An exploration of nursing home organizational processes

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.     

Factors influencing models of end-of-life care in nursing homes: results of a survey of nursing home administrators

Approximately 20% of deaths in the United States occur in nursing homes. Dying nursing home residents have unique care needs, which historically have been inadequately addressed. The goal of this study was to determine what factors influence nursing home administrators' choice of model for end-of-life care in their facilities. Thirty nursing home administrators in the Denver, Colorado, metropolitan area were interviewed. The interview used open-ended questions about: facilities' end-of-life care programming and factors that influenced which model was used; scalar questions measuring administrators' attitudes about aspects of end-of-life care; and questions that assessed key demographic characteristics of participants. Twenty-nine of the 30 facilities included in this study reported contracting with hospice. Five were also in the process of creating in-house palliative care teams, and an additional five were negotiating with hospice agencies to dedicate beds for use as hospice units. For profit status, larger facility size, and shorter duration of administrator tenure were found to be associated with greater likelihood of considering implementation of a facility-based end-of-life care model. When asked about obstacles to providing quality end-of-life care, the majority of participants (n = 16) cited an educational deficit among physicians, staff, or the public as the most significant, while an additional seven cited staff shortages and turnover. These results suggest at least two potential avenues for change to improve end-of-life care in nursing homes: (1) educational efforts on the topics of end-of-life and palliative care among both practitioners, residents, and their families, and (2) creating incentives to improve staff recruitment and retention.     

This is Heaven's waiting room: end of life in one nursing home

The purpose of this study was to describe the end of life in one midwestern nursing home from the perspective of residents who are chronically ill and declining, their family caregivers, and staff. Qualitative methods, including formal and informal interviews, participant observation, and health record abstraction, were used to describe the end of life for 13 nursing home residents. One dominating pattern, conflict, and five themes (i.e., communication, quality of life, staff education, teamwork, work environment) emerged as factors that influenced end-of-life care. The results of this study illustrate where and how problems within the nursing home industry, the participating nursing home, and between staff and residents influence and challenge care provided to dying residents.     

The pain experience of cognitively impaired nursing home residents: perceptions of family members and certified nursing assistants.

Pain in cognitively impaired nursing home (NH) elders is difficult to detect. We report the results of the qualitative interview portion of a larger study that characterized the pain experience of cognitively impaired NH residents. Interviews were conducted with 16 family members or friends and 11 certified nursing assistants (CNAs) of 20 cognitively impaired NH residents experiencing pain. Analysis of the interviews yielded themes in family and CNA perceptions of pain in cognitively impaired NH residents. Family members and CNAs concurred that knowing the resident's usual behavior and daily habits was essential to being able to detect pain in cognitively impaired NH residents. Although a majority of family members reported that their relative was "stoic" about pain expression prior to NH placement, personal care information and historical information were perceived as helpful by nursing staff members. CNAs used facial and eye cues to detect pain and pain relief in their assigned residents. In addition, CNAs reported specific pain management strategies for their residents. Major themes related to pain detection in cognitively impaired NH residents identified in this investigation include: (a) knowing the resident; (b) importance of family input about previous pain behaviors in knowing the resident; (c) CNA reliance on face and eye cues for pain detection, particularly with residents who were nonverbal; and (d) the prevalence of pain with caregiving activities. Information from multiple sources can improve pain management strategies for cognitively impaired NH residents.     

Certified Nursing Assistants' Perspectives of Nursing Home Residents' Pain Experience: Communication Patterns,Cultural Context,and the Role of Empathy

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents' pain experiences; and 3) CNAs' personal experiences with pain that may affect their empathy toward the resident's pain experience. The study consisted of a convenience sample of four focus groups (n = 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents' pain.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

Do nursing homes for older people have the support they need to provide end-of-life care? A mixed methods enquiry in England

Nursing homes are a common site of death, but older residents receive variable quality of end-of-life care. We used a mixed methods design to identify external influences on the quality of end-of-life care in nursing homes. Two qualitative case studies were conducted and a postal survey of 180 nursing homes surrounding the case study sites. In the case studies, qualitative interviews were held with seven members of nursing home staff and 10 external staff. Problems in accessing support for end-of-life care reported in the survey included variable support by general practitioners (GPs), reluctance among GPs to prescribe appropriate medication, lack of support from other agencies, lack of out of hours support, cost of syringe drivers and lack of access to training. Most care homes were implementing a care pathway. Those that were not rated their end-of-life care as in need of improvement or as average. The case studies suggest that critical factors in improving end-of-life care in nursing homes include developing clinical leadership, developing relationships with GPs, the support of 'key' external advocates and leverage of additional resources by adoption of care pathway tools.     

