Long-term Care Environment Research Articles

A Systems Approach to Improving Care for All Bereaved Families.

Bereavement services for families are an established part of hospice and palliative care. However, patients also die in the acute care and long-term care environments. Often, hospice is not involved, creating a potential gap in care. This article recounts a journey to improve care for all families of deceased patients, despite the presence or absence of hospice. A palliative care clinical nurse specialist led a quality improvement team, which used a systems thinking approach to develop and implement a downloadable bereavement booklet for families. Expected and unexpected outcomes are discussed for this replicable project.

Steps Toward Building a Better Team

Steps Toward Building a Better Team

Adopting a Multilevel Approach to Protecting Residents’ Rights to Sexuality in the Long-Term Care Environment: Policies, Staff Training, and Response Strategies

It is estimated that long-term care (LTC) facilities in the US will experience a 40 % increase in occupancy between the years 2000 to 2020 (American Health Care Association 2012). Whole-person wellness embodies multiple elements of well-being, among which sexuality and the choice to remain sexually expressive, a basic human right for older adults, should be included. However, this right is largely overlooked in the context of LTC, and oftentimes, normative sexual expression among LTC residents is mislabeled as problematic behavior. Systems and bioecological theories provide a conceptual multilevel framework for understanding interactions among relevant institutions and government entities and their influence on residents’ sexual expression. The current article addresses the issue of preserving residents’ choices to be sexually expressive and places current US laws regarding sexual expression in LTC in the context of international perspectives on sexual health rights and laws. Input from LTC Ombudsmen from the US was utilized to inform recommendations to enhance current policies and contribute feedback for effective training guidelines for LTC staff in addressing residents’ sexual expression. Both universal acknowledgement of sexuality as a human right and legal guidelines are necessary to broaden understanding of the meaning of sexuality in older adulthood and aid in ethical and person-centered response strategies which promote autonomy and preserve each individual resident’s rights to sexual expression while maintaining safety.

Care assistant experiences of dementia care in long-term nursing and residential care environments

Care assistants have a unique insight into the lives of service users and those factors which may impede or enhance the delivery of high quality dementia oriented care. To address the paucity of research in this area, the present study examined care assistant experiences of dementia care in British long-term residential and nursing environments. Semi-structured interviews were conducted with eight care assistants and transcripts were analysed using interpretive phenomenological analysis. Super-ordinate themes emerging from the data were psychological wellbeing of the care assistant, barriers to effective dementia care, the dementia reality and organisational issues within the care environment. The study revealed important deficiencies in understanding and varying levels of dementia training. Whilst person centred strategies were being implemented, task orientated care remained dominant. Furthermore, care assistants reported taking the perspectives of those with dementia into account, and actively using these to develop relationship centred care.

Hypoaminoacidemia Characterizes Chronic Traumatic Brain Injury.

Individuals with a history of traumatic brain injury (TBI) are at increased risk for a number of disorders, including Alzheimer's disease, Parkinson's disease, and chronic traumatic encephalopathy. However, mediators of the long-term morbidity are uncertain. We conducted a multi-site, prospective trial in chronic TBI patients (∼18 years post-TBI) living in long-term 24-h care environments and local controls without a history of head injury. Inability to give informed consent was exclusionary for participation. A total of 41 individuals (17 moderate-severe TBI, 24 controls) were studied before and after consumption of a standardized breakfast to determine if concentrations of amino acids, cytokines, C-reactive protein, and insulin are potential mediators of long-term TBI morbidity. Analyte concentrations were measured in serum drawn before (fasting) and 1 h after meal consumption. Mean ages were 44 ± 15 and 49 ± 11 years for controls and chronic TBI patients, respectively. Chronic TBI patients had significantly lower circulating concentrations of numerous individual amino acids, as well as essential amino acids (p = 0.03) and large neutral amino acids (p = 0.003) considered as groups, and displayed fundamentally altered cytokine-amino acid relationships. Many years after injury, TBI patients exhibit abnormal metabolic responses and altered relationships between circulating amino acids, cytokines, and hormones. This pattern is consistent with TBI, inducing a chronic disease state in patients. Understanding the mechanisms causing the chronic disease state could lead to new treatments for its prevention.

