The challenges in adopting care pathways for the dying for use in care homes

An increasing number of older people are requiring palliative care within the care home setting. There are currently a number of initiatives that are generally gaining approval and being implemented within health care in general with the goal of improving standards of palliative care. These are the Integrated Care Pathway for the dying person, the Gold Standards Framework and the Preferred Place of Care document. The Liverpool Care Pathway is being used across a wide range of care settings to improve care in the last 24–48 hours of life and is being implemented in care homes as part of a national rollout programme. This article aims to explore some of the issues associated with the use of the care pathways in care homes, particularly without the input of additional resources and support for the care homes. It also questions the appropriateness of the pathway in its current format without further work on the specific palliative care needs of the residents dying in care homes.     

Developing palliative care practice in nursing and residential care homes: the role of the clinical nurse specialist

The development of practice is but one aspect of Clinical Nurse Specialists' (CNSs) work, and a number of factors act to shape the extent to which CNSs are able to work with and develop practice with nursing and residential care homes. A postal survey of 730 community CNSs in palliative care working in the UK was undertaken to explore the involvement of these nurses with nursing and residential care homes. Much of the focus of the involvement was reactive work meeting the direct clinical needs of residents, primarily with cancer. Although the CNSs perceived that there were some educational and care deficits in these care settings, the amount of proactive work undertaken to improve practice was limited. The development work undertaken was focused on educational initiatives and establishing link nurse systems. There is potential to develop palliative care practice in nursing and residential care homes through practice development initiatives.     

A systematic review of studies investigating the care of stroke survivors in long-term care facilities

Purpose: The burden of stroke is immense, with approximately 30 million stroke survivors globally. Approximately one-quarter of residents in long-term care (LTC) facilities are stroke survivors. This review aims to integrate the existing knowledge from the literature and elucidate themes around the care of stroke survivors in LTC facilities. Method: A systematic search was performed in PubMed, Ovid MEDLINE, the Cochrane Library and CINAHL. Articles that met the eligibility criteria were selected. Synthesis of results according to similar themes was performed. Results: A total of 1920 articles were screened for eligibility, of which 22 met the eligibility criteria. Of the 22 articles selected, five and 17 articles comprised interventional and observational studies, respectively. Three themes were identified: rehabilitation, stroke specific care and secondary stroke drug prevention. These were found to be lacking within LTC facilities. There is also a dearth of interventional studies in stroke survivors from LTC facilities. Conclusions: The care of stroke survivors in LTC facilities is lacking in rehabilitation, stroke specific care and secondary stroke prevention. This needs to be addressed through conducting further research to build a strong body of evidence to influence change in the care of this vulnerable group of patients.

• Implications for Rehabilitation

• Care of stroke survivors in long-term care facilities

• Stroke survivors make up almost a quarter of residents in long-term care facilities. They suffer from functional impairments and many other disabilities as a result of more severe stroke, precluding them from living in their own homes.

• Rehabilitation, stroke-specific care and secondary stroke prevention for stroke survivors are lacking in long-term care facilities despite strong evidence showing benefits for these interventions in stroke survivors living in the community.

• Interventions to address the unmet need in stroke survivors living in long-term care facilities are vital for optimal care of this vulnerable group of patients.

     

Working with volunteers: key issues for gerontological nursing - Application to practice the contribution of volunteers in a long-term care setting: a case study

Adopting a case study approach, this paper examines the impact of a volunteers scheme in a large Jewish care home within the UK. Good practice is articulated, opportunities and challenges identified, with specific reference to religious and cultural beliefs and the role of the volunteer coordinator is examined. The paper concludes that teamwork and the role of the volunteer coordinator is pivotal to the ongoing success of the volunteer scheme.     

