Measurement of Nursing Home Culture Change: Systematic Review

Nursing home culture change (NHCC) aims to change the way care is provided in nursing homes. Valid and reliable measures are needed to evaluate the impact of NHCC on outcomes. The current systematic review provides an overview of instruments designed to measure NHCC and criteria for others to evaluate and choose instruments according to their own purpose. Ten instruments were identified that measure NHCC on an organizational level. Lack of development description hindered their assessment, and studies examining the relationship between NHCC and outcomes are rare. A common limitation of the instruments reviewed was the lack of psychometric testing; thus, their validity and reliability need further exploration. [Res Gerontol Nurs. 2018; 11(2):103-112.].

Developing inclusive residential care for older lesbian, gay, bisexual and trans (LGBT) people: An evaluation of the Care Home Challenge action research project

There have been substantial achievements in legislative and human rights for lesbian, gay, bisexual and transgender (LGBT) older people and their visibility in health and social care has equally increased. These appear to have surpassed the ability of care services to meet their needs given documented concerns about the accessibility, inclusiveness and safety of care services particularly institutionalised care. This requires systemic change not easy to operationalise. This paper describes an action research initiative where six care homes belonging to a national care provider, collaborated to assess and develop their services with the support of local LGBT "Community Advisors" and academic partners. Framed within Rogers' (2003) change management framework and combined with a participatory leadership approach, a programme of intervention was implemented comprising structured activities around seven key areas thought to promote LGBT inclusion. A formal evaluation was conducted involving 35 pre- and post-intervention qualitative interviews with 18 people (community advisors; care home managers and senior managers). The findings are presented across three key themes (1) starting points on the journey; (2) challenges encountered along the journey (organisational and interpersonal); and (3) making change happen; opportunities, initiatives and gains. We make recommendations on the value of a programme approach for achieving tangible outcomes that demonstrate increased inclusion for older LGBT people living in long-term care settings.

Characteristics, consequences and prevention of falls in institutionalised older adults in the province of Malaga (Spain): a prospective, cohort, multicentre study

OBJECTIVES

Falls are an important adverse event among institutionalised persons. It is in this clinical setting where falls occur more frequently than in any other, despite the measures commonly taken to prevent them. This study aimed to determine the characteristics of a typical institutionalised elderly patient who suffers a fall and to describe the physical harms resulting from this event. We then examined the association between falls and the preventive measures used.

METHODS

This was a prospective cohort study in 37 nursing homes in Spain. The participants were all the nursing home residents institutionalised in these centres from May 2014 to July 2016. Participants were followed up for 9 months. During this period, two observations were made to evaluate the preventive measures taken and to record the occurrence of falls.

RESULTS

896 residents were recruited, of whom 647 completed the study. During this period, 411 falls took place, affecting 213 residents. The injuries caused by the falls were mostly minor or moderate. They took place more frequently among women and provoked 22 fractures (5.35%). The most commonly used fall prevention measure was bed rails (53.53% of cases), followed by physical restraint (16.79%). The latter measure was associated with a higher incidence of injuries not requiring stitches (OR=2.06, 95% CI 1.01 to 4.22, P=0.054) and of injuries that did require stitches (OR=3.51, 95% CI 1.36 to 9.01, P=0.014) as a consequence of falls. Bed rails protected against night-time falls.

CONCLUSIONS

Falls are a very common adverse event in nursing homes. The prevention of falls is most commonly addressed by methods to restrain movement. The use of physical restraints is associated with a greater occurrence of injuries caused by a fall.

Organizational factors associated with readiness for change in residential aged care settings

BACKGROUND

Organizational change is inevitable in any workplace. Previous research has shown that leadership and a number of organizational climate and contextual variables can affect the adoption of change initiatives. The effect of these workplace variables is particularly important in stressful work sectors such as aged care where employees work with challenging older clients who frequently exhibit dementia and depression.