Plotting the Course of Well-Being

Persons above age 80 comprise the fastest growing segment of the U.S. population, and it is estimated that one in four will need long-term care due to increased disabilities and illness. A major concern for residents, families, and providers is to ensure care that “allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being.” The challenge is measuring a subjective concept such as well-being. The Eden Alternative is a current initiative aimed at improving the quality of life and well-being of long-term care residents. The initiative consists of providing long-term care environments that emphasize person-directed decision making and well-being. The purpose of this study was to explore the psychometric properties of the Eden Alternative Well-Being Assessment Tool (EAWBAT). There are three assessment tools designed to measure the well-being of elders (residents), family members of residents, and employees working in the long-term care environments. The sample consisted of 237 residents, 430 employees, and 134 family members from seven Eden Alternative organizations throughout the United States. Factor analysis was completed to identify the underlying structure in these data for elders, employees, and families. Reliability statistics were computed for each scale. Reliability statistics ranged from .876 (employee assessment tool) to .949 (family assessment tool), indicating the potential of the EAWBAT to measure the well-being of residents residing in long-term care environments, employees supporting them, and their family members.

Prevalence of Anticholinergic Medication Use in the Program of All-Inclusive Care for the Elderly.

Evaluate the prevalence of anticholinergic medication use in the Program of All-Inclusive Care for the Elderly (PACE). Cross-sectional, retrospective chart review. The Basics at Jan Werner PACE, Amarillo, Texas. PACE participants (n = 128) and long-term care residents (n = 105) 65 years of age and older. The primary outcome was percentage of prescribed medications with anticholinergic properties and risk factors associated with prescribing: study site, gender, race, age, and creatinine clearance. Anticholinergic medication prescribing was significantly lower in the PACE program (2.3% of total medications vs. 3.9%; P < 0.05) as well as total medication use (12.1 medications per subject vs. 20.8; P < 0.05 in the long-term care environment). Only the long-term care study site had a significant association with anticholinergic prescribing (odds ratio = 5.04, confidence interval 2.71-9.38). PACE participants also had lower Anticholinergic Risk Scale scores (score of 0, 60.2% PACE vs. 16.2%), reduced fall rates (23.8 per month PACE vs. 66.9), and similar hospitalization rates (5.4 per month PACE vs. 5.7). PACE participants were prescribed fewer medications and had lower anticholinergic burden, which potentially lowers their risk of adverse effects. These data support the PACE interdisciplinary model by demonstrating the benefit of team care in appropriate use of medications. It provides a potential blueprint to organizations aimed at reducing potentially inappropriate medication prescribing in older adults.

“It Doesn't Require Much Effort Once You Get to Know Them”: Certified Nursing Assistants' Views of Communication in Long-Term Care

Certified nursing assistants (CNAs) provide the majority of hands-on care and become highly sensitive to residents' communication behaviors. Yet, CNAs feel disempowered when communicating residents' concerns to higher levels of authority. A grounded theory approach using focus group interviews with 23 CNAs was used to describe the communication environment in long-term care (LTC) and explore CNAs' perceptions of the acceptability of communication plans, a recent Canadian intervention to facilitate resident-staff communication. Findings suggest the communication environment in LTC relates to three overlapping constructs: (a) CNA and resident communication style; (b) paradox of context; and (c) dedication to residents. Although CNAs frequently interact with residents, a division between "top and bottom staff" communication was apparent in the findings. The current study suggested that communication plans may improve the communication environment in LTC settings. [Journal of Gerontological Nursing, 42(4), 42-51.].

Dignity in long-term care: An application of Nordenfelt's work.

The concept of dignity is recognised as a fundamental right in many countries. It is embedded into law, human rights legislation and is often visible in organisations' philosophy of care, particularly in aged care. Yet, many authors describe difficulties in defining dignity and how it can be preserved for people living in long term care. In this article, Nordenfelt's 'four notions of dignity' are considered, drawing on research literature addressing the different perspectives of those who receive, observe or deliver care in the context of the long-term care environment. A review of the literature was undertaken using the terms 'nursing homes', 'residential care' or 'long-term care'. The terms were combined and the term 'human dignity' was added. A total of 29 articles met the inclusion criteria from the United Kingdom (14), United States (2), Australia (1), Sweden (3), Hong Kong (2), Norway (3), Nordic (1), Taiwan (1), Netherlands (1). Ethical Considerations: Every effort has been made to ensure an unbiased search of the literature with the intention of an accurate interpretation of findings. The four notions of dignity outlined by Nordenfelt provide a comprehensive description of the concept of dignity which can be linked to the experiences of people living in long-term care today and provide a useful means of contextualising the experiences of older people, their families and significant others and also of staff in long-term care facilities. Of particular interest are the similarities of perspectives of dignity between these groups. The preservation of dignity implies that dignity is a quality inherent in us all. This links directly to the exploration and conclusions drawn from the literature review. Conversely, promoting dignity implies that dignity is something that can be influenced by others and external factors. Hence, there are a number of implications for practice. We suggest that two of Nordenfelt's notions, 'dignity of identity' and 'dignity of Menschenwüde', are a common thread for residents, family members and staff when conceptualising dignity within long-term care environments.

