Adaptive Behaviour Gains in Ordinary Housing for People with Intellectual Disabilities

Fifty-one residents of 14 staffed houses for people with intellectual disabilities were assessed using the Adaptive Behavior Scale (ABS) at the beginning, middle and end of a two year period. Changes in ABS score were calculated to ascertain whether residents experienced continued development once the immediate period following resettlement from institutional services was past. Although some individuals changed little and some lost skills, ABS scores were found to increase significantly over time, particularly among the least able residents. This latter finding prompted further investigations. Conversion to percentile ranks was undertaken to provide a better basis for comparison between individuals as the raw scores cannot be interpreted as an equal interval scale. Unreliability of measurement provided a further reason for caution. Changes in percentile rank scores were relatively modest when compared to the level of unreliability. Moreover, the consistency of change found for individuals across both years of the study period was unconvincing, with the number of times change was in the same direction being only similar to that which would be predicted by chance. Overall, the study demonstrates the difficulties encountered in trying to establish whether improvements in personal competence are ongoing in community residential services for people with intellectual disabilities.     

Measuring the impact of housing on people with schizophrenia

Review of the available literature, from various countries, on housing options indicates that, for people with a mental illness, boarding houses are the least desirable type of community accommodation and that living in their own home is the most desirable type of accommodation. The present research project provides a more in-depth examination of people with schizophrenia and the impact of living in their own home compared to living in a boarding house. In this Australian study there were 3231 subjects, 3033 who were living in their own homes and 201 living in boarding house accommodation. The study used two instruments from the Mental Health Classification and Service Cost Project, specifically the Health of the Nation Outcomes Scale, which is a measure of current symptoms, and a shortened version of the Life Skills Profile, which measures global level of functioning. Results indicated that while there were no differences in the level of psychiatric symptoms experienced, people living in boarding houses had less access to social support, meaningful activities and work; they also had a significantly lower level of global functioning. These findings contradict the conventional wisdom that people with schizophrenia resort to living in boarding houses because of their level of disability and highlights an area of potential intervention for community health services.     

Fatal Airway Injuries during Operation Enduring Freedom and Operation Iraqi Freedom

Objective. To determine if a single mailing from the local volunteer fire department can increase the number of homes with proper, visible address numbering. Proper numbering is essential in rapidly locating a house during an emergency response. Methods. The study was conducted at a suburban/rural fire department providing EMS andfire suppression services to a 22 square mile area with residential mailboxes located at the street. During a hazard identification pre-plan tour, each house was examined andassigned a classification: (A) No number visible on the house or mailbox (improper); (B) Number on only one side of the mailbox (improper); (C) Number on both sides or the end of the mailbox, or visible on the house (proper). The homeowners of all residences with improper numbering (A or B) were sent a one-page letter, discussing the need for proper numbering. The tour was repeated six weeks later to determine whether deficiencies had been corrected. It was prospectively determined that a 25% improvement was sought. Results. During the pre-plan tour, 73 houses were classified as type A, 454 as type B, and1706 as type C. At the re-visit, 135 (26%) of the type A andB homes had been properly numbered. Correction of deficiencies was better at type A homes (37, or 51%) than at type B homes (98, or 22%) (p < 0.001 by Chi-square). Conclusion. For houses with improper numbering, a single mailing from the fire department can be effective in encouraging residents to post proper numbers.     

OUTCOMES OF ORDINARY HOUSING SERVICES IN WALES: OBJECTIVE INDICATORS

Outcome data were collected on fourteen, recently provided staffed houses for people with mild, moderate, severe or profound learning disabilities in order to assess the quality of service provided. Quality indicators reflected the quality of the housing provision, social and community integration, social relationships within the houses, resident engagement in activity, developmental progress over time and opportunities for autonomy and choice. The data show that the quality of the houses investigated was broadly similar to that reported for other housing services in British research which has accompanied deinstitutionalisation. Quality levels on many indicators were related to the ability of residents and the data illustrate the difficulty in providing services for people with more severe or profound learning disabilities, which are capable of achieving outcomes comparable with those attained in services for more able residents. This research provides further evidence that the extent of staff support for resident activity is critical to how much residents are able to participate fully in the everyday activities which arise in the conduct of their lives.     

The relationship between organizational climate and the content of daily life for people with dementia living in a group-dwelling

1. One factor influencing the outcome of care may be nursing staff's experience of the organizational work climate. The aim of the study was to investigate how people with dementia spend their time in group-dwelling units (GD) with either a creative or less creative organizational climate. 2. For the study, two GD units assessed as having a creative organizational climate and two units assessed as having a less creative climate were selected. Eighteen residents living in the units assessed as creative and 20 residents living in the units assessed as less creative participated in the study. 3. For measuring the organizational climate the Creative Climate Questionnaire was used. Observations of residents' activities were classified according to the Patient Activity Classification. For measuring residents' functional ability the Multi-Dimensional Dementia Assessment Scale was used. Their cognitive capacity was measured with the Mini Mental State Examination. 4. Residents living in the units assessed as having a creative organizational climate spent 45.2% of the time with nursing staff, while those in the less creative climate spent 25.6% (P < 0.001). Time spent with fellow residents in the creative climate was 13.9% and in the less creative climate 31.3% (P < 0.001). There was no significant difference between the units according time spent with relatives and time spent alone. 5. Since the purpose of GD is to offer care adapted to the abilities and psychosocial needs of people suffering from dementia, a less creative climate can be a threat to the aims of GD. In order to maintain these, it is important for managers to be aware of the work climate and its impact on care for people with dementia.     