METHODS

This study sought to examine the effect of organizational climate and leadership variables on organizational readiness for change across 21 residential aged care facilities. Staff from each facility (N = 255) completed a self-report measure assessing organizational factors including organizational climate, leadership and readiness for change.

RESULTS

A hierarchical regression model revealed that the organizational climate variables of work pressure, innovation, and transformational leadership were predictive of employee perceptions of organizational readiness for change.

CONCLUSION

These findings suggest that within aged care facilities an organization's capacity to change their organizational climate and leadership practices may enhance an organization's readiness for change.

Impact of the design of the built environment on people with dementia: an evidence-based review

OBJECTIVE

In this review the impact of the design of the built environment on people with dementia in long-term care settings is systematically analyzed and summarized. Architects and designers will be provided with credible evidence on which they can confidently base their design decisions. Researchers will be able to determine which environmental aspects have been well investigated and where there are gaps in the current state of the research.

BACKGROUND

A great number of studies have established a relationship between the design of the physical environment of long-term care settings and outcomes of people with dementia. However, the methods employed are heterogeneous and the results are often conflicting. Consequently, the process of integrating the best evidence available into architectural designs may be hindered.

METHODS

A systematic literature search was conducted reviewing studies that meet certain inclusion criteria. Using an evidence-based approach, the methodical quality of the studies was rated.

RESULTS

One hundred sixty-nine studies were found. They were thematically summarized into four main categories: basic design decisions, environmental attributes, ambience, and environmental information. The effectiveness of the interventions on the behavior, cognition, function, well being, social abilities, orientation, and care outcomes on people with dementia was illustrated by matrices.

CONCLUSIONS

Results of this review indicate that, with the exception of cognition, specific design interventions are beneficial to the outcomes of people with dementia. Overall, the field of environmental design for people with dementia is well researched in many aspects and only few gaps in knowledge were identified.

Developing a theoretical model and questionnaire survey instrument to measure the success of electronic health records in residential aged care

Electronic health records (EHR) are introduced into healthcare organizations worldwide to improve patient safety, healthcare quality and efficiency. A rigorous evaluation of this technology is important to reduce potential negative effects on patient and staff, to provide decision makers with accurate information for system improvement and to ensure return on investment. Therefore, this study develops a theoretical model and questionnaire survey instrument to assess the success of organizational EHR in routine use from the viewpoint of nursing staff in residential aged care homes. The proposed research model incorporates six variables in the reformulated DeLone and McLean information systems success model: system quality, information quality, service quality, use, user satisfaction and net benefits. Two variables training and self-efficacy were also incorporated into the model. A questionnaire survey instrument was designed to measure the eight variables in the model. After a pilot test, the measurement scale was used to collect data from 243 nursing staff members in 10 residential aged care homes belonging to three management groups in Australia. Partial least squares path modeling was conducted to validate the model. The validated EHR systems success model predicts the impact of the four antecedent variables—training, self-efficacy, system quality and information quality—on the net benefits, the indicator of EHR systems success, through the intermittent variables use and user satisfaction. A 24-item measurement scale was developed to quantitatively evaluate the performance of an EHR system. The parsimonious EHR systems success model and the measurement scale can be used to benchmark EHR systems success across organizations and units and over time.

[Nursing home, caregiving practice and new work organisation]

The recent ageing of the population is resulting in a corresponding increase in the functional dependence of elderly people. Nursing homes hosting this specific population must adapt to this new profile of resident and their arrival at an increasingly older age. Caregiving tasks are becoming more cumbersome affecting the working conditions of caregivers who also face the new management approaches which are imposed.

[Life project of residents and institutional approach in nursing homes]

The life project in a nursing home involves all the players concerned: first of all, the resident, then the caregivers, the families and the institution. This unifying tool, organised around the elderly, helps to develop collective competencies, favours the integration of new residents and reassures families. This article presents a nursing home's experience of setting up a life project.

