An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation

BackgroundIn the United Kingdom approaching 20% of people aged 85 years and over live in care homes and most will die there. Improving end-of-life care is a government health priority and homes may work with primary care staff and specialist palliative practitioners to provide comprehensive end-of-life care. Consequently effective collaboration between care home and health service practitioners is vital to ensure high quality end-of-life care.ObjectivesTo evaluate the impact of a training programme to improve end-of-life care in nursing homes, on collaboration between nursing home staff and other health practitioners.DesignEvaluation using survey methods and qualitative case studies.Participants and settingAll 95 nursing homes in the first national ‘Gold Standards Framework in Care Homes’ programme in England were invited to participate in the evaluation.MethodsA survey of homes’ characteristics, the approaches to end-of-life care, and liaison with other services, was completed pre and post programme implementation. Case studies were conducted in a sub-sample of 10 homes to provide important context and depth to the evaluation.ResultsPre and post surveys were returned by 49 (52%) homes. Improved collaborations as a result of the programme were anticipated by 31% of managers. Challenges to collaboration included working with large numbers of general practitioners, out-of-hours services and access to specialist practitioners. Improved collaborations between home staff and health service practitioners were identified by 33% of managers as one of the main programme outcomes. Staff reported increased knowledge of end-of-life care, and enhanced confidence, which in turn resulted in improved communication and collaboration. Post-programme, staff felt more confident initiating contact and discussing residents’ end-of-life care with general practitioners and those working in specialist palliative care services.ConclusionsThe Gold Standards Framework in Care Homes programme can contribute towards end-of-life care by helping to improve the quality and quantity of communication and collaboration between nursing home staff and primary care and specialist practitioners. Further research is needed to determine why this was not consistent across all homes.     

Nursing home staff perspectives on adoption of an innovation in goals of care communication

Nursing homes (NH) are important settings for end-of-life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia. Study design was a cross-sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial. Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff. Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.     

The senses in practice: enhancing the quality of care for residents with dementia in care homes

Aim. The study aimed to develop, deliver, and evaluate a training programme in care homes to enhance the quality of care for people living with dementia based on the principles of relationship‐centred care expressed through the Senses Framework. Background. There are increasing numbers of people living with dementia worldwide with a growing proportion requiring residential long‐term care. This makes the quest for enhancing the quality of care and quality of life for people with dementia ever more pressing. Design. A mixed‐methods design was used adopting a Practice Development approach. The findings from one care home in the North West of England are reported. Methods. Eight facilitated workshops based on the principles of relationship‐centred care were completed and evaluated in 2010, using pre‐ and postintervention design. A focus group was undertaken with staff on completion of the study to gain a more comprehensive understanding of the practice/training context, augmented by case examples of changes in practice identified from the study workshops. Results. Structured questionnaires were used to profile the care home before and after the training. Following the workshops, staff felt more able to collect and use biographical information. In particular, staff reported how this information supported them to initiate meaningful conversations with the person with dementia as part of everyday care routines, thus improving overall feelings of well‐being. Conclusion. Using a biographical approach to care planning structured through the Senses Framework helped staff to develop a greater understanding of the person with dementia.     

Working in care homes: a survey

AIM: To explore the impact of policy changes on care homes and the provision of nursing in care homes. METHOD: Eight hundred Royal College of Nursing (RCN) members working in nursing care homes were surveyed by postal questionnaire in 2004. RESULTS: A 37 per cent response rate (n = 296) was achieved. Of these, 274 worked in homes registered to provide care for older people and/or those with dementia. Although the majority of respondents were happy in their posts, they said that they were not always able to meet residents' needs. They voiced concerns about inappropriate admissions, the assessment process and the need to fill beds to maintain income. Although 65 per cent of residents were state-funded, almost 75 per cent of the homes charged these residents a top-up fee. CONCLUSION: Care homes should be given enough resources to ensure that the needs of residents are met. The RCN is developing a programme to lobby government for adequate resources for care home placements.     