Family caregiver perspectives on social relations of elderly residents with dementia in small‐scale versus traditional long‐term care settings in the Netherlands and Belgium

Aims and objectives. To provide insight into family caregiver perspectives on social relations within the ‘caregiving triangle’ between family caregiver, professional caregiver and elderly resident with dementia. Results were compared between traditional versus small‐scale long‐term care settings in the Netherlands and Belgium. Background. Residential dementia care is shifting towards a more holistic and person‐centred approach. Until now, little is known about family caregiver perspectives. Design. A quasi‐experimental longitudinal design. Methods. This study was part of a larger research project focusing on the quality of life of residents with dementia in traditional and small‐scale settings (n = 179). This study focused on family caregivers related to these residents (n = 64). They filled in a questionnaire containing 25 items (baseline and after 12 months) related to their perspectives on the interaction within the ‘caregiving triangle’. Analyses were performed using mixed models and logistic regression. Results. Compared to traditional settings, family caregivers of relatives with dementia living in small‐scale settings had more contact with the professional caregivers, were more satisfied with this contact and felt that staff paid more attention to their feelings as family members. They also reported that staff showed better listening skills towards the residents. Furthermore, compared to those in Belgium, family caregivers in the Netherlands perceived staff to be less hurried and more accepting of help from family and felt that staff more often takes the resident seriously. Conclusion. In the move towards more person‐centred care for residents with dementia, this study finds preliminary evidence for the importance of integrating the family perspective. Relevance to clinical practice. Gaining more insight into the perspectives of family caregivers on the social relations within the ‘caregiving triangle’ may provide knowledge about the importance of the social system surrounding elderly residents with dementia and can provide pointers for future research.     

Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice‐based audit

Background and aims Emergency admissions of frail older people in care homes, many of whom have dementia, are critical events which should be avoided if possible. To identify and influence factors related to emergency admissions and place of death. Method Design of study: Completed audit cycle. Setting: Jenner Health Centre patients in six local care homes. Data collection over 12 months in 05/6, repeated in 08/9. Emergency admissions, admitting health professional, assessment prior to admission, length of hospital stay, annual visit workload and place of death. Results Admission numbers fell from 91 (194 patients) in 05/6 to 52 (183 patients) in 08/9, related to a fall in admissions by general practitioners (GPs) and out of hours (OOH). The proportion of admissions by care home staff doubled. There was a highly significant difference (P < 0.001), between GPs and OOH in patients visited prior to admission in 05/6 which persisted in 08/9 (P < 0.01). A hospital stay >72 hours was significantly more likely if patients were visited prior to admission. In 05/6, 55% of deaths occurred in the care home rising to 75.5% in 08/9 (total numbers deaths unchanged). There was a highly significant difference (P < 0.001 05/6 and 08/9), between deaths in nursing compared with residential homes. GP visits to nursing home patients rose by 10.3% but visits to residential home patients fell by 5.4%. Conclusions The aims of the audit were achieved with a 43% reduction in emergency admissions and a 45% reduction in deaths in hospital but at the expense of a 12% increase in visits. Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future.     

Reflections on implementing an evidence-based educational intervention in residential aged care

BackgroundThe aged care sector has been subjected to ongoing public criticism about the quality and standards of care Reflections on implementing an evidenced based educational intervention in residential aged care. It is important for educators and researchers to work in partnership with staff in this sector to empower them and enhance care. This paper reports the implementation of a specifically designed educational intervention, the Tri-focal Education Program (TEP).AimTo explore whether implementing the TEP had any impact on staffs’ perceptions of the work environment, work competence, and organisational culture in a residential aged care facility.MethodsThe TEP was delivered by a nurse educator who worked with staff to develop and role model the desired practice changes. A pre (n = 52) and post (n = 33) survey, comprising two validated instruments, was used to explore the impact of the implementation of the TEP from the staff perspective.FindingsStaff reported positive perceptions of their work environment on the pre-survey and there were no significant changes post-intervention.DiscussionThere are multiple explanations for this result. It could be that a low response rate, combined with high pre-test scores, created a ceiling effect that made it difficult to demonstrate any significant post-test changes.ConclusionA more bipartisan, action research approach to the implementation of the TEP may have empowered staff, encouraged them to engage more fully with the research, and feel safe to respond accurately to the survey. Given that staff felt rushed to deliver care, a longer implementation phase that introduces change in a more gradual way may reduce the potential burden on staff.     

