Aged Care Practice Research Articles

Handling a challenging context: experiences of facilitating evidence-based elderly care.

To explore improvement facilitators' experiences of handling their commission to implement evidence-based practice in elderly care for frail older persons. Improvement facilitators were put in place across Sweden in a time-limited project by the government, with one part of the project being to evaluate the model before establishing this facilitation of evidence-based practice in elderly care. Two focus groups were interviewed twice. Each group comprised three respondents. The interviews were analysed using qualitative content analysis. A main theme, 'Moving forward by adjusting to the circumstances', described how the improvement facilitators handle their commitment. Five subthemes emerged: identifying barriers, keeping focus, maintaining motivation, building bridges and finding balance. The improvement facilitators' commitment is ambiguous because of unclear leadership of, and responsibility for the national investment. They have to handle leaders' different approaches and justify the need for evidence-based practice. The improvement facilitators did not reflect on the impact of programme adaptations on evidence-based practice. The findings emphasise the need for collaboration between the improvement facilitator and the nurse manager. To fully implement evidence-based practice, negotiations with current practitioners for adaptation to local conditions are necessary. Furthermore, the value of improving organisational performance needs to be rigorously communicated throughout the organisation.

Nurses' and personal care assistants' role in improving the relocation of older people into nursing homes.

This article presents findings from a study that explored nurses' and personal care assistants' role in improving the relocation of older people into a nursing home. Suggestions for improving the relocation process for older people moving into a nursing home have been the outcomes of studies that have interviewed residents and their families. However, the views of nurses and personal care assistants working in nursing homes have not been previously explored. An exploratory, descriptive qualitative research design. Individual interviews were conducted with 20 care staff (seven registered nurses, five enrolled nurses and eight personal care assistants) employed at four nursing homes. Using thematic analysis, two key themes were identified: 'What it's like for them' - highlighted staffs' awareness of the advantages, disadvantages and meaning of relocation, and focused on staffing and nursing care; other services provided and the environment. The second theme - 'We can make it better', revealed suggestions for improving the relocation process, and included spending time with new residents and the importance of a person-centred approach to care. Care staff have an important role in improving the relocation process of older people into a nursing home, as well as contributing to the discussion on this important clinical topic. Challenging care staff to acknowledge the importance of their role in helping older people settle into a nursing home is a key requirement of nursing practice in aged care. Nursing practice guidelines, with a focus on person-centred care, on how to manage the relocation process for an older person and their family are required for this aspect of nursing home care. Education of staff on relocation policies and procedures is essential to ensure that residents and their families are supported through this process.

The use of mystery guests by the Dutch Health Inspectorate: Results of a pilot study in long-term intramural elderly care

This paper examines the use of ‘mystery guests’ as an instrument for monitoring quality and safety in healthcare. The Dutch Health Inspectorate initiated a mystery guest pilot project in elderly care as a response to political and social pressure. An independent evaluation of this project revealed that the primary goal of this approach – to provide a better view of the exigencies of daily practice in elderly care – was not met. Inspectors did not use the information delivered by the mystery guests because how they evaluated quality and reported findings did not align with practices used by the health inspectorate. Additionally, the inspectors felt that other instruments being developed were more appropriate for providing a better view of practice. While political pressure is important for effecting change in general, the specific instruments to be used for formal supervision of health institutions should be developed and implemented within the organization in accordance with existing standards and approaches. The choice to implement a new supervision instrument, including sending mystery guests into care institutions, should be preceded by an ethical analysis that takes into account the specific context of its use.

