Nursing Home Practice Research Articles

Hydration practices in residential and nursing care homes for older people.

To scope and explore hydration practices in care homes. Older residents do not regularly consume adequate fluids to support health. Achieving this is difficult with residents who have coexisting health, sensory and functional problems, as well as challenging hydration habits. This project used a sequential exploratory mixed method design to scope and explore existing hydration practices. Data were collected via two stages. First was a survey of hydration practices. Twenty-nine responses were received from 81 care homes (response rate: 35.8%). Second was the exploration of practitioners' experiences and perceptions of hydration practice via semi-structured interviews (54 staff: 43 interviews). Descriptive statistics summarised the survey findings. Open coding and thematic analysis were applied to the qualitative data, and details of the methods are reported in adherence to COREQ criteria. It is important to provide hydration support in addition to regularly offering drinks to residents. Hydration practices include the following: use of social interaction to encourage drinking; verbal and nonverbal prompts to drink; giving fluids with routine practices and social activities; providing drinks-related activity, use of aids and equipment to support drinking; and creating a drink-friendly environment. Practices are implemented in care homes; however, no one care home implements all these hydration strategies at any one time. Older care home residents need support and encouragement to drink adequate fluids which can be difficult to achieve with residents who have complex needs and challenging drinking habits. In addition to the routine offer of drinks, hydration support should be used to facilitate residents to drink sufficient amounts of fluid. Staff working in care homes have an important role in assessing the hydration needs of residents and using multiple hydration practices to support residents to achieve their hydration requirements.

It Is Not Your Parents' Long-Term Services System: Nursing Homes in a Changing World.

The long-term services system has changed substantially since the mid-1970s, when the landmark book Last Home for the Aged argued that the move to the nursing home was the last move an older person would make until death. Using detailed nursing home utilization data from the Minimum Data Set, this study tracks three cohorts of first-time nursing home admissions in Ohio from 1994 through 2014. Each cohort was followed for a 3-year period. Study results report dramatic reductions in nursing home length of stay between the 1994 and 2011 cohorts. Reduction in length of stay has important implications for nursing home practice and quality monitoring. The article argues that administrative and regulatory practices have not kept pace with the dramatic changes in how nursing homes are now being used in the long-term services system.

Besøk på sykehjem. En kvantitativ studie av sykehjemsbeboeres besøkshyppighet

Social contact is essential for the well-being of the nursing home residents.Visiting frequency in nursing homes is rarely investigated. The purpose of this study was to map the number of visits for nursing home residents. Nursing students collected data during their nursing home practice. 355 residents were included in this cross-sectional study. We explored the association between visit frequency and age, gender, type of department, activities of daily living (ADL) and length of stay. Data was analyzed using statistical analysis. The average number of visits was 8,8 per month. However, there were differences in visit frequency among the 15 institutions. Residents in the long-term department received fewer visits compared to the dementia and short-term department. Significant correlations between ADL function, gender, length of stay, age and frequency of visits were not found. More research to identify causes for the differences in visit frequency between different institutions is needed.Keywords: nursing homes; visiting; visit frequency; sykehjem; besøk; besøkshyppighet

Nursing Home Physicians Discuss Caring for Elderly Residents: An Exploratory Study.

ABSTRACTDespite the increasing complexity of nursing home care, the role of physicians caring for residents is largely unexplored. This international, exploratory study sought to learn about physicians' roles, responsibilities, and tasks as well as investigate the unique qualities of medical practice in nursing homes. We conducted interviews with 18 physicians, who reported making important contributions to the quality of resident care, including clarifying the goals of care, working to reduce unnecessary medication and hospitalization, as well as contributing to staff education. Nursing home practice involved physicians in networks of relations that were instrumental to the quality of medical care and physicians' job satisfaction. The importance of these relationships disrupts the oft-drawn boundary between the medical and the social, suggesting that good medical practice depends on good social practice. Reflecting the exploratory nature of the study, we recommend research to better understand and support the relational dimensions of nursing home medicine.

Leadership in Nursing Homes: Directors of Nursing Aligning Practice With Regulations.