Elderly persons' experiences of striving to receive care on their own terms in nursing homes

Anderberg P, Berglund A-L. International Journal of Nursing Practice 2010; 16 : 64–68
Elderly persons' experiences of striving to receive care on their own terms in nursing homes
Elderly persons' participation in and decisions about their own care need more attention. The aim of this study was to gain a deeper understanding of elderly persons' experiences of care and help, and how their lives change in nursing homes. Fifteen elderly persons living in four nursing homes were interviewed about their experiences of needing care and help in their daily life. The interviews were analysed using van Manen's phenomenological approach. Elderly persons' experiences of care and help were described as: a balance between sorrow and relief, a struggle to maintain control and connectedness, managing to live in the present and yet worrying about the future, and an attempt to hide one's vulnerability in order to be accepted and create an inner calm in an exposed situation. In conclusion, important issues were raised concerning elderly persons' perspectives on care and help in daily life in nursing homes.     

A conceptual model for culture change evaluation in nursing homes

This article describes the development and particulars of a new, comprehensive model of nursing home culture change, the Nursing Home Integrated Model for Producing and Assessing Cultural Transformation (Nursing Home IMPACT). This model is structured into four categories, “meta constructs,” “care practices,” “workplace practices,” and “environment of care,” with multiple domains under each. It includes detailed, triangulated assessment methods capturing various stakeholder perspectives for each of the model's domains. It is hoped that this model will serve two functions: first, to help practitioners guide improvements in resident care by identifying particular areas in which culture change is having positive effects, as well as areas that could benefit from modification; and second, to emphasize the importance in culture change of the innumerable perspectives of residents, family members, staff, management, and leadership.     

District nurses' experiences of providing care in residential care home settings

Little research describes the involvement and contribution of primary health care services in residential homes, despite policy and research concerns that older people in residential homes are a vulnerable population for whom care must be improved. The aim of this research was to explore the actual and potential contribution of primary care nurses in residential homes for older people, particularly district nurses. Five focus groups were held with district nurses in one county in England, to explore how participants represented their views, values and experiences of working in residential homes. Our major finding was the importance of context in shaping the experience of district nursing involvement. General practitioner attachment determined the frequency of visiting homes and affected workload. District nurses had regular contact with residential homes for discrete nursing tasks, but appropriateness of referrals and input was not agreed. The focus group discussions with district nurses revealed how problematic their work in residential homes was and a lack of consensus about their role. The data suggested that uncertainty about providing care in a setting that straddles the health and social care, public and private divide, and anxieties about managing their workload overshadowed their acknowledged concerns about the older people in residential care homes. Further research is needed to substantiate the findings, obtain residents' views and address issues of how to achieve integrated and equitable health and social care for this group.     

Extended care referral after hospital discharge

The purpose of this study was to describe the influence of selected organizational and medical factors on communication between hospitals and extended care facilities (ECF) in the referral of elderly clients following discharge from acute care. Using a tool with previously established reliability and validity, 455 closed records of referral were purposively selected and reviewed for the amount and type of information an ECF received upon referral, as well as selected organizational and medical factors. Hospitals transferred approximately three-fourths of the patient care data recommended in the literature. Information contained in an ECF referral consisted primarily of background and medical data, with some nursing care data and limited psychosocial data. More information-rich referrals were generated by very large hospitals and by specialty care units. Similarly, proprietary ECFs received more patient care data than their not-for-profit counterparts. Research concerning patient care communication between provider organizations across the health care delivery system may assist nurses in developing better patient care information-management systems. © 1998 John Wiley & Sons, Inc. Res Nurs Health 21: 385–394, 1998     

‘We have no crystal ball’ - advance care planning at nursing homes from the perspective of nurses and physicians

Objective: To investigate clinicians’ perspectives on the factors that shape the process of advance care planning in a nursing home context.