Palliative care in nursing homes: a comparison of high- and low-level providers

The purpose of this study was to explore staff perceptions and concerns about the use of palliative care services in the nursing home setting. Six administrators from nursing homes were purposively selected for key informant interviews. Four common themes emerged, including issues related to the culture of care, the model of care, the relationships with hospice partners, and the role of staff. Recognition of staff perceptions is an important first step in improving the utilization of palliative care services. Staff insight provided clarification related to impediments in promoting a culture of care that was person-centered and relationship-based. We conclude by identifying the solutions for raising the level of dialogue to promote palliative care practice in the nursing home environment.     

Identifying educational needs in end-of-life care for staff and families of residents in care facilities

AIM: the purpose of this article is to describe educational needs in end-of-life (EoL) care for staff and families of residents in long-term care (LTC) facilities in the province of Ontario, Canada. Barriers to providing end-of-life care education in LTC facilities are also identified. DESIGN, SETTING AND PARTICIPANTS: cross-sectional survey of directors of care in all licensed LTC facilities in the province of Ontario, Canada. RESULTS: directors of care from 426 (76.9% response rate) licensed LTC facilities completed a postal-survey questionnaire. Topics identified as very important for staff education included pain and symptom management and communication with family members about EoL care. Priorities for family education included respecting the residents' expressed wishes for care and communication about EoL care. Having sufficient institutional resources was identified as a major barrier to providing continuing education to both staff and families. CONCLUSION: through examining educational needs in EoL care this study identified an environment of inadequate staffing and over-burdened care providers. The importance of increased staffing concomitant with education is a priority for LTC facilities.     

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions.

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values.     

Certified nursing assistants' perspectives of the CARES® activities of daily living dementia care program

BackgroundThere has been a proliferation of online training programs for nursing home direct care staff related to dementia care, yet little is known about the effectiveness of the training. Some evidence exists that online training is effective in addressing problem behaviors of nursing home residents with dementia by enhancing self-efficacy, improving attitudes, and increasing knowledge of nursing home staff.Study aimThe current study aim was to evaluate the implementation of an online training program consisting of ten, one-hour modules which applies the CARES® concepts and learning framework to activities of daily living (ADL) care for persons with dementia.MethodsResponses from Likert-type items, and open-ended questions were analyzed in a sample of 48 certified nursing assistants (CNAs) from 10 nursing homes in six states (ME, MT, ND, WI, MN, MO) that were part of a National Institute of Aging funded intervention study (Grant #AG026210).ResultsThe mixed-method study findings indicated that CNAs gained a better understanding, more knowledge, and more confidence in caring for persons with dementia. Recommendations were made regarding training length and technical issues, and some questioned the practicality of providing person-centered care when resident assignment was very high. CNAs expressed satisfaction with the online training, found it easy to use, and many said they would recommend the training. CARES® ADL Dementia Care online training appears to be a viable way of helping CNAs address the personal care needs of long-term care residents. Future CARES® ADL Dementia Care program research should include more racially diverse CNAs.     

