Older People In Residential Settings Research Articles

Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings

BackgroundCare homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.ObjectivesTo understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.MethodsUsing realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.FindingsPhase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.LimitationsFindings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.ConclusionsNHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Intimate relationships between older people in institutional settings: Ageism, protection or fear?

Summary Objectives To clarify the implications of human rights for older people within institutional settings wishing to continue or to develop intimate relationships. To identify key issues facing practitioners responding to intimate relationships in residential settings. To emphasise the importance of avoiding assumptions based on stereotypical views of older people. Equipment and methods A review of the literature and the law on intimate relationships between older people in residential settings.

Valuing narrative in the care of older people: a framework of narrative practice for older adult residential care settings

To report on the development of a framework of narrative practice, in residential care settings for older people. Residential care settings for older people provide care for people who are no longer able to live in their own home. To date, the impact and structure of nursing practice on care provision in these settings has proved difficult to conceptualise within a specific nursing theory framework. A hermeneutic approach incorporating narrative methods was used. Forty-six narrative interviews with older people in residential care were secondary-analysed for key themes through a three-stage process: by the first author, four focus groups of 12 clinical nurse managers and two independent experts. Themes were also derived from a focus group of eight residents who explored person-centredness and narrative. Finally, the combined findings were used to derive a single set of themes. The secondary data analysis process led to the development of a framework of narrative practice for the care of older people in residential settings. The framework is influenced by narrative enquiry, person-centred practice and practice development. It has four pillars, prerequisites, care processes, care environment and narrative aspects of care. To operationalise the framework of narrative practice, three narrative elements, narrative knowing, narrative being and narrative doing, need to be considered. Working with the foundational pillars and the narrative elements would enable staff to 'work in a storied way' and provide person-centred outcomes and a narrative informed philosophy of care for older adults in residential care. This framework provides nurses with a template that confirms the identity of the older person taking account of their biography. The framework outlines an approach that provides staff with a template on how to provide person-centred care in a narrative way.

Why are some care homes better than others? An empirical study of the factors associated with quality of care for older people in residential homes in Surrey, England

This paper reports an empirical study that investigated associations between the quality of care received by older people in residential settings and features of the care homes in which they live. Data were gathered from the first announced inspection reports (2002-2003) of all 258 care homes for older people in one county of England (Surrey). The number of inspected standards failed in each home was used as the main indicator of quality of care. Independent variables (for each home) were: size, type, specialist registration, on-site nursing, ownership, year registered, location, maximum fee, vacancies, resident dependency, whether the home took publicly funded residents, care staff qualifications and managerial quality. Quality of care was modelled using a Poisson count maximum likelihood method based on 245 (91%) of the inspected homes for which relevant data were available. The results showed that quality of care (as defined by failures on national standards) was statistically associated with features of care homes and their residents. A higher probability of failing a standard was significantly associated with being a home that: was a for-profit small business (adjusted risk ratio (RR) = 1.17); was registered before 2000 (adj. RR = 1.22), accommodated publicly funded residents (adj. RR = 1.12); was registered to provide nursing care (adj. RR = 1.12). Fewer failures were associated with homes that were corporate for-profit (adj. RR = 0.82); held a specialist registration (adj. RR = 0.91); charged higher maximum fees (adj. RR = 0.98 per 100 pound sterling unit). A secondary analysis revealed a stronger model: higher scores on managerial standards correlated with fewer failures on other standards (r = 0.65, P < 0.001). The results of this study may help inform future policy. They are discussed in the context of alternative approaches to measuring quality of residential care, and in terms of their generalisability.

Using humour to promote psychological wellbeing in residential homes for older people

The impact of a structured humorous activity on the psychological wellbeing of older people in residential settings was assessed. Residents who participated in the humorous activity were found to have significantly reduced levels of anxiety, as measured by the General Health Questionnaire, and significantly reduced levels of anxiety and depression, as measured by the Hospital Anxiety and Depression Scale, when compared to residents who received no intervention.