Nursing homes use team nursing, with minimal RN presence, leaving the majority of direct care to licensed practical/vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP), including medication aides. The current article describes challenges faced by nursing home directors of nursing (DONs) leading and managing a team nursing approach, including consideration of scope of practice, delegation and supervision regulations, and related policy implications. A secondary data analysis was performed of qualitative data from a study to develop and test DON guidelines for delegation in nursing home practice. A convenience sample (N = 29) of current or previous DONs and other nursing home leaders with knowledge and expertise in the DON role participated in in-depth, guided interviews. The findings highlight a core concern to nursing licensure policy and regulation: knowledge and practice gaps related to scope of practice and delegation and supervision among DONs, RNs, and LPNs/LVNs, as well as administrators, and the role of nursing leaders in supporting appropriate delegation practices. The findings offer directions for research and practice in addressing challenges in aligning team nursing practices with regulatory standards as well as the related gaps in knowledge among DONs, administrators, and nursing staff. [Journal of Gerontological Nursing, 44(6), 10-14.].

Facilitation of an end-of-life care programme into practice within UK nursing care homes: A mixed-methods study

BackgroundThe predicted demographic changes internationally have implications for the nature of care that older people receive and place of care as they age. Healthcare policy now promotes the implementation of end-of-life care interventions to improve care delivery within different settings. The Gold Standards Framework in Care Homes (GSFCH) programme is one end-of-life care initiative recommended by the English Department of Health. Only a small number of care homes that start the programme complete it, which raises questions about the implementation process. AimTo identify the type, role, impact and cost of facilitation when implementing the GSFCH programme into nursing care home practice. DesignA mixed-methods study. SettingNursing care homes in south-east England. ParticipantsStaff from 38 nursing care homes undertaking the GSFCH programme. Staff in 24 nursing care homes received high facilitation. Of those, 12 also received action learning. The remaining 14 nursing care homes received usual local facilitation of the GSFCH programme. MethodsStudy data were collected from staff employed within nursing care homes (home managers and GSFCH coordinators) and external facilitators associated with the homes. Data collection included interviews, surveys and facilitator activity logs. Following separate quantitative (descriptive statistics) and qualitative (template) data analysis the data sets were integrated by ‘following a thread’. This paper reports study data in relation to facilitation. ResultsThree facilitation approaches were provided to nursing home staff when implementing the GSFCH programme: ‘fitting it in’ facilitation; ‘as requested’ facilitation; and ‘being present’ facilitation. ‘Being present’ facilitation most effectively enabled the completion of the programme, through to accreditation. However, it was not sufficient to just be present. Without mastery and commitment, from all participants, including the external facilitator, learning and initiation of change failed to occur. Implementation of the programme required an external facilitator who could mediate multi-layered learning at an individual, organisational and appreciative system level. The cost savings in the study outweighed the cost of providing a ‘being present’ approach to facilitation. ConclusionsDifferent types of facilitation are offered to support the implementation of end-of-life care initiatives. However, in this study ‘being present’ facilitation, when supported by multi-layered learning, was the only approach that initiated the change required.

Daring involvement and the importance of compulsory activities as first-year students learn person-centred care in nursing homes.

There has been an increased focus on person-centred care in nursing homes, which is grounded in a therapeutic relationship and fostering personal and holistic care. The nursing profession and nursing education are unprepared for the new expectations. The aim of this article is to present a grounded theory of Daring involvement which explains how first-year nursing students learn person-centred care in nursing home practice. Two hundred and eighty-four reflective journals and eight focus group interviews from 36 first-year students were analysed using grounded theory. The students' main concern was How to become a professional nurse, and was resolved in a two-phased substantive grounded theory called Daring involvement. In the first phase, labelled Musting, students use the strategies of Accepting assignments, Exposing experiences and Reflecting. When students discover the humanity in the older residents, their motivation changes from external to internal motivation and they proceed to phase two; Enlivening the person. This phase has four strategies: Tuning in, Key searching, Overcoming obstacles and Involving in activities. When students discover the residents as fellow human beings and involve themselves in a therapeutic relationship, a reciprocal process starts and both residents and students feel enlivened. The students feel rewarded and this grows their professional identity.

Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia.

Ensuring fidelity to a behavioral intervention implemented in nursing homes requires awareness of the unique considerations of this setting for research. The purpose of this article is to describe the goals of care cluster-randomized trial and the methods used to monitor and promote fidelity to a goals of care decision aid intervention delivered in nursing homes. The cluster randomized trial tested whether a decision aid for goals of care in advanced dementia could improve (1) the quality of communication and decision-making, (2) the quality of palliative care, and (3) the quality of dying for nursing home residents with advanced dementia. In 11 intervention nursing homes, family decision-makers for residents with advanced dementia received a two-component intervention: viewing a video decision aid about goals of care choices and then participating in a structured decision-making discussion with the nursing home care plan team, ideally within 3 months after the decision aid was viewed. Following guidelines from the National Institutes of Health Behavior Change Consortium, fidelity was assessed in study design, in nursing home staff training for intervention implementation, and in monitoring and receipt of the intervention. We also monitored the content and timing of goals of care discussions. Investigators enrolled 151 family decision-maker/resident dyads in intervention sites; of those, 136 (90%) received both components of the intervention, and 92%-99% of discussions addressed each of four recommended content areas-health status, goals of care, choice of a goal, and treatment planning. A total of 94 (69%) of the discussions between family decision-makers and the nursing home care team were completed within 3 months. The methods we used for intervention fidelity allowed nursing home staff to implement a goals of care decision aid intervention for advanced dementia. Key supports for implementation included design features that aligned with nursing home practice, efficient staff training, and a structured guide for goals of care discussions between family decision-makers and staff. These approaches may be used to promote fidelity to behavioral interventions in future clinical trials.

When care situations evoke difficult emotions in nursing staff members: an ethnographic study in two Norwegian nursing homes.

BackgroundCaring practice in nursing homes is a complex topic, especially the challenges of meeting the basic needs of residents when their behaviour evokes difficult emotions. Cognitive and physical changes related to aging and disability can contribute to behaviours considered to be unacceptable. For example, resident behaviours such as spitting, making a mess with food or grinding teeth are behaviours that most people do not want to see, hear or experience. The aim of this study was to gain a deeper understanding of how nursing home staff members deal with such behaviours in care situations.MethodsThis article draws on ethnographic data to describe how nursing home staff members manage unpleasant resident behaviours. The study was based on two long-term units in two Norwegian public nursing homes. The Region’s Medical Ethics Committee and the Norwegian Social Science Data Services granted approval. In total, 45 participants (37 nursing aides and eight nurses) agreed to participate in this study. Ten of the participants were interviewed at the end of the field study.ResultsThis study indicates that nursing home staff members experience difficult emotions related to some residents’ behaviours. However, they found these feelings difficult to express and rarely verbalized them openly. In addition, they were characterized by a strong obligation to help all residents, despite their own feelings. Therefore, it appears that an inner struggle occurs as a part of everyday practice.ConclusionsDespite these difficult emotions, nursing staff members believed that they needed to manage their responses and continued to offer good care to all residents. These findings extend our understanding of this unarticulated part of nursing home practice.

Efficacy and safety of single-dose zoledronic acid for osteoporosis in frail elderly women: a randomized clinical trial.