[Nutritional status of residents of a nursing home and optimisation of the working time of caregivers]

The lack of time to devote to care is a frequent complaint of nurses and nursing assistants. The results of a study show that an improvement in the nutritional status of nursing home residents could help to improve their quality of life and to optimise the working time of the nursing teams, thanks to the reduction of pressure ulcers, diarrhoea, falls, fractures and infections.

Involvement of people with dementia in making decisions about their lives: a qualitative study that appraises shared decision-making concerning daycare

OBJECTIVE

To explore how people with dementia, their informal caregivers and their professionals participate in decision making about daycare and to develop a typology of participation trajectories.

DESIGN

A qualitative study with a prospective, multiperspective design, based on 244 semistructured interviews, conducted during three interview rounds over the course of a year. Analysis was by means of content analysis and typology construction.

SETTING

Community settings and nursing homes in the Netherlands.

PARTICIPANTS

19 people with dementia, 36 of their informal caregivers and 38 of their professionals (including nurses, daycare employees and case managers).

RESULTS

The participants' responses related to three critical points in the decision-making trajectory about daycare: (1) the initial positive or negative expectations of daycare; (2) negotiation about trying out daycare by promoting, resisting or attuning to others; and (3) trying daycare, which resulted in positive or negative reactions from people with dementia and led to a decision. The ways in which care networks proceeded through these three critical points resulted in a typology of participation trajectories, including (1) working together positively toward daycare, (2) bringing conflicting perspectives together toward trying daycare and (3) not reaching commitment to try daycare.

CONCLUSION

Shared decision making with people with dementia is possible and requires and adapted process of decision making. Our results show that initial preferences based on information alone may change when people with dementia experience daycare. It is important to have a try-out period so that people with dementia can experience daycare without having to decide whether to continue it. Whereas shared decision making in general aims at moving from initial preferences to informed preferences, professionals should focus more on moving from initial preferences to experienced preferences for people with dementia. Professionals can play a crucial role in facilitating the possibilities for a try-out period.

Clinical Update on Nursing Home Medicine: 2017

This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered are hypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary disease risk factors, diagnosis and management including end-of-life planning, and the difficulties with exacerbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; and wound care and pressure ulcer management.

"Bringing the outside world in": Enriching social connection through health student placements in a teaching aged care facility

BACKGROUND

Older adults living in residential aged care facilities (RACFs) often experience limited opportunities for social connection despite close proximity to peers, which has implications for mental health and quality of life (QoL). The introduction of large-scale undergraduate health student placements in RACFs may enhance opportunities for meaningful engagement through social connection, although this remains unexplored.

OBJECTIVE

This research explores whether interpersonal encounters between health students and RACF residents influence residents' opportunities for social connection and QoL.

METHODS

A mixed methods design was employed which included questionnaire data from residents, and qualitative interview data from residents, family members and RACF staff. Data were collected during and after student placements to allow for an in-depth exploration of residents, family members and staff perspectives.

RESULTS

Forty-three participants (28 residents, 10 staff and five family members) were recruited during 2014. Overall, many residents had clinical levels of depression, mild cognitive impairment and multiple morbidities, however reported moderate-to-good QoL. Thematic analysis was undertaken on interview transcripts, and three themes emerged: (i) social isolation and loneliness fostered by residents' age-related conditions, (ii) students expand socially supportive connections beyond the RACF and (iii) meaning making by sharing health experiences, which was found to help renegotiate older adults' pervasive narrative of vulnerability.

CONCLUSION

Supported and structured health student placements in RACFs enable older adults to participate in meaningful encounters with younger people. These encounters focus on sharing health experiences and address long-standing issues of isolation and loneliness by providing opportunities for social connection.