‘Everyday Advocates’ for Inclusive Care? Perspectives on Enhancing the Provision of Long-Term Care Services for Older Lesbian, Gay and Bisexual Adults in Wales: Table 1

This paper centres on a neglected area of social work with older people-the social inclusion of older lesbian, gay and bisexual (LGB) adults in long-term care environments. The translation of equality law into the delivery of adult care services is a challenging endeavour for organisations, even more so in the morally contested terrain of sexual well-being. In this paper, we report findings from a mixed-methods study into the provision of long-term care for older adults who identify as LGB. Herein we present findings from a survey of care workers and managers (n = 121) and from focus groups with equality and LGB stakeholder represent atives (n = 20) in Wales. Focusing on the current knowledge and understanding of staff, we suggest that affirmative beliefs and practices with sexual minorities are evidentamongst care workers and managers;however, theinclusion of LGB residents needs to be advanced systemically at structural, cultural and individual levels of provision. There is a need for enhancing awareness of the legacy of enduring discrimination for older LGB people, for cultural acceptance in care environments of older people's sexual desires and relationships, and for a more explicit implementation of equality legislation. Social workers in adult care can advance this agenda.

Join the Revolution: How Montessori for Aging and Dementia can Change Long-Term Care Culture.

Efforts to improve the quality of life of persons with dementia in long-term care through the implementation of various approaches to person-centered care have been underway for the past two decades. Studies have yielded conflicting reports evaluating the evidence for these approaches. The purpose of this article is to outline the findings of several systematic reviews of this literature, highlighting the areas of improvement needs, and to describe a new person-centered care model, DementiAbility Methods: The Montessori Way. This model focuses on the abilities, needs, interests, and strengths of the person and creating worthwhile and meaningful roles, routines, and activities for the person within a supportive physical environment. This is accomplished through gaining the commitment of the facility's leaders, training staff, and monitoring program implementation. The potential for a culture change in long-term care environments is dependent on the development and rigorous evaluation of person-centered care approaches.

A Randomized Control Trial Investigating the Impact of Individualized Seating Provision for Older Adults in Long-Term Care

Abstract Date Presented 4/16/2015 This study details the results of a clinical trial examining the effectiveness of specialized seating assessment and provision within the long-term care environment for older adults with complex seating needs and the significant impact on skin integrity and postural management.

Implement Safety Measures to Avoid Resident Elopements

Implement Safety Measures to Avoid Resident Elopements

The Use of Physical Restraints in Acute and Long-term Care

Purpose: The purpose of this article was to review current evidence regarding the use and efficacy of physical restraints in inpatient settings and to discuss the regulations, ethical implications, and legal considerations surrounding their use. This study provides an update to a previous report published over a decade ago. Findings: The rate of physical restraint use has declined significantly over the past few decades, largely because of a lack of support for their efficacy in keeping patients safe, coupled with evidence of negative outcomes associated with their use. Many studies have shown that restraint use can actually increase the risk of falls, injury, negative events like self-extubation, and even death. Conclusion: While restraints are less prevalent, their use in acute, critical, and long-term care environments continues into the 21st century. The historical rationale that restraints should be used to prevent falls, keep patients safe, and limit interference with medical treatment is not supported by the literature. Continuing to reduce their use in all inpatient health care settings appears to be the most appropriate, patient-centered course of action. Physical therapists are experts at assessing and improving patient safety, mobility, and functional independence and are in an excellent position to encourage the use of restraint alternatives to maximize patient safety.

Discharge Criteria and Follow-Up Support for Dementia Care Units.

Specialized dementia care units (DCUs) house individuals whose behaviors cannot be managed in other settings. To ensure environmental fit, admission/discharge criteria are recommended for DCUs; however, there is no consensus about what criteria should be used. This study aimed to describe, in a random sample of DCUs, the current admission criteria, current/recommended discharge criteria, and services to support discharge. Usable surveys were returned by 23 of 30 facilities. Residents were most frequently admitted because they had a diagnosis of dementia and exhibited cognitive/behavioral problems. The four most common discharge criteria in place/recommended were resident ability to manage in a non-specialized long-term care environment, lack of socially inappropriate behaviors, dependency in activities of daily living, and inability to participate in dementia care activities. These findings suggest that discharge from DCUs is relatively ad hoc. The study lays the groundwork for future research to evaluate the use/appropriateness of these criteria.