Is the influence of nurse care practices and nursing home organization understood? A qualitative study

palacios-ceña d., cachón-pérez j.m., gómez-pérez d., gómez-calero c., brea-rivero m. & fernández-de-las-peñas c. (2012) Journal of Nursing Management
Is the influence of nurse care practices and nursing home organization understood? A qualitative study Aim To describe residents’ experience of nursing home organization and nursing care practices in a region of Spain. Background Nursing home organization, nursing practices and rules within the institution may all influence residents’ daily living and their perception on the quality of care provided. Design A qualitative approach was conducted, using purposeful and theoretical sampling. Data were collected from nursing home residents, following unstructured and semi-structured interviews, researcher field notes and residents’ personal diaries and letters. Giorgi analysis was conducted. Results Two main themes emerged. (1) ‘Following nursing home rules’. Norms may be seen as boundaries, especially for those residents who were independent before admission. (2) ‘Prioritizing nursing care in residents’. Prioritizing the nursing care may limit the autonomy of residents because it does not meet their preferences and needs. Conclusion Understanding the meaning of nursing home organization and nursing care practices with nursing home residents might provide deeper insight into their expectations. Implications for nursing management Nursing staff should have greater involvement in the nursing home organization, as well as in prioritizing the care provision based on resident’s needs and preferences.     

Perspectives on caregiving: A qualitative evaluation of certified nursing assistants

This study sought Certified Nursing Assistants' (CNAs) perspectives on the activities that compose quality care. CNAs provide the majority of hands on care in nursing homes positioning them to have a unique perspective on factors that constitute good quality care. Using semi-structured interviews, 23 CNAs from New York State nursing homes were asked to identify factors they felt were components of good care. Interviews were recorded, transcribed verbatim, and coded using open coding. Three themes emerged: (1) technical aspects of care; (2) care of the environment; and (3) a little bit more. Our results emphasize the complexities of providing care that go beyond items that can be regulated. Assessments of quality care should incorporate the voices of CNAs.     

The palliative care education needs of nursing home staff

BACKGROUND: Palliative care is delivered in a number of settings, including nursing homes, where staff often have limited training in palliative care. AIM: We explored the level of palliative care knowledge among qualified staff delivering end-of-life care in nursing home settings, to inform the development of an appropriate education and training programme. DESIGN: An audit of the educational needs assessment was performed using an anonymous postal questionnaire sent to 528 qualified nursing staff within 48 nursing homes. FINDINGS: In total, 227 questionnaires were returned giving a response rate of 43%. Results indicated that less than half the sample had obtained formal training in the area of pain assessment and management and less than a quarter had obtained training in non-malignant conditions. Registered nurses in this study reported a lack of awareness of palliative care principles or national guidelines. CONCLUSION: Qualified nursing home staff agree that palliative care is a valuable model for care in their setting. There are clear opportunities for improvement in nursing home care, based on education and training in palliative care. Results also support the need for enhanced liaison between nursing homes and specialist palliative care services.     

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse’s role in transfer decisions

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution’s mission and the nursing service’s values. (Geriatr Nurs 2001;22:313-7)     

Barriers to safe medication administration in the nursing home--exploring staff perceptions and concerns about the medication use process

The purpose of this study was to explore staff perceptions and concerns about the medication use process in the nursing home setting. A total of 76 staff members from 5 nursing homes in 3 Midwestern states participated in key informant interviews and focus groups. Common themes included issues related to communication, competing demands, and the challenges of a paper-based medication administration record. Concerns frequently were associated with the timeliness and accuracy of the medication administration process. Recognition of staff concerns are an important first step in improving the nursing home medication use process. Staff insight provided clarification related to impediments to safe medication practices. This study provides insight into how technology can improve the nursing home medication use process.     

Spiritual caring: end of life in a nursing home

The purpose of this qualitative study was to explore spiritual care for dying nursing home residents from the perspectives of registered nurses, practical nurses, certified nursing assistants, advanced practice nurses, and physicians. Five major themes emerged: honoring the person's dignity, intimate knowing in the nursing home environment, wishing we could do more, personal knowing of self as caregiver, and struggling with end-of-life treatment decisions. Spiritual caring was described within the context of deep personal relationships, holistic care, and support for residents. Spiritual care responses and similarities and differences in the experiences of participants are presented. Education and research about how to assist residents and families as they struggle with difficult end-of-life decisions, adequate time and staff to provide the kind of care they "wished they could," and development of models that honor the close connection and attachment of staff to residents could enhance end-of-life care in this setting.