The meaning of working in a person-centred way in nursing homes: a phenomenological-hermeneutical study

It's Like Doing Simultaneous Mind Puzzles: Exploring How Care is Understood and Experienced by Nursing Assistants Working in Sweden with Older Persons

Background

The care of older persons is facing several challenges, especially as care tasks are becoming increasingly rationalized with less opportunity for relational engagement between nurse assistants and older persons. Evidence suggests this engagement is needed to promote well-being and satisfaction among the older persons with whom they work. The aim of this study was to explore how care, in the context of worker perspectives, is understood and experienced in home or residential care facilities.

Participants and Methods

Focus-group interviews were conducted with experienced nursing assistants (n = 14) working in urban municipalities in Sweden. Data were analyzed using reflexive thematic analysis.

Findings

The main theme: "This work is more than a checklist of tasks, it's like simultaneous mind puzzles", exposes the shortcomings of a "task and time" oriented care system while expecting individualized relational care practices. Three subthemes emerged: "It's about responsibility, not remuneration", "Knowing them is part of the job" and "We do a lot that is not our job". Participants expressed working responsibly day-to-day to find solutions to meet the needs of older persons. Tensions experienced between task and relational care orientations align to variation in understandings of care. These subthemes highlight that their work requires being context-sensitive to adapt in the moment, much like trying to solve mind puzzles.

Conclusion

Increased rationalization of care, while expecting focus on relational aspects, sets nursing assistants in a challenging position. This paradox negatively affects the health of nursing assistants by creating unsustainable work. Without recognition of the required cognitive engagement in problem solving that is part of their work, the challenges of retention, sick leave and burnout are unlikely to be addressed. To ensure coordinated continuative care for older persons, nursing assistants need time and agency to enact relational practices that facilitate doing their work's dynamic care puzzles.

Evaluating De-Escalation Training for Direct and Indirect Employees Caring for Residents With Huntington's Disease

INTRODUCTION

Little is known about reducing the challenges for caregivers and patients with Huntington's disease (HD). HD creates behavioral disturbances, cognitive decline, and motor disorder progression over the lifetime requiring some individuals to need long-term facility care.

AIMS

There are concerns about safety and confidence of employees caring for residents with HD.

METHODS

Nursing staff, administrators, and auxiliary employees were recruited from a long-term care (LTC) facility in rural Iowa, from July 2020 to August 2020. A de-escalation training intervention was delivered. The 1-day intervention included resident behaviors, planning and safety, teamwork, communication, and included role play and simulation. A pre- and post-survey measured confidence and competence in caring for people with HD before and after a training intervention. A resident medical record audit explored challenging behaviors before and after the training intervention.

RESULTS

Of 25 participants, six were registered nurses/licensed practical nurses (RNs/LPNs; 24%), four administrators (16%), eight nursing assistants (32%), and seven auxiliary employees (28%). There was improvement in employees perceived safety (33.3%), co-workers enjoyment working with HD residents (54%), understanding symptoms of HD (44.4%), confidence in job abilities (21.0%), and confidence in ability to care for patients with HD (26.3%). A medical record audit showed decreased documentation of resident aggression and care refusal post-intervention.

CONCLUSIONS

These findings suggest de-escalation training in LTC facilities increased perception of job safety, co-workers' enjoyment, understanding HD symptoms, confidence in ability to care for patients with HD, and decreased resident agitation and care refusal.

Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study

OBJECTIVES

Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders.

METHODS

A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis.

RESULTS

The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources.

CONCLUSIONS

Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation.

CLINICAL IMPLICATIONS

These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

A pilot study of an intergenerational program for people in residential aged care with cognitive impairment and children from a co-located early learning centre during COVID-19

Intergenerational programs in residential aged care may improve well-being and combat loneliness and social isolation in older people with cognitive impairment. This pilot study investigated the effects of a semi-structured intergenerational group, including children from a co-located early learning centre and people living in residential aged care with cognitive impairment. This 9-week study used a mixed methods pre- and post-program design. Sessions were designed and delivered once per week by Occupational Therapists and took into account residents' interests and children's developmental needs and interests, identified in pre-program interviews. Nine older people with cognitive impairment and 13 children participated. The program was well attended despite disruptions and complications caused by COVID-19 and weather conditions. Older people valued the opportunity to engage with the children. Children were observed to gain confidence in communicating and forming friendships with older people with different levels of ability. There did not appear to be any change in loneliness or neuropsychiatric symptoms. The intergenerational program benefited participants and received strong support from family members and staff of the early learning centre and aged care home.

Are the content and usability of a new direct observation tool adequate for assessing competency in delivering person-centred care: a think-aloud study with patients and healthcare professionals in Sweden

OBJECTIVE

To evaluate the content and usability of a new direct observation tool for assessing competency in delivering person-centred care based on the Gothenburg Centre for Person-Centred Care (gPCC) framework.

DESIGN

This is a qualitative study using think-aloud techniques and retrospective probing interviews and analyzed using deductive content analysis.

SETTING

Sessions were conducted remotely via Zoom with participants in their homes or offices.

PARTICIPANTS

11 participants with lengthy experience of receiving, delivering and/or implementing gPCC were recruited using purposeful sampling and selected to represent a broad variety of stakeholders and potential end-users.