Veiklos tyrimas dalyvaujant socialines paslaugas teikiančių organizacijų tyrimuose

The aim of publication is to discuss the nature of participatory action research (PAR) in different types of elderly care organizations – private and public sectors. Participatory action research in organization is considered as interpretative qualitative research method for empowering and emancipation of managers and employees, promoting reflection and critical consciousness. The research is aimed to initiate changes of different directions in organizations fostering humanization approach in private organizations and commercial approach in public organizations. Public elderly care sector in Lithuania is characterized by critical shortage of services. As consequence, not publicly funded and profit-oriented private providers of elderly care emerged in the sector. In the context of enhancement of neoliberal social policy these two types of organizations face challenges to meet needs of users. Private organizations are fostered to promote values based on critical humanistic theory. Public organizations are fostered to introduce neoliberal concept of empowerment. Methodology of PAR is designed implementing several stages of research in private and public elderly care organizations to meet current challenges. The first stage of research project involved explorative focus groups in four organizations (two private and two public) seeking to reveal needs for change in elderly care organizations and to create scenarios for implementationof these changes. The second stage implies practical realization of scenarios in organizations what will be led by reflections and critical group discussions with managers and employees. The last stage concludes the process of research by providing methodological guidance for promoting changes in organizations of different sectors and produce knowledge on development of practice in elderly care. The paper presents results of explorative focus groups analysis that enabled researchers and research participants to build scenarios for promoting change.

Fostering resilience later in life: a narrative approach involving people facing disabling circumstances, carers and members of minority groups

ABSTRACTOver the last two decades, the concept of resilience has become the focus of a growing body of gerontological research. However, there is a dearth of qualitative research that explores how socio-economic and socio-cultural factors shape older people's resilience. This study addresses this gap and explores the concept of resilience through the lens of 25 Australians from a variety of backgrounds, investigating the resilience strategies they employed in the face of different challenging life events. A qualitative narrative methodology involving one focus group and semi-structured interviews was employed. A stratified convenience sample of 34 people aged 60 and over participated in semi-structured interviews between 2009 and 2011. The study describes the meaning participants assigned to the term resilience, and focuses on the range of resilience responses and strategies they employed, bringing to light some key commonalities and differences. The study's findings suggest that access to economic and cultural resources and the nature of the adversity older people face can shape and limit their resilience strategies. The article outlines how the concept of resilience could be incorporated into aged care practice and argues that resilience-focused interventions that potentially broaden the resilience repertoire of older people should be explored within an aged care context.

The effectiveness of audit and feedback as a quality improvement strategy in residential aged care: a systematic review protocol

Review question/objective The objective of this systematic review is to synthesize the best available evidence for the effectiveness of audit and feedback as a quality improvement strategy. More specifically, the objectives are to identify: 1. What characteristics contribute to an effective audit and feedback cycle in aged care. 2. Whether audit and feedback is an effective quality improvement strategy for improving health outcomes for older people in residential aged care facilities. 3. What the most effective feedback mechanisms as part of an audit and feedback cycle in implementing practice change are. Inclusion criteria Types of participants This review will consider studies that include people aged 65 years or older in nursing homes, long-term care and/or residential aged care. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the effect of (i) audit and feedback or clinical audit alone and (ii) audit and feedback or clinical audit and feedback combined with other interventions as an initial review of available studies indicate that there are limited or no studies that have evaluated the impact of audit and feedback as the sole intervention. Audit and feedback will review the system and process utilized within the audit whilst other interventions will relate to how feedback was provided. The review will consider the system and processes use to develop the audit tool and the outcome of the interventions used to provide feedback. Types of outcomes This review will consider studies that have evaluated the impact on clinical outcome (quality indicators/measures): such as but not limited to behaviors of concern, chemical or physical restraint, end of life, falls and pain.

Four perspectives on self-management support by nurses for people with chronic conditions: A Q-methodological study