What makes extra care housing an appropriate setting for people with dementia? An exploration of staff decision-making

Extra care housing facilities in the UK are intended to offer a community-based alternative to care home placement. However, little is known about staff’s views of the appropriateness of extra care housing for people with dementia. This paper describes a mixed-methods study which explored this issue using statistical modelling of frontline staff’s recommendations of the best care setting for care home entrants; thematic analysis of transcripts from a simulated Resource Allocation Management Panel meeting; and content analysis of care coordinators’ reasons for not considering extra care housing in actual care home applications. Frontline practitioners saw extra care housing as a valuable alternative for a significant minority of care home entrants. However, extra care housing was not recommended if people needed care at night. Social care managers expressed general support for the idea of extra care housing, but appeared overwhelmingly focused on maintaining people at home and unsure where in the care pathway extra care housing sat. More evidence is needed on whether extra care housing can be an alternative to care homes and how services should be arranged to meet the needs of people living in extra care housing.

Conflicting rationales: leader's experienced ethical challenges in community health care for older people

BACKGROUND

Ethical challenges arise in all types of care, and leaders need to be aware of how to resolve these challenges. Healthcare systems tend to be organised around medical conditions, and the patient is often faced with a series of uncoordinated visits to multiple specialties. Ideally, care should be organised around the patient's needs.

AIM

The purpose of this article was to highlight some ethical challenges perceived by leaders with responsibility for management and service distribution, finance and ensuring quality of community health services for older people.

METHOD

This study had a qualitative design with a qualitative content analysis of one focus group with six leaders that met four times in total. Leaders from the community healthcare sector in one Norwegian municipality were included, representing both nursing homes and home-based health care. The study followed the intentions of the Declaration of Helsinki and standard ethical principles. The Norwegian Social Science Data Services approved the study. All participants voluntarily gave written informed consent.

FINDINGS

The main theme that emerged from this study was the ethical challenge leaders felt in the form of an inherent conflict between a caring rationale versus economic or technological rationales. Four categories emerged: (i) Management: quality versus economy; (ii) Prioritisation: fair distribution of healthcare services; (iii) Responsibility: considering individuals' needs versus the needs of the whole community; and (iv) Welfare technology: possibilities and challenges.

CONCLUSION

Leaders' responsibilities in community health care for older people need to strike a balance between ethical principles in the management of limited resources.

Developing Caring Conversations in care homes: an appreciative inquiry

Relationship-centred practice is key to delivering quality care in care homes. Evidence is strong about the centrality of human interaction in developing relationships that promote dignity and compassion. The Caring Conversations framework is a framework for delivering compassionate care based on human interactions that was developed in the acute healthcare setting. The key attributes are: be courageous, connect emotionally, be curious, consider other perspectives, collaborate, compromise and celebrate. This paper reports on a study to explore its relevance to the care home setting and the development of an educational intervention, based on the framework, to enhance development of human interaction. The study used the approach of appreciative inquiry to develop Caring Conversations in the care home setting. Appreciative inquiry has a unique focus on what is working well, understanding why these aspects work well and co-creating strategies to help these good practices happen more of the time. The aim of the study was to celebrate and develop excellent human interaction that promotes dignity between staff, residents and families in care homes. The study took place in 2013-2014 in one care home in Scotland, over 10 months. Participants included staff (n = 37), residents (n = 20) and relatives (n = 18). Data generation methods involving residents, relatives and staff included observation and interviews about experiences of interaction. An iterative process of data analysis involved mapping core themes to the Caring Conversations framework with findings showing how people communicated correlated well with the Caring Conversations framework. Building on knowledge of what works well, staff developed small 'tests of change' that enabled these good practices to happen more of the time. Appreciative inquiry proved a valuable approach to exploring Caring Conversations, developing practice and developing an educational intervention that could be shared across other care settings.

