The Impact of Nursing Homes Staff Education on End-of-Life Care in Residents With Advanced Dementia: A Quality Improvement Study

The effectiveness of educational interventions in enhancing health professionals' and students' pain assessment for people living with dementia: A systematic review

OBJECTIVES

To evaluate the effectiveness of educational interventions in improving the knowledge, attitudes, beliefs, self-efficacy, and confidence of health professionals' and students' pain assessment in dementia.

DESIGN

A systematic review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Eight English databases were searched: Medline, Psychological Information Database, Cochrane Library, PubMed, Cumulative Index of Nursing and Allied Health Literature, ProQuest, Scopus, and Web of Science.

REVIEW METHODS

Databases were searched without any time limit using synonyms for "health personnel", "health students", "pain assessment", "dementia", "educational intervention", "knowledge", "attitude", "beliefs", "self-efficacy", and "confidence". The review included studies published up to 26 March 2024. Reference lists and review papers were screened to identify additional papers. Data was synthesised according to the intervention designs and outcome measures and presented narratively.

RESULTS

The seven studies retained involved 517 registered nurses, 17 physical therapists, eight occupational therapists, 17 physicians, 99 nursing students, and 161 medical students. All seven studies evaluated the effectiveness of educational interventions on knowledge, three on attitudes, two on confidence, one on self-efficacy, and none on beliefs of pain assessment in dementia. Health professionals' and students' knowledge scores improved irrespective of the training delivery mode and duration. Their confidence scores improved irrespective of training duration. Health professionals' self-efficacy scores improved upon completion of online training. Overall attitude scores for most health professionals and students did not increase upon educational intervention completion, irrespective of the training delivery mode and duration. Educational interventions mainly focused on methods that assess pain in both communicative and non-communicative people with dementia.

CONCLUSIONS

Educational interventions enhance health professionals' and students' knowledge, self-efficacy, and confidence in pain assessment in dementia. Studies showed mixed findings related to attitudes, and there is a limited understanding of interventions' effectiveness in correcting erroneous beliefs.

Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial

BACKGROUND

People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care.

OBJECTIVE

The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia.

DESIGN

Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside.

SUBJECTS & SETTING

One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff.

METHODS

Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes.

RESULTS

At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified.

CONCLUSION

This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257 . Registered 14 December 2018.

Defining end of life in dementia: A systematic review

BACKGROUND

Dementia is a life-limiting condition that affects 50 million people globally. Existing definitions of end of life do not account for the uncertain trajectory of dementia. People living with dementia may live in the advanced stage for several years, or even die before they reach the advanced stage of dementia.

AIM

To identify how end of life in people with dementia is measured and conceptualised, and to identify the factors that contribute towards identifying end of life in people with dementia.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Electronic databases MEDLINE, EMBASE, PsychInfo and CINAHL, were searched in April 2020. Eligible studies included adults with any dementia diagnosis, family carers and healthcare professionals caring for people with dementia and a definition for end of life in dementia.

RESULTS

Thirty-three studies met the inclusion criteria. Various cut-off scores from validated tools, estimated prognoses and descriptive definitions were used to define end of life. Most studies used single measure tools which focused on cognition or function. There was no pattern across care settings in how end of life was defined. Healthcare professionals and family carers had difficulty recognising when people with dementia were approaching the end of life.

CONCLUSION

End-of-life care and research that focuses only on cognitive and functional decline may fail to recognise the complexities and unmet needs relevant to dementia and end of life. Research and clinical practice should adopt a needs-based approach for people with dementia and not define end of life by stage of disease.

Preliminary Effect and Acceptability of an Intervention to Improve End-of-Life Care in Long-Term-Care Facilities: A Feasibility Study

The number of deaths of older adults in long-term care settings will increase with the aging population. Nurses and care workers in these settings face various challenges in providing end-of-life care, and interventions for quality end-of-life care may be useful. This feasibility study aims to explore the preliminary effect and acceptability of an intervention named the EOL Care Tool to improve end-of-life care in long-term-care facilities. We conducted a single-arm quasi-experimental study using mixed methods. This tool consisted of multiple components: professionalized lectures, newly developed structured documents, regular conferences regarding end-of-life care, and educational support from administrators. Twenty-four nurses and fifty-five care workers employed in a long-term care facility participated. For nurses, improvement in attitudes toward end-of-life care (p < 0.05) and interdisciplinary collaboration (p < 0.05) were shown quantitatively. Regarding acceptability, nurses and care workers evaluated the tool positively except for the difficulty of using the new documents. However, qualitative results showed that care workers felt the reluctance to address the work regarding end-of-life care. Therefore, a good preliminary effect and acceptability for nurses were indicated, while acceptability for care workers was only moderate. Revision to address the mentioned issues and evaluation of the revised tool with a more robust research design are required.

Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review

OBJECTIVES

Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life.

DESIGN

Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271).

SETTING AND PARTICIPANTS

Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life.

MEASUREMENTS

The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources.

RESULTS

After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance.

CONCLUSIONS AND IMPLICATIONS

The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.

End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes

OBJECTIVE

To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs.

METHODS

A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21).

RESULTS

The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.

Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature

BACKGROUND

Given the increase in the number of deaths within long-term care facilities (LTCFs), the need for palliative and end-of-life (EOL) care education among such facilities has been increasing. As such, a systematic synthesis of global palliative and EOL care educational approaches and evaluation can aid further educational development.

OBJECTIVE

To synthesise the current literature on palliative and EOL care educational interventions for staff working in LTCFs and identify barriers to, and facilitators of, intervention implementation.