RESULTS

Participants generally considered the content of the four main domains of the tool, that is, person-centred care activities, clinician manner, clinician skills and person-centred care goals, to be comprehensive and relevant for assessing person-centred care in general and gPCC in particular. Some participants pointed to the need to expand person-centred care activities to better reflect the emphasis on eliciting patient resources/capabilities and psychosocial needs in the gPCC framework. Think-aloud analyses revealed some usability issues primarily regarding difficulties or uncertainties in understanding several words and in using the rating scale. Probing interviews indicated that these problems could be mitigated by improving written instructions regarding response options and by replacing some words. Participants generally were satisfied with the layout and structure of the tool, but some suggested enlarging font size and text spacing to improve readability.

CONCLUSION

The tool appears to satisfactorily cover major person-centred care activities outlined in the gPCC framework. The inclusion of content concerning clinician manner and skills was seen as a relevant embellishment of the framework and as contributing to a more comprehensive assessment of clinician performance in the delivery of person-centred care. A revised version addressing observed content and usability issues will be tested for inter-rater and intra-rater reliability and for feasibility of use in healthcare education and quality improvement efforts.

Clinical leadership in nursing homes: A qualitative study of healthcare professionals' perspectives on concept and characteristics

AIM(S)

To conceptualise and identify characteristics of clinical leadership in the nursing home setting.

DESIGN

A qualitative study using semi-structured focus group interviews and a thematic analysis.

METHODS

Five semi-structured focus group interviews were conducted with 41 healthcare professionals from nursing and other healthcare disciplines working in nursing homes (such as nurse assistants, licensed practical nurses, registered nurses (RNs), occupational therapists, recreational therapists, psychologists and gerontologists). Qualitative thematic content analysis of the gathered data was done.

RESULTS

Clinical leaders in nursing homes can be defined as passionate healthcare professionals providing person-centred care with strong communication skills. They are clinical experts in their field and motivated to engage in lifelong learning. They are team players with informal leadership skills. They are visionary, committed, resilient and responsive. Awareness of the definition and the main characteristics of clinical leadership is necessary to facilitate the identification, support and development of healthcare professionals. Focussing on the development of competencies, training courses and monitoring and assessment methods is necessary to improve the evidence of clinical leadership in nursing homes.

The Delivery of Person-Centered Care for People Living With Dementia in Residential Aged Care: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Person-centered care is the gold standard of care for people living with dementia, yet few systematic reviews have detailed how it is delivered in practice. This mixed-methods review aimed to examine the delivery of person-centered care, and its effectiveness, for people living with dementia in residential aged care.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis. Eligible studies were identified across 4 databases. Quantitative and qualitative studies containing data on person-centered care delivered to people with dementia living in residential aged care were included. Meta-analysis using a random-effects model was conducted where more than 3 studies measured the same outcome. A narrative meta-synthesis approach was undertaken to categorize verbatim participant quotes into representative themes. Risk of bias was undertaken using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

41 studies were identified for inclusion. There were 34 person-centered care initiatives delivered, targeting 14 person-centered care outcomes. 3 outcomes could be pooled. Meta-analyses demonstrated no reduction in agitation (standardized mean difference -0.27, 95% confidence interval [CI], -0.58, 0.03), improvement in quality of life (standardized mean difference -0.63, 95% CI: -1.95, 0.70), or reduced neuropsychiatric symptoms (mean difference -1.06, 95% CI: -2.16, 0.05). Narrative meta-synthesis revealed barriers (e.g., time constraints) and enablers (e.g., staff collaboration) to providing person-centered care from a staff perspective.

DISCUSSION AND IMPLICATIONS

The effectiveness of person-centered care initiatives delivered to people with dementia in residential aged care is conflicting. Further high-quality research over an extended time is required to identify how person-centered care can be best implemented to improve resident outcomes.

"Just pee in the diaper" - a constructivist grounded theory study of moral distress enabling neglect in nursing homes

BACKGROUND

A growing body of evidence shows that many nursing home residents' basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: "How do nursing home staff manage their moral distress related to neglectful care practices?"

METHODS

A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway.

RESULTS

Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes.

CONCLUSIONS

Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Nurses' experiences of integrating the salutogenic perspective with person-centered care for older people in Swedish nursing home care: an interview-based qualitative study

BACKGROUND

Even though there has been a cultural change within residential aged care to a more person-centered care, there remain improvements to be made for a more consistent way of working. Using a salutogenic approach along with person-centered care is a potential way to promote it. This study aimed to describe nurses' experiences of combining person-centered care with a salutogenic approach at a nursing home for older people.

METHODS

Nine nurses, specially trained in salutogenesis and Sense of coherence, were individually interviewed using a semi-structured interview approach. Data was analysed through qualitative content analysis.

RESULTS

The nurses experienced that the residential aged care was improved by using salutogenesis and Sense of coherence as a complement to person-centered care. Core aspects of person-centered care were thereby promoted, as the resources of the older persons were emphasized, and aged care became more holistic. In addition to improved residential aged care, the results indicate that this manner of working also contributed to enhanced work satisfaction of the care personnel themselves.

CONCLUSIONS

The results suggest that a salutogenic approach facilitates the implementation of person-centered care by focusing on the older persons' resources and maintaining health. The organization needs to prioritize training staff in salutogenesis and person-centered care, as it supports working toward a common goal and benefits both the older persons and the staff.

The impact of need-based care on formal caregivers' wellbeing in nursing homes: A cluster randomized controlled trial

BACKGROUND

Need-based care is a structured and standardized model that supports formal caregivers in nursing homes in delivering person-centered care by responding with tailored non-pharmacological interventions on residents' unmet needs as well as having positive effects on behavioral and psychological symptoms on residents with dementia. However, limited resources as well as the shortage of caregivers in nursing homes make the implementation of need-based care challenging, especially when it comes to finding ways to spend more time with residents. The aim of this study is to evaluate the impact of the implementation of need-based care in nursing homes on formal caregivers' wellbeing.