[Governance in a project addressing care of disabled elderly persons within the regional healthcare system of Tuscany, Italy]

Population aging and the concurrent increase of age-related chronic degenerative diseases and disability are associated with an increased proportion of elderly persons who are dependent in activities of daily living (ADL). ADL-dependent persons need continuous and long-term health and social care according to the "taking charge" rationale, in order to warrant access and continuity of care. A healthcare system needs to respond to the long-term and complex needs, such as those of disabled elderly people, by providing appropriate health and social care services in Primary Care. A Primary Health Care system is organized according to two governance levels have distinct aims but are closely inter-dependent in their operational mechanisms. The system governance is accountable for the community and individual health protection while the delivery governance is accountable for the provision of services in accordance with appropriateness, safety and economic criteria. Delivery governance can be considered "integrated governance" as a synergy exists between two decision-making systems guiding provider choices, which are corporate governance and clinical governance. The aim of this study was to analyse the abovementioned governance levels within the healthcare system in Tuscany (Italy) referring to long-term residential care for disabled elderly people. The case of excessive accesses to emergency departments from different types of Nursing Homes (NH) is used as an example to analyse different levels of responsibility involved in the management of a critical phenomenon. Suggestions for improvement in the different levels of governance for disabled elderly people are provided, in order to support institutional programming activities.

Poor outdoor access linked to depression

Lack of access to gardens and outdoor spaces could harm care home residents' mental health, a study published in The Gerontologist has found.

Enhancing resiliency for elderly populations : Shelter-in-place planning and training at facilities serving elderly populations through the Rhode Island Senior Resiliency Project

Elderly populations are disproportionately affected by disasters. In part, this is true because for many older adults, special assistance is needed to mitigate the consequences of disasters on their health and wellbeing. In addition, many older adults may reside in diverse living complexes such as long-term care facilities, assisted living facilities and independent-living senior housing complexes. Planning for each type of facility is different and the unique features of these facilities must be considered to develop readiness to deal with disasters. Based on this, the Rhode Island Department of Health established the Senior Resiliency Project to bolster the level of resiliency for the types of living facilities housing older adults. The project involves performing onsite assessments of energy resources, developing site-specific sheltering-inplace and energy resiliency plans, and educating and training facility employees and residents on these plans and steps they can take to be better prepared. Based on the feasibility of conducting these activities within a variety of facilities housing older adults, the project is segmented into three phases. This paper describes survey findings, outcomes of interventions, challenges and recommendations for bridging gaps observed in phases 1 and 2 of the project.

GP services and care homes

Essential facts Improving how GPs and care home staff work together is essential if residents are to receive more timely care, according to the Social Care Institute for Excellence (SCIE).

Pneumonia in Nursing Home Patients With Advanced Dementia: Decisions, Intravenous Rehydration Therapy, and Discomfort

BACKGROUND

Comfort may be an appropriate goal in advanced dementia. Longitudinal studies on physician decision-making and discomfort assessed by direct observation are rare, and intravenous rehydration therapy is controversial.

METHODS

To assess treatment decisions and discomfort in patients with advanced dementia and pneumonia and to compare by intravenous rehydration therapy, we used data from the observational multicenter Italian End of Life Observatory-Prospective Study On DEmentia patients Care. We analyzed 109 episodes of pneumonia, which involved decisions in 77 nursing home patients with Functional Assessment Staging Tool stage 7. We assessed decisions, decision-making, and treatments every fortnight. Trained observers assessed discomfort with the Discomfort Scale-Dementia Alzheimer Type (DS-DAT).

RESULTS

Most decisions referred to treatment with antibiotics (90%; 98 of 109) and intravenous rehydration therapy (53%; 58 of 109), but hospitalization was rare (1%). Selecting decisions with antibiotics, with rehydration therapy, the prognosis was more frequently <15 days (34% vs 5% without rehydration therapy; P = .001), and a goal to reduce symptoms/suffering was more common (96% vs 74%; P = .005) while there was no difference in striving for life prolongation (a minority). With rehydration therapy, the decision was more often discussed with family rather than communicated only. Mean DS-DAT scores over time proximate to the first decision ranged between 9.2 and 10.5.

CONCLUSIONS

Italian nursing home patients with advanced dementia and pneumonia frequently received invasive rehydration therapy in addition to antibiotics, however, mostly with a palliative intent. Discomfort was high overall and symptom relief may be improved. Relations between invasive rehydration therapy and discomfort need further study.