Nursing home staff attitudes towards residents with dementia: strain and satisfaction with work

BACKGROUND: Occupational and resident characteristics affect levels of staff stress and satisfaction in nursing homes, and levels of staff turnover are high. Working with more cognitively impaired residents, especially on day shift, is associated with high levels of stress in nursing home staff. Workload is highly predictive of the experience of burden and job pressure, while these outcomes vary according to whether staff work full- or part-time. AIMS: To investigate the attitudes of nursing home staff towards residents, strain related to dementia care and satisfaction with work and their associations with demographic, occupational and behavioural disturbance in the home. METHODS: A cross-sectional design was adopted, using a self-completion questionnaire survey of 253 nursing home staff from 12 nursing homes in Sydney's eastern suburbs, and behavioural assessment of all 647 residents from 11 of the 12 homes. Staff attitudes and strain were measured using the Swedish Strain in Nursing Care Assessment Scale and satisfaction using the Swedish Satisfaction with Nursing Care and Work Assessment Scale. RESULTS: Staff members' five most prevalent perceptions of residents with dementia were that they are anxious, have little control over their difficult behaviour, are unpredictable, lonely and frightened/vulnerable. The five attributes staff found most difficult to cope with were being aggressive/hostile, having little control over their difficult behaviour, being stubborn/resistive, deliberately difficult, and unpredictable. Although 91% of staff reported that they were happy in their job, a quarter reported that residents provided no job satisfaction. The five satisfaction statements most agreed with were "The patients/residents at work nearly always receive good care", "It is important to try and enter into the way patients experience what happens to them", "Relatives are given enough information about care and treatment", "I enjoy my current work situation" and "Our work organisation is good". There were significant differences between homes in levels of strain related to dementia care that were not accounted for by the level of behavioural disturbance. CONCLUSIONS: Nursing home staff tended to perceive residents in more negative than positive ways. Staff were generally satisfied with their work. Factors other than resident behavioural disturbance are important influences in nursing staff strain.     

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.     

Impact of a person-centred dementia care training programme on hospital staff attitudes,role efficacy and perceptions of caring for people with dementia: A repeated measures study

BackgroundPeople with dementia occupy up to one quarter of acute hospital beds. However, the quality of care delivered to this patient group is of national concern. Staff working in acute hospitals report lack of knowledge, skills and confidence in caring for people with dementia. There is limited evidence about the most effective approaches to supporting acute hospital staff to deliver more person-centred care.ObjectivesThis study aimed to evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction and feelings of caring efficacy, in provision of care to people with dementia.DesignA repeated measures design, with measures completed immediately prior to commencing training (T1), after completion of Foundation level training (T2: 4–6 weeks post-baseline), and following Intermediate level training (T3: 3–4 months post-baseline).SettingOne NHS Trust in the North of England, UK.Participants40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses.MethodsAll participants received the 3.5 day Person-centred Care Training for Acute Hospitals (PCTAH) programme, comprised of two levels, Foundation (0.5 day) and Intermediate (3 days), delivered over a 3–4 months period. Staff demographics and previous exposure to dementia training were collected via a questionnaire. Staff attitudes were measured using the Approaches to Dementia Questionnaire (ADQ), satisfaction in caring for people with dementia was captured using the Staff Experiences of Working with Demented Residents questionnaire (SEWDR) and perceived caring efficacy was measured using the Caring Efficacy Scale (CES).ResultsThe training programme was effective in producing a significant positive change on all three outcome measures following intermediate training compared to baseline. A significant positive effect was found on the ADQ between baseline and after completion of Foundation level training, but not for either of the other measures.ConclusionsTraining acute hospital staff in Intermediate level person-centred dementia care is effective in producing significant improvements in attitudes towards and satisfaction in caring for people with dementia and feelings of caring efficacy. Foundation level training is effective in changing attitudes but does not seem to be sufficient to bring about change in satisfaction or caring efficacy.     

