcome was change in personality dysfunction, assessed by Severity Indices of Personality Problems–Short Form (SIPP-SF) at baseline and end of treatment. Secondary outcome was pre-post difference in the presence of (any) personality disorder according to DSM-IV criteria as measured with the Structured Clinical Interview for DSM-IV Axis-II PDs (SCID-II). All analyses were adjusted for PTSD severity, therapy duration, and other treatment (co-interventions) which was kept constant.

A linear mixed model approach showed an increase in SIPP-SF scores from pre- to posttreatment, a significant influence of pre-post CAPS-5 for the total sample (F(1,37.5)=6.95), p=.012) and a marginal significant effect of other treatment (F(1,21.9)=4.04), p=.057). No significant main effects of time, therapy duration (3, 6, or 9 months), CAPS-5 by time was found (all p>.05).

EMDR treatment resulted in improved personality functioning. Other treatment next to EMDR had a negative impact on the increased of personality functioning.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week group treatment program for patients with borderline personality disorders (BPD). STEPPS is an evidence-based treatment to reduce BPD symptoms. However, the mean age of patients studied thus far is 33 years. Studies evaluating STEPPS in older adults are lacking. Aim of this study was to investigate the feasibility of STEPPS in older adults with BPD symptoms.

A naturalistic, pre- vs post-treatment pilot study design. Twenty-four patients (mean age 64 years) completed the Dutch version of the STEPPS program. Primary outcome was BPD symptoms and secondary outcome was psychological distress and maladaptive personality functioning.

The STEPPS pilot in older adults demonstrated a significant decrease in BPD symptoms (Cohen’s d = 1.6), improved self-control of emotions and impulses (r = 0.58), and improved identity integration (Cohen’s d = 0.5). No significant differences were found for psychological distress.

STEPPS is feasible for older adults with BPD symptoms. The treatment program led to a decreased in BPD symptoms and improvement of emotion regulation skills in older adults.

To further improve the feasibility of STEPSS in older adults a Delphi study was performed with seven experts in the field. The results of this Delphi study will additionally be discussed in this presentation. Most important recommendations were the addition of age-specific topics to the STEPPS program, e.g., changing social roles, life review, and/or physical limitations.

tDCS application to the DLPFC is associated with the improvements of executive function, memory enhancement, language, processing speed, global cognitive symptoms and apathy over time after treatment. DLB is the second most common form of degenerative dementia. There is no FDA-approved medications that can slow, stop or improve the progression of cognitive declines in DLB. Identifying effective treatments is a critical issue for DLB. In neuropathology, extracelluar α-syn oligomers interfere with the expression of long-term potentiation(LTP), and influence memory and learning. tDCS has been proposed to affect long-term synaptic plasticity through LTP and long-term depression, thereby improving cognitive ability. So far, only two studies have evaluated the effect of tDCS in DLB. In this pilot study, we investigate the effect of tDCS on left DLPFC in DLB.

Fourteen DLB aged 55-90 years (mean age 76.4, with 4 males and 10 females) were included in a double-blind, randomized, sham-controlled cross over design study. DLB diagnostics is according to DSM-5 criteria. CDR ratings for DLB participants ranged from 0.5 to 2. The active tDCS (or sham) process consists of daily sessions of active tDCS (or sham) for 10 consecutive days. The anodal electrode was placed over the left DLPFC and the cathodal electrode was placed over the right supraorbital area, with a current intensity of 2 mA and an electrode size of 25 cm2 for 30 min in a session. Before and after these treatment sessions, all subjects received a series of neuropsychological tests, including CDR, MMSE, CASI, NPI and WCST. Chi-square test, Wilcoxon signed ranks test and Mann-Whitney U test were used to assess differences in participant demographic characteristics and to compare differences among groups.

The active tDCS group showed significant improvements on the three items of CASI, ‘language ability’, ‘concentration and calculation’, ‘categorical verbal fluency’, after active stimulations. There is no improvement in MMSE, CASI, NPI and WCST scores in the sham groups.

These results suggest that left DLPFC anodal, and right deltoid cathodal tDCS, may have some cognitive benefits in DLB. Larger-scale trials are needed to confirm the effect of tDCS in DLB.

Key words: Transcranial Direct Current Stimulation, Dementia with Lewy Bodies, cognitive function, Wisconsin Card Sorting Test, left DLPFC