Implementation and Evaluation of Active Support

Objectives Active support was implemented in three community houses (active support houses), with 11 service users with severe learning disabilities. Methods This was evaluated with reference to changes in levels of engagement, challenging behaviour (major and minor) and staff contact, measured against three comparison services (non‐active support houses). Results All measures increased for the active support houses. Significant increases in activity levels were found in one house. Statistically significant increases in activity and minor challenging behaviour were also found when all active support houses were compared with all non‐active support houses. In the non‐active support houses, all measures decreased, with the exception of mean level of staff contact in one house. Conclusions Unlike previous research findings, those service users who were less able did not receive comparatively more support from staff post‐training and changes appeared unrelated to staff contact.     

'No going back' to institutional care for people with severe disability: reflections on practice through an interpretive study

Purpose. This paper evaluated quality of life for people with a disability with high health and high support needs following a move from a congregate care institution to community housing. The study explored residents' perceptions of the service, level of community involvement, lifestyle choices, and input into decision-making.

Method. An exploratory interpretative study was conducted using semi structured interviews with nine community house residents, ten community house staff and five family members.

Results. Participants were clear they definitely would not go back to the institution, but the relocation experience was not without difficulties. These issues related to 'site', 'staff' & 'skills'.

Conclusions. Direct support staff hold considerable power to increase or diminish residents' quality of life. A targeted programme addressing specific site, staff & skill issues would strengthen quality of life for these very dependent residents.     

‘No going back’ to institutional care for people with severe disability: Reflections on practice through an interpretive study

Purpose. This paper evaluated quality of life for people with a disability with high health and high support needs following a move from a congregate care institution to community housing. The study explored residents' perceptions of the service, level of community involvement, lifestyle choices, and input into decision-making.

Method. An exploratory interpretative study was conducted using semi structured interviews with nine community house residents, ten community house staff and five family members.

Results. Participants were clear they definitely would not go back to the institution, but the relocation experience was not without difficulties. These issues related to ‘site’, ‘staff’ & ‘skills’.

Conclusions. Direct support staff hold considerable power to increase or diminish residents' quality of life. A targeted programme addressing specific site, staff & skill issues would strengthen quality of life for these very dependent residents.     

Tasks performance by registered nurses and care assistants in nursing homes: a quantitative comparison of survey data

OBJECTIVES: To examine the care tasks performed for residents of Belgian care institutions for older people and the association between the performance of care tasks by persons of different staffing categories (registered nurses (RN) and care assistants (CA)) and the characteristics (the dependency level and the diagnosis of dementia) of the residents. STUDY DESIGN AND SETTING: Survey on the care for residents, aged 65 or over, living in 26 care institutions for aged people. MAIN OUTCOME MEASURES: Separate bivariate comparisons of care time spent on residents with and without dementia and bivariate comparisons of care time spent on six task categories on residents of different dependency levels were performed. The median number of minutes over seven days (mosd) and the inter quartile range (IQR) are presented as summary measures. The proportion of the time spent by RNs and CAs per resident and per task category was calculated. RESULTS: Time spent was highest on primary care tasks (34,554 mosd; 48.7%), followed by in order of time spent, supportive tasks (10,845 mosd; 15.3%), logistic tasks (10,697 mosd; 15.1%), practical nursing procedures (8,689 mosd; 12.2%), administrative tasks (3,357 mosd; 4.7%) and communication tasks (2,814 mosd; 4.0%). Overall there was no significant difference between the total time spent by RNs (median=190 mosd; IQR 105-334) and the total time spent by CAs (median=196 mosd; IQR 91-331; p=0.89). RNs were spending significantly more time than CAs in practical nursing procedures, communication tasks and administrative tasks. CONCLUSIONS: There was a sharp task demarcation between RNs and CAs in the three less frequent task categories. There was no indication that RNs were delegating tasks to CAs.     

Community ambulation before and after hip fracture: a qualitative analysis

Purpose.?This qualitative study explored mobility levels around the home and in the community before and after hip fracture.

Methods.?Twenty-four people receiving rehabilitation after hip fracture were interviewed using an in-depth semi-structured format: 12 who were receiving rehabilitation as inpatients, and 12 who had been discharged home from inpatient rehabilitation and were continuing therapy as outpatients. The recorded interviews were transcribed and coded independently by two researchers. From these codes themes were developed.

Results.?Before their fracture, participants were independent about their houses, but their level of community ambulation had been reducing over recent months or years, often associated with another health problem. Participants who had returned home after inpatient rehabilitation for hip fracture reported much reduced levels of mobility both in their house and in the community compared with their pre-fracture performance. This reduced level of mobility was associated with psychological factors (fear, lack of confidence, frustration), physical factors (pain, the presence of another health problem) and social/environmental factors (reliance on daughter, and car). The level of optimism expressed by people receiving inpatient rehabilitation contrasted with the pessimism of those receiving outpatient rehabilitation.