Soothing the senses

The Namaste programme is a systematic method of treating people with advanced dementia. It uses sensory approaches - such as massage and aromatherapy - to reach people who are often overlooked at the end of their lives. Here, nurses in south London care homes explain how it has brought comfort and pleasure to the'silent residents' and made nursing more purposeful and rewarding.     

How namaste principles improve residents' lives

Namaste Care is a programme developed in the United States to offer meaningful activities to care home residents with advanced dementia. The programme focuses on calming and soothing residents using sound, touch, smell and taste. These sensory techniques are delivered daily in a dedicated communal space. Christian Duffin visits a care home in Kent that has adopted the Namaste principles and talks to staff about the effect they have had on enabling residents to feel comforted and cared for. He also speaks to nurse consultant Jo Hockley who is leading a pilot study of the Namaste programme. Anecdotal evidence from the pilot suggests that staff involved in its delivery work better as a team, which means they provide better care to residents.     

A diabetes education initiative for residential care home staff

About one in eight elderly people living in residential care homes will be known to have diabetes. Lack of appropriate training for care home staff is an important barrier to improved care for this vulnerable and neglected group. A multidisciplinary, multi-agency group have begun to address this problem with a district-wide diabetes education programme for care home staff.     

Meeting the holistic needs of dependent older people

AIM: To investigate whether national vocational qualifications (NVQs) have the potential to improve the quality of care for vulnerable older people. training METHOD: An antecedent study was carried out by interviewing care staff in care homes to determine the process of achieving an NVQ and to identify the specific areas of enquiry. Individual face-to-face interviews were conducted with representatives of six training providers, who were contracted by a county council to provide training and assessment to care staff undertaking NVQ in Care levels 2 and 3. Face-to-face interviews were also carried out with care staff working in residential and nursing homes, registered with the training providers. FINDINGS: The majority of care staff receive some training, usually in-house, but this training is not necessarily specific to NVQ. Achieving an NVQ in Care is not dependent on the ability to demonstrate competence in all aspects of care, because there is a choice of units for which candidates provide evidence. The extent to which the knowledge and skills of care staff are assessed, and the standards of care that they provide to meet the holistic needs of residents, depend largely on the competence of the assessor. NVQ in Care levels 2 and 3 are mainly concerned with personal care needs rather than the healthcare reguirements of residents. CONCLUSION: NVQ in Care is an assessment process and not a training course leading to a qualification. However, some training providers offer a set course, while others assess competence on knowledge and skills. The unit contents of NVQ in Care levels 2 and 3 do not address the holistic needs of older people because some important aspects of care, for example, enabling clients to eat, drink and use toilet facilities, are optional.     

Telehealth Palliative Care Needs Rounds During a Pandemic

Older people living in care homes deserve access to specialist palliative care in their last months of life, and this has never been more important than during a global pandemic. Palliative Care Needs Rounds facilitated by nurse practitioners are cost-effective, reduce avoidable hospital transfers, improve quality of death and dying, and increase the capacity of staff to recognize and plan for care for dying residents in care homes. Conducting Palliative Care Needs Rounds via telehealth increases access to specialist palliative care while reducing the risk of coronavirus disease 2019 transmission.     

Outcomes of family involvement in care intervention for caregivers of individuals with dementia