Eighty-five percent of institutionalized elderly people have osteoporosis and bone fracture rates 8 to 9 times higher than rates observed among community-dwelling elderly people. Nevertheless, most of these persons are left untreated and are excluded from pivotal osteoporosis trials. To determine the efficacy and safety of zoledronic acid to treat osteoporosis in frail elderly women in long-term care facilities. We conducted a 2-year, randomized, placebo-controlled, double-blinded study from December 2007 through March 2012. Included were 181 women 65 or older with osteoporosis, including those with cognitive impairment, immobility, and multimorbidity, who were living in nursing homes and assisted-living facilities. One 5-mg dose of zoledronic acid or placebo intravenously and daily calcium and vitamin D supplementation. Hip and spine bone mineral density (BMD) at 12 and 24 months and adverse events. There were no baseline differences in mean (SE) age (85.4 [0.6] years), BMD, or functional or cognitive status, but the treatment group included more participants with frailty, falls history, diabetes, and anticonvulsant medication use. Values for BMD were available for 87% of participants at 12 months and 73% at 24 months. Mean (SE) BMD changes were greater in the treatment group: 3.2 (0.7) and 3.9 (0.7) percentage-point differences in the total hip at 12 and 24 months, respectively (P < .01 for both comparisons), and 1.8 (0.7) and 3.6 (0.7) percentage-point differences at the spine (P < .01); adjusted analyses were similar. The treatment and placebo groups' fracture rates were 20% and 16%, respectively (OR, 1.30; 95% CI, 0.61-2.78); mortality rates were 16% and 13% (OR, 1.24; 95% CI, 0.54-2.86). Groups did not differ in the proportion of single fallers (28% vs 24%; OR, 1.24; 95% CI, 0.64-2.42; P = .52), but more participants in the treatment group had multiple falls (49% vs 35%; OR, 1.83; 95% CI, 1.01-3.33; P = .047); however, this difference was no longer significant when adjusted for baseline frailty. In this group of frail elderly women with osteoporosis, 1 dose of zoledronic acid improved BMD over 2 years. The clinical importance of nonsignificant increases in fracture and mortality rates in the treatment group needs further study. Since it is not known whether such therapy reduces the risk of fracture in this cohort, any change in nursing home practice must await results of larger trials powered to assess fracture rates. clinicaltrials.gov Identifier: NCT00558012.

Hospitalists Promote New Care Transitions Paradigm

Hospitalists Promote New Care Transitions Paradigm

Nursing home practices following resident death: The experience of Certified Nursing Assistants

This study examined certified nursing assistants' (CNAs) experiences of nursing home practices following resident death. Participants were 140 CNAs who had experienced recent resident death. In semi-structured, in-person interviews, CNAs were asked about their experiences with the removal of the resident's body, filling the bed with a new resident, and how they were notified about the death. The facilities' practice of filling the bed quickly was most often experienced as negative. Responses to body removal and staff notification varied, but negative experiences were reported by a substantial minority. Being notified prior to returning to work was associated with a more positive experience. Learning about the death by walking into a room to find the bed empty or already filled was the most negative experience. Study findings suggest that more mindful approaches to the transitions related to resident deaths would be valued by CNAs and could improve their work experience.

Teaching Delegation to RN Students

Registered nurse (RN) students have difficulty learning delegation and supervision, and new RNs lack confidence in executing these skills. To improve safety, therefore, RN educators require new teaching and learning strategies to help prelicensure students develop delegation and supervision skills. Our team of nurse educators and researchers developed, implemented, and evaluated a classroom learning activity on delegation and supervision for RN students. The activity, which is grounded in David Kolb's (1983) experiential learning theory, was developed from a research study on delegation and supervision in nursing homes. Drawing on the research data, we constructed robust case studies that authentically illustrate the nursing home practice environment, including the realistic impediments to best practice. Students in our Accelerated Bachelor of Nursing program found the learning activity beneficial to their understanding of and readiness to engage in delegation and supervision.

Development and psychometric evaluation of the Knowledge of Malnutrition – Geriatric (KoM‐G) questionnaire to measure malnutrition knowledge among nursing staff inAustrian nursing homes

Malnutrition is an internationally prevalent healthcare phenomenon in nursing home residents entailing serious consequences for those who are affected. Lack of knowledge among nursing staff is often discussed as a reason for deficits in nutritional practice. For this reason, a valid and reliable tool is necessary to assess knowledge of malnutrition (KoM) care. The objective of this study was to develop and psychometrically evaluate a questionnaire aimed at assessing the KoM care among nursing staff in Austrian nursing homes. This study follows a psychometric methodological design. The dimensions and items of the questionnaire were derived from a literature review. The content validity was evaluated using a Delphi technique with eight international experts in the field of malnutrition. Item validity in terms of distribution of response alternatives, item difficulty and discrimination index, construct validity in terms of a comparison between predefined known groups and internal consistency using Kuder-Richardson 20 were analysed in a sample of 1152 registered nurses/nurse aides from 66 Austrian nursing homes. The Knowledge of Malnutrition - Geriatric (KoM-G) questionnaire consists of 20 items with six answer options including 'I don't know' with established content validity. The quality of response alternatives ranged from 0.3 to 96.9%. The item difficulty of the total questionnaire was 59.3% and the discrimination index was 0.37, whereas one item had a discrimination index below 0.20 and was therefore deleted. Significant differences in percentage of correct answers between registered nurses and nurse aides, nursing staff with training in nutrition and without as well as between nursing staff with positive attitudes towards nutritional care and neutral or negative attitudes were found. The Kuder-Richardson 20 was 0.69. The KoM-G shows acceptable psychometric properties covering a wide range of items regarding malnutrition and can be applied in nursing home practice, education and research.