METHODS

A three-arm cluster randomized controlled trial was set up in 24 Belgian nursing homes: formal caregivers in the 'need-based care' group (intervention; n = 195) spent time twice a week with residents who had behavioral and psychological symptoms according to the principles of need-based care while formal caregivers in the 'time' group (n = 257) filled in the way they spent time twice a week; a third group delivered standard care (n = 299). An implementation strategy was built upon the Implementation Quality Framework and used in the 'need-based care group'. A total of 741 formal caregivers completed the digital questionnaire at one or more of the five time points (every nine weeks) between November 2021 and July 2022; they rated their sense of competence in dementia care, level of burnout, and, level of engagement. Moments of time were registered in a printed registration book.

RESULTS

Only formal caregivers from the 'need-based care' group experienced a higher sense of competence in dementia care at time points three (p = 0.010) and four (p = 0.001) compared with baseline with an increase of respectively 1.5 (95 % confidence interval [0.25, 2.84]) and 2.4 (95 % confidence interval [0.77, 4.04]) points. No differences in scores on burnout and engagement were found.

CONCLUSION

Despite challenging workforce circumstances in nursing homes, caregivers in the need-based care group as well as in the time group were able to spend time twice a week with residents with behavioral and psychological symptoms. No negative effects were found on formal caregivers' wellbeing after the implementation of need-based care in nursing homes. However, it requires strong leadership and the use of well-considered implementation strategies including reflective practice.

TRIAL REGISTRY

Trial registration number ISRCTN56768265 (10/08/2023).

Telemedicine experiences and perspectives of healthcare providers in long-term care: A scoping review

OBJECTIVE

To consolidate existing evidence on experiences and perspectives of healthcare providers involved in telemedicine services in long-term residential care.

METHODS

A scoping review was conducted. A systematic search for articles published in 2000-2021 was performed in CINAHL, Web of Science, PubMed, EMBASE and Scopus; further, relevant journals and grey literature websites were hand searched. Key search terms included 'telemedicine', 'telehealth' and 'nursing homes'.

RESULTS

Twenty-six articles were included. A narrative synthesis of evidence was conducted. The review identified four themes: (1) Presence of multidisciplinary care, (2) perceived usefulness of telemedicine, (3) perceived ease of use and (4) expanded role of nursing home staff. The presence of multidisciplinary care providers provided a wide range of telemedicine services to residents and promoted interprofessional collaboration between acute and long-term care. Telemedicine was perceived to increase timely onsite management by remote specialists, which enabled care quality improvement. However, technical problems associated with equipment usage reduced the ease of use of telemedicine. Concerns emerged from the expanded role of nursing home staff, which could negatively affect clinical decision-making and create medico-legal risks.

CONCLUSION AND IMPLICATIONS

Telemedicine is valuable in distance-based care, especially in the current 2019 coronavirus pandemic, for supporting continuity of care to nursing home residents. This review provided evidence from multiple healthcare providers' perspectives. Further research can elucidate their specific roles and responsibilities in telemedicine and challenges in work processes, which will facilitate developing evidence-based competencies and improving technical infrastructure, thus contributing to personal and organisational readiness for telemedicine integration.

Moving between doing and being-Meanings of person-centredness as narrated by nursing home managers. A phenomenological hermeneutical study

AIM

This study aimed to illuminate meanings of person-centredness as narrated by nursing home managers in nursing homes rated as highly person-centred.

DESIGN

A phenomenological hermeneutical approach was used.

METHODS

Twelve nursing home managers in 11 highly person-centred nursing homes in 7 municipalities in Sweden were included in this interview study. The findings were interpreted, reflected and discussed through the lens of Ricoeur.

RESULTS

Meanings of person-centredness could be understand as moving between doing and being through knowing, sensing, sharing and giving for person-centredness. These aspects contributed via knowledge, understanding, interaction and action that involved doing for and being with older persons through these caring dimensions. By moving between doing for, being with and being part of the overall nursing home narrative, knowing, sensing, sharing and giving could support the persons' identity in different ways. This may also contribute to sense-making, preserving dignity and promoting self-esteem when aiming to provide a good life for older persons in nursing homes, within an ever-present ethical frame.

NO PATIENT OR PUBLIC CONTRIBUTION

This study illuminated meanings of person-centredness as narrated by nursing home managers. No patient of public contribution was investigated.

Creating age-friendly nursing homes: The time is now

The current global age-friendly movement supports older adults by promoting different policies and services. However, there is a dearth of attention to nursing home (NH) residents as part of age-friendly movements. The pioneering idea of an age-friendly health system, i.e., the "4 Ms" model is significant for NHs and formative for further developments; however, it does not identify unique components of NH care. This article aims to identify specific aspects of person-centered care in the literature to advance the development of a standardized conceptual framework. Along with residents, NH staff and administrators are integral parts of NHs. Incorporating the central role of caregivers, this study proposes a new "8 Ms" framework to describe the age-friendly NH. The traditional 4 Ms model notes that everything related to care matters to residents, along with care related to medication, mobility, and mentation. The proposed age-friendly framework introduces five additional "M," i.e., meaningful care, motivation, moderation, modification, and monitoring. This framework is proposed to advance education, training, clinical practice, research, and advocacy to promote quality of care in NHs. Application of the 8 Ms framework may yield multiple benefits, assuring good quality of care to residents, caregivers' job satisfaction, and supporting NH management in providing residents optimal care.