METHODS

The study used an integrative review framework wherein indexed databases, namely, CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, Cochrane Library and Japan Medical Abstract Society, were systematically searched for studies published in English and Japanese between 2007 and 2019. Search terms that are related to palliative care, LTCF, and education were combined to increase search sensitivity. The quality of the papers was assessed using Joanna Briggs Institute Critical Appraisal Tools and the Mixed-Methods Appraisal Tool.

RESULTS

A total of 52 studies were included in the review. Our results suggested that although studies in this area and setting have been evolving, suboptimal developmental research and educational practices, global variability and unstandardised approaches to education and lacking viewpoints from service users have remained. Barriers to intervention implementation were also reported due to the specific characteristics of LTCFs, which include high staff turnover and considerable variation in professional skills and experience.

CONCLUSIONS

Given the different LTCF types, systems and policies across each country or region, further research on standardised educational interventions with contextual considerations using large-scale studies with robust methodology is needed to meet the increasing demand for palliative and EOL care among the global ageing population.

IMPLICATIONS FOR PRACTICE

Palliative and EOL care educational intervention for LTCF staff need to include more consideration of context, organisational culture and the user involvement throughout the process of education and research to enhance the quality of care in this complex setting.

Nursing staff participation in end-of-life nutrition and hydration decision-making in a nursing home: A qualitative study

AIM

To better understand the participation of nursing staff in end-of-life nutrition and hydration decision-making in an American nursing home.

DESIGN

A qualitative exploration with ethnographic focus.

METHODS

In April 2017, in-person, semi-structured interviews were performed with 19 nursing staff members in a nursing home located in the south-eastern United States. Additional information was gathered through participant observation during interviews and review of organizational and regulatory policies. Transcripts were coded and analysed using qualitative methods described by Roper and Shapira (2000).

RESULTS

Three primary themes relating to nursing staff participation in end-of-life nutrition and hydration decision-making were identified: (a) Formal decision-making: decisions made and implemented by persons with the authority to make legal and binding care decisions in the nursing home setting; (b) Informal decision-making: decisions not requiring medical orders; and (c) Influential factors: factors that influence actions of nursing staff.

CONCLUSION

A variety of factors have an impact on nursing staff participation in end-of-life nutrition and hydration decision-making. Participation is closely aligned with the type of decision, whether formal or informal, and role, whether Certified Nursing Assistant/Aide, Licensed Practical/Vocational Nurse, or Registered Nurse.

IMPACT

End-of-life nutrition and hydration decision-making in nursing homes differs from decision-making in other care settings and presents a challenge globally. Interventions that support the participation of nursing staff in end-of-life nutrition and hydration decision-making have the potential to positively impact the experiences of residents and family members faced with these issues in the nursing home setting.

Effect of palliative care training on perceived self-efficacy of the nurses

Background

Nurses are involved in providing end-of-life care for end stage individuals and their self-efficacy is one of the key factors bearing on such care. The purpose of this study was to determine the effect of palliative care on perceived self-efficacy of the nurses.

Methods

This is a quasi-experimental study with pretest-posttest design. Sampling was randomized and included 40 individuals. The intervention consisted of palliative care training for four sessions, each lasting 45 min. Data were collected using demographic and perceived self-efficacy questionnaires completed before and after the intervention. Data were then analyzed by SPSS 16 software using descriptive and inferential statistics.

Results

The mean age of the participants was 38.6 and their work experience was 14.25 years. The majority of the participants were female (85%) and had a bachelor level of education (92.5%). The findings showed that “perceived self-efficacy”, “psychosocial support” and “symptom management” improved significantly after intervention (p < 0.05).

Conclusion

Based on the results, palliative care education has the potential to increase nurses’ perceived self-efficacy. Since all members of the health care team Including nurses play an important role in providing palliative care, nursing managers can take an effective step to maximize the capacity of nurses by planning and supporting training in this regard.

Components of palliative care interventions addressing the needs of people with dementia living in long-term care: A systematic review

BACKGROUND

People with dementia requiring palliative care have multiple needs, which are amplified in long-term care settings. The European Association for Palliative Care White Paper offers recommendations for optimal palliative care in dementia integral for this population, providing useful guidance to inform interventions addressing their specific needs.

AIM

The aim of this study is to describe the components of palliative care interventions for people with dementia in long-term care focusing on shared decision-making and examine their alignment to the European Association for Palliative Care domains of care.

DESIGN

Systematic review with narrative synthesis (PROSPERO ID: CRD42018095649).

DATA SOURCES

Four databases (MEDLINE, CINAHL, PsycINFO and CENTRAL) were searched (earliest records - July 2019) for peer-reviewed articles and protocols in English, reporting on palliative care interventions for people with dementia in long-term care, addressing European Association for Palliative Care Domains 2 (person-centred) or 3 (setting care goals) and ⩾1 other domain.

RESULTS

Fifty-one papers were included, reporting on 32 studies. For each domain (1-10), there were interventions found aiming to address its goal, although no single intervention addressed all domains. Domain 7 (symptom management; n = 19), 6 (avoiding overly aggressive treatment; n = 18) and 10 (education; n = 17) were the most commonly addressed; Domain 5 (prognostication; n = 7) and 4 (continuity of care; n = 2) were the least addressed.

CONCLUSION

Almost all domains were addressed across all interventions currently offered for this population to various degrees, but not within a singular intervention. Future research optimally needs to be theory driven when developing dementia-specific interventions at the end of life, with the European Association for Palliative Care domains serving as a foundation to inform the best care for this population.

The last week of life of nursing home residents with advanced dementia: a retrospective study

BACKGROUND

Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region.

METHODS

This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death.

RESULTS

Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death.

CONCLUSIONS

Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.