The effects of arts-in-medicine programming on the medical-surgical work environment

Background: Arts in medicine programs have significant impacts on patients and staff in long-term care environments, but the literature lacks evidence of effectiveness on hospital units with shorter average lengths of stay. Methods: The qualitative study used individual structured interviews to assess the impacts of arts programming on job satisfaction, stress, unit culture, support, quality of care, and patient outcomes on a short-term medical-surgical unit, and used a qualitative cross comparison grounded theory methodology to analyze data. Results: The study confirmed that arts programming can positively affect unit culture, nursing practice, and quality of care on short-stay medical-surgical units. Significant insights related to nursing practice and the art program were found, including that music can cause negative distraction for staff. Conclusions: While positive impacts of arts programming on the medical-surgical environment are clear, potential negative effects also need to be considered in the development of practice protocols for artists.

Long-Term Care and the Law

The law exerts a significant influence on the quality, accessibility, and affordability of long-term care (LTC) services that are, or that at some future time may be, needed by older Americans. The interaction between the legal system and the various participants involved in the provision and receipt of LTC - consumers, family members, providers, payers, regulators, and advocates - is complex and multi-faceted. This chapter, written for a textbook on long-term care, attempts to outline some of the most salient aspects of this interaction so as to equip the reader both to more fully and accurately appreciate the roles of the law and lawyers in shaping the long-term care environment and to evaluate the actual impact of the legal system on those whom it seeks to benefit, empower, oversee, or punish. Specific topics covered include: the sources and functions of legal authority; specific forms of legal regulation pertaining to long-term care; legal implications of consumer driven home- and community-based LTC; and behavioral manifestations of the regulatory environment.

Exploring the Experience of Nursing Home Residents Participation in a Hope-Focused Group

A qualitative intervention was used to explore how older adults living in a long-term care environment (nursing home) understand hope and experience being participants in a group in which a hope intervention was carried out. A group project in which each session focused intentionally on a hope strategy was carried out with a convenience sample of 10 women (ages 75–99) who were members of an existing group. Data were analyzed using thematic analysis of the interviews (conducted before the group intervention was carried out and again at the end), field notes, and collaborative conversations regarding emerging themes. Findings from this study suggest that hope is not static and that it can change over time in response to one's situations and circumstances. Also evident in this study is the potential for using a group process in long-term care to foster hope in an intentional way to make it more visible in the lives of the residents and their environment suggesting that one is “never too old for hope.”

Relational Sustainability

Patients undergoing bone marrow transplant, using spinal cord services, and with traumatic brain injury represent a relatively new patient type, requiring both intense care and long-term care in the same facility. As medical advances allow these patients the opportunity to recover from their critical illnesses or injuries, designers and caregivers must give increased attention to the long-term critical care environment. Designing for this type of care requires an understanding of new technologies and the potential for the built environment to address the wide range of physical, sensory, and psychological issues long-term inpatients face. Recent work by SmithGroupJJR has provided valuable insights into the ways in which lighting, patient room and unit layouts, spatial volumes, and other design elements can contribute to the recovery of patients who must spend weeks or months in a critical care environment. This knowledge was gained through an approach that allows design professionals to immerse themselves in a health care institution's values, culture, and work processes. By mapping both operational flow and patients' experiences, project teams can develop design solutions that sustain the well-being of higher-acuity patients and their family members and caregivers.

Personal care workers in Australian aged care: retention and turnover intentions

This study examined factors influencing personal care workers' intentions to stay or leave Australian aged care employment - especially for older workers. Retention of personal care workers is particularly important in aged care as they provide the majority of the direct care via community aged care or long-term aged care environments. However, there is limited research on what drives their turnover and retention. A survey was conducted during 2012 collecting 206 responses from workers within community and long-term aged care in four organisations in Australia. Perceived supervisor support, on-the-job embeddedness and area of employment were identified as predictors of both intention to stay and to leave, although the relationship strength differed. Community care workers were more likely to stay and reported more supervisor support than long-term care workers. Unexpectedly, age and health status were not predictors of staying or leaving. While there are similarities between retention and turnover motivators, there are also differences. Within a global context of health worker shortages, such new knowledge is keenly sought to enhance organisational effectiveness and sustain the provision of quality aged care. Retention strategies for older workers should involve increasing supervisor support, and seeking to embed workers more fully within their organisation.