Forming Nursing Home Practices That Support Quality of Care for Residents. A Qualitative Observational Study

Background

Residents of nursing homes are increasingly frail and dependent. At the same time, there are increased demands for quality of care and social life for individual residents. In this article, we explore how care workers contribute to quality of care and social life in shared living rooms in nursing homes.

Methods

An ethnographically inspired design was applied, and a purposive sample of six units for long-term care in three nursing homes in Norway was included in the study. Data were collected by participant observation, including informal conversations with the staff and residents, and the data were analyzed using thematic analysis.

Results

The analysis identified three main themes: working within the given context, creating care practices and organizing activities. The empirical findings demonstrate that care work focuses on meeting both the residents' physical and social needs and aiming for high-quality care and social life for the residents in nursing homes.

Conclusion

The results of this study illustrate that nursing home practices are focused on residents as a group. However, care workers take advantage of personal skills and resources to work towards person-centred care within the given context. The quality of care is recognized in terms of how care workers meet individual residents' needs. The quality of care seems highly related to the capability and skills of individual care workers.

Healthcare professionals' experiences of job satisfaction when providing person-centred care: a systematic review of qualitative studies

OBJECTIVES

This qualitative systematic review aimed to explore and synthesise healthcare professionals' (HCPs) experiences of job satisfaction when providing person-centred care (PCC) in healthcare settings in Europe.

METHOD

This systematic review of qualitative studies was followed by a thematic synthesis applying an inductive approach. Studies concerning HCPs and different levels of healthcare in Europe were eligible for inclusion. The CINAHL, PubMed and Scopus databases were searched. Study titles, abstracts and full texts were screened for relevance. Included studies were assessed for methodological quality using a quality appraisal checklist. Data were extracted and synthesised via thematic synthesis, generating analytical themes.

RESULTS

Seventeen studies were included in the final thematic synthesis, and eight analytical themes were derived. Most studies were conducted in Sweden and the UK and were performed in hospitals, nursing homes, elderly care and primary care. Thirteen of these studies were qualitative and four used a mixed-method design in which the qualitative part was used for analysis. HCPs experienced challenges adapting to a new remoulded professional role and felt torn and inadequate due to ambiguities between organisational structures, task-oriented care and PCC. Improved job satisfaction was experienced when providing PCC in line with ethical expectations, patients and colleagues expressed appreciation and team collaboration improved, while learning new skills generated motivation.

CONCLUSION

This systematic review found varied experiences among HCPs. Notably, the new professional role was experienced to entail disorientation and uncertainty; importantly, it also entailed experiences of job satisfaction such as meaningfulness, an improved relationship between HCPs and patients, appreciation and collaboration. To facilitate PCC implementation, healthcare organisations should focus on supporting HCPs through collaborational structures, and resources such as time, space and staffing.

PROSPERO REGISTRATION NUMBER

CRD42022304732.

The Influence of Care Home Managers' Leadership on the Delivery of Person-Centred Care for People Living with Dementia: A Systematic Review

Background

Care home managers' leadership is recognised as directly influencing the care received by people living with dementia. What enables care home managers to promote and sustain person-centred care for residents is less well understood.

Method

A mixed-methods systematic review synthesised evidence on care home managers' leadership on the delivery of person-centred care for people living with dementia. Electronic databases (PubMed, Scopus, Cochrane Library, CINAHL, and Google Scholar) were searched between 2009-2021. Thematic synthesis identified commonalities, facilitators, and barriers to managers enabling person-centred care.

Results

Twenty-one studies met the inclusion criteria. Approaches demonstrated by care home managers that enabled person-centred care for people living with dementia included valuing and recognising staffs' work; involving residents and relatives in decision making; providing feedback to staff; promoting a positive work environment and care culture; and involving staff in organisational changes. Barriers to person-centred care were a lack of organisational support for care home managers; staff shortages; managers not having time to work with staff; manager-staff turnover; limited access to dementia training; and a lack of leadership education and training for care home managers.

Conclusion

Care home managers are central to the delivery of person-centred care for people living with dementia. The review identified key resources and activities that support this work. The wide variation in leadership approach and a persistent lack of detail about the frequency of educational and organisational support demonstrate a need to explore what enables care home managers to support their staff to deliver person-centred care.

Intergenerational live-in student programmes for meaningful engagement: Creating cohesive and supportive collectives in aged-care facilities

BACKGROUND AND OBJECTIVES

Older adults in residential aged-care facilities (RACFs) experience segregation from society and face limited opportunities to meaningfully engage on a social and/or occupational level due to various structural and systemic challenges. An occupational therapy-coordinated intergenerational live-in student programme (ILiSP) with allied health students was successfully pioneered across Sydney (Australia) to facilitate ongoing intergenerational contact. We explored how ongoing intergenerational contact influenced meaningful engagement of older adults in RACFs by investigating routinely collected clinical data and exploring stakeholders' perspectives.

RESEARCH DESIGN AND METHODS

We employed a concurrent nested mixed-methods design. Residents' attendance in weekly organisational activities and students' monthly volunteer hour reports were analysed to produce statistics for demonstrating the changes in residents' activity attendance alongside ongoing intergenerational contact. Qualitative data from discussions directed by the nominal group technique (NGT) with staff, management and students, individual interviews with relatives and residents, and narrative clinical documentation were thematically analysed.

RESULTS

The Wilcoxon signed-rank test indicated that residents' activity attendance increased during intergenerational contact. Qualitative data yielded three main themes-interdependence, meaningful engagement, and kinship-all associated with intergenerational contact as part of established ongoing relationships. The NGT highlighted consensus on on-site living for maintaining a cohesive and supportive collective.