BackgroundSelf-management support is a major task of nurses in chronic care. Several conceptualizations on what self-management support encompasses are described in the literature. However, nurses’ attitudes and perceptions related to self-management support are not known. ObjectiveTo reveal distinctive perspectives of nurses toward self-management support in chronic care. Design and methodsA Q-methodological study was conducted in which nurses rank-ordered 37 statements on self-management support. Thereafter they motivated their ranking in semi-structured interviews. Participants and settingA purposive sample of 49 Dutch nurses with a variety of educational levels, age, and from different healthcare settings was invited by e-mail to participate in the study. Thirty-nine nurses (aged 21–54 years) eventually participated. The nurses worked in the following settings: hospital (n=11, 28%), home-care (n=14, 36%), mental health care (n=7, 17%), elderly care (n=6, 15%) and general practice (n=1, 3%). ResultsFour distinct perspectives on the goals for self-management support were identified: the Coach, the Clinician, the Gatekeeper and the Educator perspective. The Coach nurse focuses on the patient's daily life activities, whereas the nurses of the Clinician type aim to achieve adherence to treatment. The goal of self-management support from the Gatekeeper perspective is to reduce health care costs. Finally, the Educator nurse focuses on instructing patients in managing the illness. ConclusionsThe changing role of chronic patients with regard to self-management asks for a new understanding of nurses’ supportive tasks. Nurses appear to have dissimilar perceptions of what self-management support entails. These distinct perceptions reflect different patient realities and demand that nurses are capable of reflexivity and sensitivity to patient needs. Different perspectives toward self-management support also call for diverse competencies and consequently, also for adaptation of educational nursing programs.

Studying Design and Use of Healthcare Technologies in Interaction: The Social Learning Perspective in a Dutch Quality Improvement Collaborative Program

Designing technologies is a process that relies on multiple interactions between design and use contexts. These interactions are essential to the development and establishment of technologies. This article seeks to understand the attempts of healthcare organisations to integrate use contexts into the design of healthcare technologies following insights of the theoretical approaches of social learning and user representations. We present a multiple case study of three healthcare technologies involved in improving elderly care practice. These cases were part of a Dutch quality improvement collaborative program, which urged that development of these technologies was not “just” development, but should occur in close collaboration with other parts of the collaborative program, which were more focused on implementation. These cases illustrate different ways to develop technologies in interaction with use contexts and users. Despite the infrastructure of the collaborative program, interactions were not without problems. We conclude by arguing that interactions between design and use are not naturally occurring phenomena, but must be actively organised in order to create effects.

The Ethical Intersection of Elder Law and Elder Care Practices

Clinical geriatricians and other healthcare providers who care for older adults are at times put in situations outside of their elder care settings. Elder law is one area that sometimes overlaps with elder care. Elder law is the practice of law that addresses the legal needs of older adults. Some of the common legal documents executed as part of an elder law practice are wills, trusts, transfers of property, living wills, and healthcare proxies. It is not as important for healthcare providers to understand the intricacies of the above-mentioned documents as it is to understand that all of the above are important legal documents that can have significant consequences and are a means for older adults to put their wishes into writing. Often, and many times because of convenience, healthcare providers are asked to witness the execution of these documents. This letter aims to touch on some general ethical points before one agrees to serve as a witness in the execution of a legal document. Before agreeing to take part in the execution any of the above-mentioned documents, it is important to understand the four “Cs” of elder law practice:1 understanding who the client is, understanding the importance of confidentiality, the potential of conflicts of interest, and questions regarding the capacity of the client.1 The client is often your older adult patient in the hospital setting or a resident in the senior living center. Litigation with respect to elder law often involves determining whether the client had legal capacity to execute the document in question and whether there were any conflicts of interest. Legal capacity exists on a continuum and is context specific.1 That is, the standard of legal capacity is different with respect to the document being executed. Affidavits are sometimes executed along with the primary legal document to reassure the courts that legal capacity was met. Before signing as a witness to any of these documents, be sure to carefully read the affidavit itself because it often outlines some of the capacity standards. If there is an attorney present, ask the attorney for clarification before signing as a witness. Does the client truly understand the consequences of executing a given document, and is the client mentally able to make such decision? If there is any question with respect to capacity, one should not take part in the execution of the legal document. Like geriatric practices, elder law practices also often involve family members. Similar to conducting family conferences in a geriatrics practice, when taking part in the execution of a legal document, it is always important to remember who the client is. A conflict of interest may arise when an adult child seeks arrangements for a loved one, but the child clearly will gain from the execution of a particular legal document.1 It is important not to get distracted with the needs and instructions of family members but to speak directly with the client (your patient). If there is any question with respect to conflict of interest, one should not take part in the execution of the legal document. It is helpful and often convenient for healthcare providers in older adult settings to serve as witnesses to the execution of important legal documents, but before agreeing to serve as a witness, one should be aware of the four Cs and make sure that the client's (patient's) rights and needs are not being compromised. Conflict of Interest: None. The University of Rochester CTSA award KL2 RR024136 funded this work. Author Contributions: Both authors contributed significantly to the research and writing of this paper. Sponsor's Role: None.