Design: Interviews. Latent qualitative content analysis.

Setting: Nine nursing homes in Sweden.

Subjects: 14 physicians and 11 nurses working at nursing homes.

Main outcome measures: Participants’ views on advance care planning (ACP) at nursing homes.

Results: The analysis of the interviews resulted in four manifest categories: Exploration of preferences and views, e.g. exploring patient wishes regarding end-of-life issues and restrictions in care at an early stage, and sensitivity to patient’s readiness to discuss end-of-life issues; Integration of preferences and views, e.g. integration of patient’s preferences and staff’s and family member’s views; Decision & documentation of the ACP, e.g. clear documentation in patient’s medical records that are up-to-date and available for staff caring for the patient, and Implementation & re-evaluation of the ACP, e.g. nurse following up after ACP-appointment to confirm the content of the documented ACP. The latent theme, Establishing beneficence – defending oneself against tacit accusations of maleficence, emerged as a deeper meaning of all the four (manifest) parts of the ACP-process

Conclusion: This study stresses the importance of involving patients, family members, and the team in the work with advance care planning in nursing homes. In addition, clear medical record documentation and proficiency in end-of-life communication related to advance care planning for physicians as well as nurses may also be factors that significantly shape advance care planning in a nursing home context.

• Key Points

• Advance care planning can help patients to receive care in line with their preferences and can positively impact quality of end-of-life care.

• Our results describe a process consisting of four manifest categories and one latent theme constituting the process of advance care planning, that may be considered in education in advance care planning.

• The significance of nurses and physicians perceiving beneficence as well as fear of accusations of maleficence are important factors to contemplate.

• The study has implications for healthcare staff caring for patients near the end of their lives, in particular patients in nursing homes.

     

广州市养老机构护理人员人文关怀品质的现状调查

目的 了解广州市养老机构护理人员人文关怀品质现状和影响因素,为今后开展护理人员人文关怀教育,提升养老服务质量提供依据.方法 采用方便抽样的方法,抽取广州市8所养老机构270名护理人员为调查对象,使用一般资料调查问卷及护士人文关怀品质量表进行调查,并采用多元逐步回归法分析其影响因素.结果 广州市8所养老机构护理人员人文关怀品质总分（113.59±9.78）分,低于该量表设计者刘于昌等提供的2010年上海市部分综合性医院护士人文关怀品质评价的参考值（118.36±16.75）分,处于较低水平.护理人员的家庭所在地、政治面貌、同事关怀度、是否接受过人文关怀方面的教育培训不同,其人文关怀品质得分比较差异有统计学意义;多元线性回归分析显示,同事关怀度、是否接受过人文关怀方面的教育培训为主要影响因素.结论 广州市8所养老机构护理人员人文关怀品质偏低,关怀能力和关怀理念方面尤为薄弱.养老机构可与高校合作,制定一套养老机构护理人员人文关怀品质的培训课程,通过系统、规范的培训提升人文关怀品质,提高养老服务质量.     

Resident and family member perceptions of cultural diversity in aged care homes

Similar to many developed nations, older people living in residential aged care homes in Australia and the staff who care for them have become increasingly multicultural. This cultural diversity adds challenges for residents in adapting to the care home. This study explores: (i) residents' and family members' perceptions about staff and cultural diversity, and (ii) culturally and linguistically diverse residents' and family members' experiences. An interpretive study design employing a thematic analysis was applied. Twenty‐three residents and seven family members participated in interviews. Four themes were identified from interpreting residents and family members' perceptions of the impact of cultural diversity on their adaptation to aged care homes: (i) perceiving diversity as an attraction; (ii) adapting to cross‐cultural communication; (iii) adjusting to diet in the residential care home; and (iv) anticipating individualized psychosocial interactions. The findings have implications for identifying strategies to support staff from all cultural backgrounds in order to create a caring environment that facilitates positive relationships with residents and supports residents to adjust to the care home.