CONCLUSION

Despite structural and systemic challenges within RACFs that dissuade community integration, ILiSP created opportunities for students to connect/reconnect residents to new/established networks and to support residents to maintain or re-engage with previous lifestyle preferences. Therefore, ongoing intergenerational contact fostered a cohesive collective in support of the social and occupational needs of residents, which should be capitalised on by policymakers (e.g., the National Aged Care Mandatory Quality Indicator Program) and interested organisations.

The Required Competencies of Bachelor- and Master-Educated Nurses in Facilitating the Development of an Effective Workplace Culture in Nursing Homes: An Integrative Review

BACKGROUND

Nursing home care is undergoing significant changes. This requires innovative teams operating in an effective workplace culture characterized by person-centeredness and offering evidence-based care. A pivotal role for bachelor- and master-educated nurses (BNs/MNs) is foreseen to facilitate such cultures; however, there is currently no comprehensive overview of what competencies this requires.

OBJECTIVES

To identify what competencies are required from BNs/MNs in facilitating the development of an effective workplace culture in nursing homes.

METHODS AND DESIGN

We conducted an integrative review (IR) using Whittemore and Knafl's method. We searched the PubMed, CINAHL, and PsycINFO databases for studies published between January 2010 and December 2021 in English. Two independent reviewers determined whether studies met inclusion: bachelor- or master-educated nurse; nursing home; professional competencies; and mixed methods or qualitative and qualitative studies. We applied the CASP appraisal tool and analyzed the data by applying content analysis.

RESULTS

Sixteen articles were included. Five themes were identified representing required competencies for BNs/MNs facilitating: (1) learning cultures in nursing practice; (2) effective work relationships within teams; (3) leadership capability within teams; (4) implementation of guidelines, standards, and protocols; (5) a work environment acknowledging grief and loss of residents within teams.

CONCLUSIONS

It shows that the BN/MN applies five competencies associated with a facilitator role to promote the development of an effective workplace culture to achieve a safe, high-level quality of care, satisfaction, and well-being. An overarching leadership as a change champion will support teams to achieve a quality that should guide the transformation in nursing care.

Long-term care staff 's positive experiences of caring for people living with dementia: Narratives' content and lessons learned

Research on caregiving for persons with dementia has mainly focused on its negative impact on caregivers. However, while some studies have found that positive aspects of care can also be found among informal caregivers, little attention has been paid to these positive aspects among staff working in long-term care facilities. The aim of this is study is to explore what kind of positive stories of caring for a person living with dementia staff working in long-term care facilities recall, and what kind of lessons they extracted from these experiences. Forty-two staff members currently working in four Spanish long-term care facilities (21 nursing assistants; 21 technical staff) were interviewed. They were asked about positive stories related to caring for people living with dementia. Data were analyzed using content analysis, aimed at identifying common ideas in the responses. Results showed that the type of stories were quite diverse, but can be grouped into three main themes: attachment, awakening, and mastery. The stories imply different lessons learned, including the importance of individualized care, the value of persistence and patience, and the relevance of technical knowledge and strategies to provide good care. The articles discusses how recording, reflecting on and discussing positive experiences that care staff encounter in their daily practice, may be key to skill development, reinforce job satisfaction, and improve quality of care in a person-centered care direction.

Dignity in bodily care at the end of life in a nursing home: an ethnographic study

BACKGROUND

Nursing homes (NHs) are populated by the frailest older people who have multiple physical or mental conditions and palliative care needs that may convey the violation of dignity. Although dignity is a commonly used concept and a core value of end-of-life care, it is assumed to be complex, ambiguous, and multivalent. Thus, the aim of this study was to explore aspects of dignity in older persons' everyday lives in a NH.

DESIGN

A focused ethnographic study design.

METHODS

Data consisted of 170 h of fieldwork, including observations (n = 39) with residents (n = 19) and assistant nurses (n = 22) in a Swedish NH. Interviews were undertaken with residents several times (in total, n = 35, mean 70 min/resident). To study dignity and dignity-related concerns, we used the Chochinov model of dignity to direct the deductive analysis.

RESULTS

The study showed that residents suffered from illness-related concerns that inhibited their possibilities to live a dignified life at the NH. Their failing bodies were the most significant threat to their dignity, as loss of abilities was constantly progressing. Together with a fear of becoming more dependent, this caused feelings of agony, loneliness, and meaninglessness. The most dignity-conserving repertoire came from within themselves. Their self-knowledge had provided them with tools to distinguish what was still possible from what they just had to accept. Socially, the residents' dignity depended on assistant nurses' routines and behaviour. Their dignity was violated by long waiting times, lack of integrity in care, deteriorating routines, and also by distanced and sometimes harsh encounters with assistant nurses. Because the residents cherished autonomy and self-determination, while still needing much help, these circumstances placed them in a vulnerable situation.

CONCLUSIONS

According to residents' narratives, important dignity-conserving abilities came from within themselves. Dignity-conserving interventions did occur, such as emphatic listening and bodily care, performed in respect for residents' preferences. However, no strategies for future crises or preparing for death were observed. To protect residents' dignity, NHs must apply a palliative care approach to provide holistic care that comprises attention to personal, bodily, social, spiritual, and psychological needs to increase well-being and prevent suffering.