Deprescribing in the Last Year of Life

ABSTRACTPolypharmacy and adverse drug reactions are common with ageing. Deprescribing or ceasing unnecessary or harmful medications is an important component of aged care practice, especially in the final year of life. Changes in pharmacokinetics and pharmacodynamics with ageing can affect decisions about deprescribing. Similarly, the balance between risk and benefit for medications is often altered in patients in their final year of life and needs to be taken into account. There is evidence for medicines that can be safely ceased abruptly and medicines that need to be weaned. An individualised approach is required to assess prognosis, trajectory of decline and therapeutic goals for each patient. An algorithm is provided in this review to guide safe, rational deprescribing for patients who are believed to be in their last year of life.

Elderly Care Practice by the Classification of the First Level Based on International Classification of Functioning, Disability and Health

Elderly Care Practice by the Classification of the First Level Based on International Classification of Functioning, Disability and Health

Beyond ‘doing’: Supporting clinical leadership and nursing practice in aged care through innovative models of care

Contemporary health care environments are increasingly challenged by issues associated with the recruitment and retention of qualified nursing staff. This challenge is particularly felt by residential aged care providers, with registered nurse (RN) numbers already limited and resident acuity rapidly rising. As a result, aged care service providers are increasingly exploring creative and alternative models of care. This article details exploratory research into a pre-existing, alternative model of care in a medium sized, regional residential aged care facility. Research findings suggest that the model of care is complex and multi-faceted and is an example of an integrated model of care. As a result of the implementation of this model of care a number of shifts have occurred in the practice experiences and clinical culture within this facility. Results suggest that the main benefits of this model are: (1) increased opportunities for RNs to engage in clinical leadership and proactive care management; (2) improved management and communication in relation to work processes and practices; and (3) enhanced recruitment and retention of both RNs and care workers.

Facilitating best practice in aged care: exploring influential factors through critical incident technique

Aim. The focus of this study is on the perspective of facilitators of evidence-based aged care in long-term care (LTC) homes about the factors that influence the outcome of their efforts to encourage nursing staff use of best practice knowledge. Design. Critical incident technique was used to examine facilitators' experiences. Methods. Thirty-four participants submitted critical incident stories about their facilitation experiences through face-to-face interviews, telephone interviews, and/or a web-based written questionnaire. The resultant 123 stories were analysed using an inductive qualitative approach. Results. Factors at individual and contextual levels impacted the success of facilitators' work. The approaches and traits of facilitators as well as the emotionality and intellectual capacity of nursing staff were the individual factors of influence. On a contextual level, the inherent leadership, culture, and workload demands within LTC homes, as well as externally imposed standards were influential. Conclusions. Primary factors influencing the facilitation of best aged care in LTC homes appear to be largely relational in nature and intimately connected to the emotionality of those who work within these settings. Enhancing the interactional patterns amongst staff and leaders as well as promoting a positive emotional climate may be particularly effective in promoting better aged care nursing practice.

Tai Chi and Health‐Related Quality of Life in Nursing Home Residents

Health-related quality of life (HRQOL) that is good is regarded as the goal of elderly residential care. However, limited evidence exists indicating a promising intervention that can achieve this goal. The aim of this study is to examine the effect of Tai Chi on HRQOL in nursing home residents. A nonequivalent pretest-posttest control-group design. A convenience sample of 139 residents from six nursing homes in Hong Kong was used. The experimental group (n=66) joined a 26-week Tai Chi program, while the control group (n=73) continued with usual daily activities. The physical and mental components of HRQOL were designated as the dependent variables. Resident satisfaction was considered as a covariate. Doubly multivariate repeated measures analysis of covariance was done to examine the intervention effect. After adjusting for the confounding effect of resident satisfaction, a statistically significant difference (p<0.05) in the physical and mental components of HRQOL between the experimental and control groups was found. Findings showed significant improvement in HRQOL after residents practiced Tai Chi. These investigators contribute additional knowledge about the health benefits of Tai Chi among nursing home residents and indicates support for its use in this population to improve HRQOL. Tai Chi has unique characteristics as a health exercise that is particularly suitable for nursing home residents. The inclusion of Tai Chi exercise in elderly residential care practice is recommended.