International Survey of Nursing Home Research Priorities

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

The dark side of Norwegian nursing homes: factors influencing inadequate care

Purpose– The purpose of this paper is to investigate factors that influence the probability that staff will commit acts of inadequate care, abuse, and neglect.Design/methodology/approach– A cross-sectional survey study was carried out in one county in the middle of Norway (Sør-Trøndelag). Random sampling, stratified by size of nursing homes, and location (rural or urban areas), was used to select a variety of nursing homes from a total population of 55 nursing homes. All staff working in 16 nursing homes working were asked to participate in the study. A response rate of 79 per cent was achieved (n=616).Findings– Findings reveal that location and size of the nursing home, age of the staff, education level, job satisfaction, resident aggression, and conflicts between residents and staff predict inadequate care, abuse, and neglect. The most consistent findings are that resident aggression increases the risk for all three types of inadequate care, and that conflicts predict different types of inadequate care depending on whether the conflicts are related to direct care-giving activities or not.Practical implications– Nursing home care is an important part of care for the elderly, and should be characterized by good-quality services. The relation between inadequate care and resident aggression, conflicts, and other factors shown in this study points to the relevance of further improvements in nursing home practices to minimize the occurrence of episodes of inadequate care, abuse, and neglect.Originality/value– This study investigated the relationships between 11 specific factors and different types of inadequate care in a nursing home context.

Quality Improvements in Resident Mobility Care: Using Person- and Relationship-Centered Frameworks

Research is needed to demonstrate the application of person- and relationship-centered care to nursing home practice. This article aimed to find a suitable person/relationship-centered framework to assist with mobility care practice improvements in nursing homes. The authors discuss the task of mobility care, the nature of person- and relationship-centered care, and the significance of such approaches to mobility care. The Senses Framework (Nolan, Davies, Ryan, & Keady, 2008) is employed to develop mobility care practice improvement objectives. The objectives are used to evaluate outcomes from 2 hypothetical scenarios to illustrate the possible value of the Senses Framework. The Senses Framework facilitated development of objectives for mobility care practice improvement that considers the needs of all stakeholders.

The double embarrassment: Understanding the actions of nursing staff in an unexpected situation

A nursing home is a complex multifactorial environment that influences the decisions and actions of nursing staff. Many of the actions performed by nursing staff appear to be straightforward or simple because they are repetitive, encompassing everyday activities such as helping a resident to get up in the morning, shower or get dressed. These daily activities are usually performed smoothly as part of normal care. This article draws on ethnographic data from a study of caring practices in a nursing home with the aim of investigating how a seemingly ordinary, but unexpected, event can develop into a chaotic situation. Staff appeared to have difficulty managing the situation, and they seemed to be disorganized in the application of their skills. First, we describe the situation in detail before investigating and discussing the situation to provide a deeper understanding of the complexity of nursing home practice.

Annual Conference Gave Cautious Preview of LTC Policy

Annual Conference Gave Cautious Preview of LTC Policy

Strategic planning to ensure future practice success

As the end of 2012 approached, I had two interesting conversations that helped me focus on my practice and what I ultimately want to achieve. The fi rst was with a colleague who was starting an independent practice in a physician clinic and asked about my policy and procedure manual, as he needed to create one to be compliant with his pharmacy contracts. The second was with a friend of mine who asked me what my 5-year plan was for my practice and business.