What does person-centred care mean, if you weren't considered a person anyway: An engagement with person-centred care and Black, queer, feminist, and posthuman approaches

Despite the prominence of person-centred care (PCC) in nursing, there is no general agreement on the assumptions and the meaning of PCC. We sympathize with the work of others who rethink PCC towards relational, embedded, and temporal selfhood rather than individual personhood. Our perspective addresses criticism of humanist assumptions in PCC using critical posthumanism as a diffraction from dominant values  We highlight the problematic realities that might be produced in healthcare, leading to some people being more likely to be disenfranchised from healthcare than others. We point to the colonial, homo- and transphobic, racist, ableist, and ageist consequences of humanist traditions that have influenced the development of PCC. We describe the deep rooted conditions that structurally uphold inequality and undermine nursing practice that PCC reproduces. We advocate for the self-determination of patients and emphasize that we support the fundamental mechanisms of PCC enabling patients' choice; however, without critical introspection, these are limited to a portion of humans. Last, we present limitations of our perspective based on our white*-cisheteropatriarchy** positionality. We point to the fact that any reimagining of models such as PCC should be carefully done by listening, following, and ceding power to people with diversity dimensions*** and the lived experience or expertise that exists from diverse perspectives. We point towards Black, queer feminism, and critical disabilities studies to contextualize our point of critique with humanism and PCC to amplify equity for all people and communities. Theory and philosophy are useful to understand restrictive factors in healthcare delivery and to inform systematic strategies to improve the quality of care so as not to perpetuate the oppression of groups of people with diversity dimensions. ^* We purposely capitalize Black and use lower case for white to decentre whiteness and as an intentional act of antiracism (see White Homework a podcast series by Tori W. Douglas). ^** Cisheteropatriarchy describes people with intersecting identities of dominant social groups; cisgender is the gender identity that aligns with the gender you were assigned at birth, hetero means heterosexual, and patriarchy refers to structural systems of power based on maleness where women are often excluded and hold less power. ^*** With diversity dimensions, we refer to subjective lived experience and material realities of people that exist outside the 'dominant minorities' of white-cisheteropatriarchy, meaning groups of people in society who historically and currently hold more power and through this, structurally dominate the norms and possibilities of living for other people.

Delivering person-centred palliative care in long-term care settings: is humanism a quality of health-care employees or their organisations?

Reflecting on sustained calls for patient-centredness and culture change in long-term care, we evaluated the relative importance of personal and organisational predictors of palliative care, hypothesising the former as weaker predictors than the latter. Health-care employees (N = 184) from four Canadian long-term care homes completed a survey of person-centred care, self-efficacy, employee wellbeing and occupational characteristics. Using backward stepwise regression models, we examined the relative contributions of these variables to person-centred palliative care. Specifically, blocks of variables representing personal, organisational and occupational characteristics; palliative care self-efficacy; and employee wellbeing were simultaneously regressed on variables representing aspects of person-centred care. The change in R2 associated with the removal of each block was examined to determine each block's overall contribution to the model. We found that occupational characteristics (involvement in care planning), employee wellbeing (compassion satisfaction) and self-efficacy were reliably associated with person-centred palliative care (p < 0.05). Facility size was not associated, and facility profit status was less consistently associated. Demographic characteristics (gender, work experience, education level) and some aspects of employee wellbeing (burnout, secondary trauma) were also not reliably associated. Overall, these results raise the possibility that humanistic care is less related to intrinsic characteristics of employees, and more related to workplace factors, or to personal qualities that can be cultivated in the workplace, including meaningful role engagement, compassion and self-efficacy.

A Hospitality Improvement Intervention in Residential Care Does Not Warrant Staff Job Satisfaction or Turnover Intention: A Cross-Sectional Survey Study Investigating the Hostmanship Program

Background

Accountability pressure is rising in healthcare, and this demonstrates that the quality of care provided within a residential care setting is of utmost importance. Hostmanship is a quality improvement program focusing on person-centered care in residential care settings.

Objectives

This study aimed to explore the influencing factors for job satisfaction and intention to leave among healthcare workers and the difference in job satisfaction and intention to leave the employer between residential care centers with and without Hostmanship.

Methods

A quantitative, cross-sectional study was conducted in sixteen Flemish residential care settings in Belgium. A total of 293 participants completed the questionnaire, divided into two groups: the group with Hostmanship (n = 139), at least one year into a change process implementing Hostmanship, and the group without the Hostmanship program (n = 154). Hierarchical logistic regression analysis estimated effects between demographic characteristics (block one), facility management, staffing and Hostmanship (block two), work characteristics (block three), and work engagement or burnout dimensions (block four) as explanatory variables of job satisfaction and turnover intention as outcome variables.

Results

This study confirmed the positive impact of social capital and decision latitude on staff member job satisfaction, as shown in previous findings. Age and workload were associated with turnover intentions. A hierarchical logistic regression model explained 68.7 % of the variance in workers' job satisfaction, and a hierarchical logistic regression explained 49.2% of the variance in their intent to leave. Also, no effects were found for Hostmanship on staff job satisfaction and intention to leave.

Conclusions

This study shows how a quality improvement project such as Hostmanship could produce counterintuitive results for organizations in elderly residential centers. However, results inconsistent with literature were found. It is unclear whether Hostmanship warrants job satisfaction or retaining personnel. Future research must take into consideration success factors when implementing new quality initiatives. A general framework for successful implementation in the healthcare sector should be provided.