Nursing home team-care deprescribing study: a stepped-wedge randomised controlled trial protocol

INTRODUCTION

An ageing population has become an urgent concern for Asia in recent times. In nursing homes, polypharmacy has also become a compounding issue. Deprescribing practice is an evidence-based strategy to provide a better outcome in this group of patients; however, its implementation in nursing homes is often challenging, and prospective outcome data on deprescribing practice in the elderly is lacking. Our study assesses the implementation of team-care deprescribing to understand the benefits of this practice in geriatric setting and to explore the factors affecting deprescribing practice.

METHODS AND ANALYSIS

This multicentre prospective study consists of a prestudy interview questionnaire, and a preintervention and postintervention study to be conducted in the nursing home setting on residents at least 65 years old and on five or more medications. We will employ a cluster randomised stepped-wedge interventional design, based on a five-step (reviewing, checking, discussion, communication and documentation) team-care deprescribing practice coupled with the use of a deprescribing guide (consisting of Beers and STOPP criteria, as well as drug interaction checking), to assess the health and pharmacoeconomic outcome in nursing homes' practice. Primary outcome measures of the intervention will consist of fall risks using a fall risk assessment tool. Other outcomes assessed include fall rates, pill burden including number of pills per day, number of doses per day and number of medications prescribed. Cost-related measures will include the use of cost-benefit analysis, which is calculated from the medication cost savings from deprescribing. For the prestudy interview questionnaire, findings will be analysed qualitatively using thematic analysis.

ETHICS AND DISSEMINATION

This study is approved by the Domain Specific Review Board of National Healthcare Group, Singapore (2016/00422) and Monash University Human Research Ethics Committee (2016-1430-7791). The study findings shall be disseminated in international conferences and peer-reviewed publications. The study is registered with ClinicalTrials.gov (NCT02863341), Pre-results.

Developing the Supporting Choice Observational Tool (SCOT): A Formative Assessment Tool to Assist Nursing Home Staff in Realizing Resident Choice

Quality of care in nursing homes has begun to address the importance of resident choice in daily life, yet there are no published tools to teach nursing home staff how to offer such choice. In the current study, a formative assessment tool was developed that can provide staff with detailed and concrete feedback on how to realize resident choice. The tool was created and refined through 22 hours of ethnographic observation in two Veterans Health Administration Community Living Centers (CLCs), 22 hours of developmental testing in two CLCs, review by a modified Delphi panel, and use of an algorithm to assess its logical structure. The resulting Supporting Choice Observational Tool (SCOT) documents how choice is or is not offered and is or is not enabled within a singular staff-resident interaction. SCOT findings could be used in clinical teaching, quality improvement, or research efforts intent on enhancing nursing home resident quality of life. [Res Gerontol Nurs. 2017; 10(3):129-138.].

Assessment of Activity of Daily Living Among Older Adult Patients in Home Healthcare and Skilled Nursing Facilities: An Integrative Review

Older adult's ability to self-manage illness is dependent on their ability to perform activities of daily living (ADL). Forty-five percent of those older than 65 years will have ongoing clinical needs after hospital discharge and require postacute care (PAC) services in settings such as home healthcare (HHC) and skilled nursing facilities (SNF). The Improving Medicare Post-Acute Care Transformation Act of 2014 requires PAC providers to begin collecting and reporting ADL data to build a coordinated approach to payment and standardize patient assessments and quality measurement. The aim of this integrative review was to compare the methods of assessing ADLs in HHC to SNF. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to ensure results were reported systematically. A scientific literature search without date restriction within the PubMed and Cumulative Index of Nursing and Allied Health Literature databases was conducted. Two independent investigators assessed study quality using the quality appraisal instrument developed by Kmet et al. Study quality was high. Of the 18,749 articles identified by the search, 8 met inclusion criteria and four tools were identified that are used to assess ADLs in SNF and HHC. Although SNF and HHC collect similar ADL information, the range of content covered, item definitions, scoring, and psychometrics are not comparable across settings.