Activity Analysis, Summarization, and Visualization for Indoor Human Activity Monitoring

In this work, we study how continuous video monitoring and intelligent video processing can be used in eldercare to assist the independent living of elders and to improve the efficiency of eldercare practice. More specifically, we develop an automated activity analysis and summarization for eldercare video monitoring. At the object level, we construct an advanced silhouette extraction, human detection and tracking algorithm for indoor environments. At the feature level, we develop an adaptive learning method to estimate the physical location and moving speed of a person from a single camera view without calibration. At the action level, we explore hierarchical decision tree and dimension reduction methods for human action recognition. We extract important ADL (activities of daily living) statistics for automated functional assessment. To test and evaluate the proposed algorithms and methods, we deploy the camera system in a real living environment for about a month and have collected more than 200 hours (in excess of 600 G bytes) of activity monitoring videos. Our extensive tests over these massive video datasets demonstrate that the proposed automated activity analysis system is very efficient.

Elder Care Practices in Okinawa: Tradition in Transition

Elder Care Practices in Okinawa: Tradition in Transition

Maintaining oral hydration in older adults living in residential aged care facilities

Background The Clinical Fellowship program was developed to address the need for best practice in aged care and therefore improve outcomes for residents in Residential Aged Care. The project chosen for this program was Oral Hydration with the aim of improving the hydration status of Nursing Home residents and management of those at risk of dehydration. Method The clinical audit tool used was the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES). This tool allows measurement of current practice against best practice. The Getting Research into Practice program was then used to address non-compliance with best practice. This program requires consultation with key stakeholders to identify limitations to achieving best practice and plan action to address these limitations where possible. Conclusion While 100% compliance with all audit criteria was not achieved, strategies to improve current practice were identified and are in the process of being implemented. The tools developed by The JBI have been beneficial in identifying, measuring and implementing best practice. The process has the potential to contribute to improved resident outcomes and best practice in residential aged care through clinical audit and feedback.

Developing clinical leaders in Australian aged care homes

The role of clinical leadership in implementing evidence based practice is increasingly recognised in the health and social care fields. This paper briefly reviews the literature on clinical leadership and evidence-based practice in aged care and describes the established of an aged care clinical fellowship program in Australia. The purpose of this paper is to introduce the reports of four aged care clinical fellows reported elsewhere in this issue of the International Journal of Evidence-Based Healthcare.

New scheme to develop best practice in aged care

New scheme to develop best practice in aged care

The paradox of the Aged Care Act 1997: the marginalisation of nursing discourse.

This paper examines the marginalisation of nursing discourse, which followed the enactment of the Aged Care Act 1997. This neo-reform period in aged care, dominated by theories of economic rationalism, enshrined legislation based upon market principles and by implication, the provision of care at the cheapest possible price. This paper exposes some of the gaps in the neo-reform period and challenges the assertion that the amalgamation of nursing homes and hostels in such an environment can provide better quality of care and life for residents. It argues that this amalgamation entails a transformation towards a social model of care and fails to address the professional healthcare needs of the acutely sick and complex extreme old person and makes evident new gaps in the provision of aged care services. The paper proceeds to present strategies where the future for nursing practice in aged care necessarily involves a judicious balancing of individual cases alongside economic prescriptions of care and ever-changing public policy initiatives. It concludes that this can be achieved through a more interactive public, professional and advocacy discourse. The methodology involves extensive analysis of public documents including media, academic journals, government reports and interviews with recognised leaders in the field of aged care. The study utilises a critical interpretative framework consistent with the logic of Michel Foucault.