Everyday Life and Social Contacts of Dementia and Non-Dementia Residents over 80 Years in Long-Term Inpatient Care: A Multi-Level Analysis on the Effect of Staffing

The relationship between nurse staffing, physical outcomes of residents, as well as quality of care receives major attention. The impact of staffing levels on residents’ ability to organize their everyday life and maintain social contacts, however, has not been analyzed to date. This study examines whether a relationship between the staff-to-resident ratio for registered nurses and nursing home residents with and without dementia aged over 80 exists. Secondary data collected in the project inQS (indikatorengestützte Qualitätsförderung) were used (n = 1782, mean age = 88.14). The analyzed cross-sectional data were collected in winter 2019 in facilities of the Diocesan Caritas Association in Germany. A sum score formed from variables measuring residents’ abilities to independently organize their everyday life and maintain social contacts functioned as the dependent variable. A multi-level regression analysis was performed. The results revealed that the ability of residents without dementia was significantly associated with the staff-to-resident ratio of registered nurses. This was not true for residents with dementia. For the latter, however, whether the facility offers a segregated care unit turned out to be significant. Additional and longitudinal research is indispensable to explain the inequality between the two groups analyzed.

Work-related stress and intention to leave among midwives working in Swiss maternity hospitals - a cross-sectional study

Background

Health systems around the globe are struggling to recruit qualified health professionals. Work-related stress plays an important role in why health professionals leave their profession prematurely. However, little is known about midwives’ working conditions and intentions to leave their profession, although this knowledge is key to work force retention. Therefore, we aimed to investigate work-related stress among midwives working in Swiss maternity hospitals, as well as differences between midwives and other health professionals and the stressors associated with midwives’ intention to leave the profession.

Methods

We conducted a data analysis of two cross-sectional studies encompassing midwives working in labour, postpartum and/or gynaecology wards of 12 public Swiss maternity hospitals. Data was collected by self-report questionnaire assessing potential stressors and long-term consequences of stress at work. Data were analysed using descriptive statistics, Kruskal Wallis tests and logistic regression modelling.

Results

A total of 98 midwives took part in the study and one in three midwives reported doing overtime sometimes-always. Also, the score for work-private life conflicts was significantly higher among midwives than among other health professionals, with the exception of physicians (M = 37.0 versus 50.2, p < .001). Midwives’ meaning of work score (M = 89.4) was significantly higher than that of other health professionals (e.g. nurses (M = 83.0, p < .001) or physicians (M = 82.5, p < .01)). Generation Y midwives showed a significantly higher intention to leave their organisation than did the baby boomers (Mean scores 29.3 versus 10.0, p < .01). Results of the regression model revealed that if midwives could compensate for their overtime in the same month, their intention to leave the profession was lower (OR = 0.23, p < .05). Additionally, the more midwives were affected by work-private life conflicts (OR = 3.01, p < .05) and thoughts about leaving their organisation (OR = 6.81, p < .05), the higher was their intention to leave their profession prematurely.

Conclusions

The comparison with other health professions and the higher intention to leave the profession of younger midwife generations are important findings for heads of institutions as well as policy makers, and should stimulate them to develop strategies for keeping midwives on their staff. More extensive studies should implement and test interventions for reducing work-related stress and increasing the job and occupational satisfaction of midwives.

More than just a task: intimate care delivery in the nursing home

Purpose: Intimate care procedures, such as bathing and toileting, are often regarded as simple, humble tasks. However, the provision of such care transforms a very private, personal activity into a social process. Understanding this complex process and the psychological impact it has on those providing and receiving care is critical in order to mitigate potential distress. The purpose of this study to examine the experience of delivering and receiving intimate personal care in the NH.

Methods: A focused ethnographic approach with participant observation, semi-structured interviews, focus groups and drop-in sessions, document review, and field notes. Data were analysed using constant comparative analysis.

Results: Quality care in this context is predicated on the care provider recognition of the emotional impact of care delivery on the care recipient. Our analysis identified that the overarching theme, of providing quality person-centred intimate care, requires creating and maintaining a relational space that promotes integrity.

Conclusions: The provision of intimate personal care consists of a complex interplay at the level of resident/care provider interaction (micro level); health care organization (meso level); and policy (macro level). Each of these levels interacts with and influences the other two. The components identified in our model may provide the basis from which to further examine resident experiences of quality intimate personal care.

Perceptions and experiences of person-centered care among nurses and nurse aides in long term residential care facilities: A systematic review of qualitative studies

OBJECTIVE

The aim of this study is to report the findings of meta-synthesis of the experiences and perceptions of person-centered care among nurses and nurse aides in long term care facilities to help managers and policy makers in providing and improving health services.

METHODS

This is a meta-synthesis of qualitative studies guided by seven steps process of meta-ethnography developed by Noblit and Hare. Systematic literature searching was conducted in CINAHL, MEDLINE, Web of Science, PubMed, PsycINFO, Scopus, Cochrane library and ProQuest dissertations databases. We assessed quality of the studies using Critical Appraisal Skills Program tool.

RESULTS

Eleven studies and one dissertation were identified as relevant for the review. The analysis of this systematic review was resulted in three categories: Recognizing resident's emotional needs and preferences under the task-based workload; holistic understanding to build relationship and participation; teamwork, being recognized and ongoing training to overcome the challenges.

CONCLUSION

The concept of PCC in direct care level is perceived well with majority of the study participants but the reality between perceived and practicing PCC is different which indicates mostly lack of organizational rearrangements and support.