BACKGROUND: Despite the increasing number of individuals with dementia relocated from caregiving at home to a nursing home, there is only a small body of literature examining the influence of institutional family-oriented practices on family member perceptions of care and family-staff relationships. OBJECTIVE: The study tested the effects of the Family Involvement in Care partnership intervention on family members' perceptions of their caregiving role, relationships with staff, and satisfaction with the care of relatives with dementia residing in special care units as well as the effects on staff attitudes toward families and staff satisfaction with a caregiving role. METHODS: A quasi-experimental design with nonequivalent groups and repeated pretest and posttest measures was used to examine the effects of the Family Involvement in Care intervention. The study recruited 14 Midwestern nursing home special dementia care units, matched by aegis and staff turnover, and randomized from matched pairs to experimental and control conditions. The samples included 185 family members and 895 staff. The Family Involvement in Care intervention is a protocol for family and staff negotiation of a written partnership agreement. Family caregiver outcomes were measured using instruments pretested for reliability and validity. Data were analyzed using hierarchical linear modeling. RESULTS: With adjustment for multiple tests, statistically significant beneficial intervention effects were found in three areas of family caregiver outcomes (emotional reactions to the caregiving role, perceptions of relationships with staff, and perceptions of care for relatives) and in one of three areas of staff outcomes (staff perceptions of the family caregiving role). For family members, effects were found for the measures assessing loss, captivity, staff disregard, resident activities, and physical care. Some of the intervention effects for family members were found only for caregivers of the same generation as the resident. For staff, effects were found for measures of dominion, disruption by family, and irrelevance of family. CONCLUSIONS: The results of the study indicate that the Family Involvement in Care intervention improves the caregiving experience of family members in nursing homes as well as nursing home staff attitudes toward family members. The intervention did not influence the perceived conflict with staff on the part of family caregivers or the perception of a partnership with family caregivers on the part of staff.     

Adequacy of training in dementia care for acute hospital staff

People with dementia are frequently admitted to general wards where their dementia is often unrecognised and related healthcare needs are unaddressed. This article examines how staff view the training they have received in assessing and caring for people with dementia who are admitted to hospital. It reports on the results of the National Audit of Dementia (Care in General Hospitals); staff completed questionnaires reporting the sufficiency of their training in 13 main areas related to dementia care. Responses were obtained from 270 doctors, 968 qualified nurses and 541 healthcare assistants (HCAs); 690 worked on medical wards, 677 on surgical/orthopaedic wards and 412 on care of older people wards. Doctors felt more adequately trained than nurses or HCAs. Nurses on medical and surgical/orthopaedic wards thought their training was less sufficient than their colleagues working on care of older people wards. The authors conclude that nurses and HCAs working on wards not specialising in the care of older people should receive increased training in dementia care.     

Care providers’ perceptions of the importance of oral care and its performance within everyday caregiving for nursing home residents with dementia

Scand J Caring Sci; 2011; 25; 92–99
Care providers’ perceptions of the importance of oral care and its performance within everyday caregiving for nursing home residents with dementia Background: The oral caregiving in nursing homes for persons with dementia often becomes complicated due to the patients’ lack of compliance, which in turn can result in giving oral care a low priority in daily care. Furthermore, directives for responsibilities are unclear. Objective: The aim of this article was to describe care providers’ perception of and reasoning for the oral care for nursing home residents with dementia and to describe registered nurses’ reasoning in relation to their responsibility for monitoring oral care interventions within the regular caregiving routines for nursing home residents with dementia. Methods: Two sub‐studies were carried out; focus group discussions with nine care providers and interviews with four nurses. All participants were staff in nursing home units specialized in dementia. Results: The focus group discussion revealed three themes: Art of caregiving, Barriers and Treatment strategies. Themes related to the nurses’ statements about oral hygiene within caregiving were Care, Responsibility for care and Information. Conclusion: Three main findings from the study are discussed: Unclear responsibilities of different staff members related to daily oral care for the nursing home patients; a lack of guidelines and routines for oral hygiene and a lack of guidelines for sharing information between the different professional groups.     

Can multidisciplinary guidelines improve the palliation of symptoms in the terminal phase of dementia?

Dementia is a progressive terminal disease. More than 95% of patients will require 24-hour care either in long-stay hospital wards or in nursing homes at the end of life. There are many issues in the care of patients with dementia that parallel palliative cancer care, but relatively few patients with dementia currently access palliative care. Following an initial audit that found that many patients dying with dementia had symptoms that were not palliated, multidisciplinary guidelines were developed jointly by medical and nursing staff working in psychiatry for older people, together with pharmacy and palliative care staff. Following the implementation of guidelines, there was a significant decrease in the prescribing of antibiotics in the last 2 weeks of life and patients were much more likely to be prescribed analgesia, including opiates. This small study suggests that when developed collaboratively, multidisciplinary guidelines can have a positive impact on palliative care for non-oncology patients.     

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.