'This Adds Another Perspective': Qualitative Descriptive Study Evaluating Simulation-Based Training for Health Care Assistants, to Enhance the Quality of Care in Nursing Homes

Much of the UK's ageing population lives in care homes, often with complex care needs including dementia. Optimal care requires strong clinical leadership, but opportunities for staff development in these settings are limited. Training using simulation can enable experiential learning in situ. In two nursing homes, Health Care Assistants (HCAs) received training in clinical communication skills (Situation-Background-Assessment-Recommendation Education through Technology and Simulation, SETS: group training with an actor simulating scenarios); and dementia (A Walk Through Dementia, AWTD: digital simulation, delivered one-to-one). In this qualitative descriptive study, we evaluated the potential of this training to enhance HCAs' clinical leadership skills, through thematic analysis of 24 semi-structured interviews with HCAs (before/after training) and their managers and mentors. Themes were checked by both interviewers. HCAs benefitted from watching colleagues respond to SETS scenarios and reported greater confidence in communicating with registered healthcare professionals. Some found role-play participation challenging. AWTD sensitised HCAs to the experiences of residents with dementia, and those with limited dementia experience gained a fuller understanding of the disease's effects. Staffing constraints affected participation in group training. Training using simulation is valuable in this setting, particularly when delivered flexibly. Further work is needed to explore its potential on a larger scale.

How Important Are Choice, Autonomy, and Relationships in Predicting the Quality of Life of Nursing Home Residents?

Older people face major challenges when they move into nursing homes, particularly in relation to independence and their ability to influence their activities of daily living (ADLs). This study evaluated the contribution of resident choice, as well as the staff-resident relationship, to promoting resident quality of life (QoL). A total of 604 residents from 33 nursing homes in Australia completed measures of QoL, perceived levels of choice in various ADLs, and the staff-resident relationship. A hierarchical regression demonstrated that the predictor variables accounted for 25% of the variance in QoL. Two of the four predictor variables (resident choice over socializing and the staff-resident relationship) significantly contributed to resident QoL. These findings reinforce the important contribution of autonomy and social relationships to resident QoL. Nursing home staff have a key role to play in supporting resident autonomy as a means of building residents' chosen social connections, and thereby promoting QoL.

Recognizing expressions of thriving among persons living in nursing homes: a qualitative study

Background

Thriving has emerged as a contemporary and health-promoting concept for older people living in nursing homes; however, there has been limited research to explore how nursing home staff identify thriving in their everyday practice. The aim of this study was to explore how staff recognize expressions of thriving among persons living in nursing homes.

Methods

Semi-structured interviews were conducted with 14 nurses working at a nursing home in Victoria, Australia. The interviews were audio-recorded, transcribed and analyzed using qualitative content analysis.

Results

The analysis resulted in six sub-categories and three main categories. Expressions of thriving were recognized in relation to how staff understood thriving, observed thriving and sensed thriving. Staff described comparing and contrasting clinical assessment indicators with their own personal and professional understandings of thriving, as well as their overall sense of the individual person within the wider situational and environmental context.

Conclusions

Our results illuminate how staff recognize everyday expressions of thriving for people living in nursing homes and emphasizes the importance of utilizing person-centred care principles in clinical assessments. These findings have practical implications with regards to how thriving is identified and assessed in long-term care, and could be used to inform and guide staff education, person-centred care strategies, and organizational policies to better support and promote thriving in nursing homes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-020-00526-7.

Care workers' perspectives of factors affecting a sustainable aged care workforce

AIMS

To identify the reasons why workers decide to enter, stay or leave the aged care workforce; and the factors influencing them to transition between community and residential sectors in Australia.

BACKGROUND

Factors affecting the recruitment and retention of suitable care workers in aged care are complex and influenced by personal, institutional and societal factors.

METHODS

A qualitative description study design.

RESULTS

In total, 32 staff participated in the study. Five main themes were identified: entering aged care with a passion for the job; entering aged care as it is the only employment option; factors attracting care workers to stay in aged care; factors influencing care workers to leave the job; and preferring to work in residential aged care rather than community aged care.

CONCLUSION

Issues relating to the attraction and retention of aged care workers are influenced by personal, institutional and societal factors. Critical shortages in the aged care workforce make the industry more susceptible to crises such as COVID-19 outbreaks.

IMPLICATION FOR NURSING PRACTICE

Aged care organizations need to create a positive psychosocial work environment for staff to improve the attraction and retention of skilled care workers. They also need to develop staff recruitment guidelines to ensure care workers with the appropriate skills and training and a passion for working with older adults are selected. Staff development programmes need to focus on learning activities that enable staff to build peers support in the work environment.

IMPLICATIONS FOR HEALTH POLICY

There is a need to mandate curriculum to enable nursing students to receive more gerontological education and exposure to aged care throughout their education. Aged care quality standards need to mandate transition support for new graduate nurses.

Effects of a person-centred and thriving-promoting intervention on nursing home staff job satisfaction: A multi-centre, non-equivalent controlled before-after study

Aim

To evaluate the effects of a person‐centred and thriving‐promoting intervention in nursing homes on staff job satisfaction, stress of conscience and the person‐centredness of care and of the environment.

Design

A multi‐centre, non‐equivalent control group, before–after trial design.

Methods

Staff (N = 341) from six nursing homes in Australia, Norway and Sweden were assigned to the intervention or the control group and both groups were evaluated before the intervention, immediately after and by 6 months follow‐up. Staff completed a questionnaire about job satisfaction (primary endpoint), stress of conscience and the person‐centredness of care and of the environment (secondary endpoints). Linear regression models were used to identify the mean scores and to analyse group differences to test the effects of the intervention.

Results

The intervention had no statistically significant effects on staff job satisfaction, level of stress of conscience or the perceived person‐centredness of care and of the environment.