Conclusions.?Patients living back in the community after hip fracture described a reduced level of functioning and a pessimism that contrasted with the optimism expressed by people who were still in the inpatient phase of rehabilitation. These findings, and the importance of psychological factors and social support, may be considered when designing rehabilitation strategies to support the successful transition of people to their community after hip fracture.     

Nurse discharge planning in the emergency department: a Toowoomba, Australia, study

Aim. This study aimed to ascertain whether a model of risk screening carried out by an experienced community nurse was effective in decreasing re‐presentations and readmissions and the length of stay of older people presenting to an Australian emergency department. Objectives. The objectives of the study were to (i) identify all older people who presented to the emergency department of an Australian regional hospital; (ii) identify the proportion of re‐presentations and readmissions within this cohort of patients; and (iii) risk‐screen all older patients and provide referrals when necessary to community services. Design. The study involved the application of a risk screening tool to 2139 men and women over 70 years of age from October 2002 to June 2003. Of these, 1102 (51·5%) were admitted and 246 (11·5%) were re‐presentations with the same illness. Patients presenting from Monday to Friday from 08:00 to 16:00 hours were risk‐screened face to face in the emergency department. Outside of these hours, but within 72 hours of presentation, risk screening was carried out by telephone if the patient was discharged or within the ward if the patient had been admitted. Results. There was a 16% decrease in the re‐presentation rate of people over 70 years of age to the emergency department. Additionally during this time there was a 5·5% decrease in the readmission rate (this decrease did not reach significance). There was a decrease in the average length of stay in hospital from 6·17 days per patient in October 2002 to 5·37 days per patient in June 2003. An unexpected finding was the decrease in re‐presentations in people who represented to the emergency department three or more times per month (known as ‘frequent flyers’). Conclusions. Risk screening of older people in the emergency department by a specialist community nurse resulted in a decrease of re‐presentations to the emergency department. There was some evidence of a decreased length of stay. It is suggested that the decrease in re‐presentations was the result of increased referral and use of community services. It appears that the use of a specialist community nurse to undertake risk screening rather than the triage nurse may impact on service utilization. Relevance to clinical practice. It is apparent that older people presenting to the emergency department have complex care needs. Undertaking risk screening using an experienced community nurse to ascertain the correct level of community assistance required and ensuring speedy referral to appropriate community services has positive outcomes for both the hospital and the patient.     

上海青浦区18岁以上成年人含糖饮料饮用情况及影响因素分析

目的：了解上海市青浦区18岁以上成年人含糖饮料饮用情况及其影响因素，为开展健康干预提供参考依据。方法：采用修改后的上海市成人慢病危险因素调查问卷（2016版），对青浦区11个街道、镇近6000名社区居民开展问卷调查，了解社区居民含糖饮料摄取情况及其影响因素。结果：本研究共纳入5753人，其中589人（10.24%）经常摄取含糖饮料（>750 ml/周）。经多因素回归分析后发现，男性含糖饮料饮用率显著高于女性，18~29岁人群饮用率显著高于30岁及以上人群，初高中和大专文化水平的调查对象摄取含糖饮料显著高于小学及以下文化程度者。结论：社区居民中有10.24%经常摄取含糖饮料，男性、18~29岁、文化程度为初中高中及大专的居民应作为本地区重点人群加强健康教育和健康管理，需加强对媒体广告等管理，改变社区居民的饮食习惯，逐步降低含糖饮料的摄取，从而预防控制含糖饮料相关的代谢性疾病。     

Daily rehabilitation nursing increases the nursing time spent on residents

Nurses are primary managers of rehabilitation nursing activities. When improving rehabilitation nursing, it is important to understand the content of care provided and time spent on residents. This study discusses the allocation of nursing staff time within a context of rehabilitation nursing. The variables of rehabilitation nursing and residents' characteristics were derived from the Resident Assessment Instrument. The wage-adjusted direct nursing time was obtained from a time measurement study carried out in November 2002 in long-term care facilities in southern Finland. The average direct wage-adjusted nursing time spent on resident was 93.8 min per day. Residents receiving daily rehabilitation nursing were allocated ∼8 min more wage-adjusted direct nursing time than their peers. More 'hands in care' staff is required for adopting rehabilitation nursing in long-term care units. Maximizing residents' independency should be the goal for rehabilitation care and therefore the focus for allocating both nursing and rehabilitation staff to units and facilities.     

The Minimum Data Set bedfast quality indicator: differences among nursing homes

BACKGROUND: Excessive time in bed has negative effects on both physical conditioning and functioning. There are no data or practice guidelines relevant to how nurses should manage the in-bed times of nursing home residents, although all nursing homes receive a bedfast prevalence quality indicator report generated from the Minimum Data Set. OBJECTIVES: To compare nursing homes that score in the upper and lower quartiles on the Minimum Data Set bedfast prevalence quality indicator for proportion of bedfast residents, activity and mobility nursing care, and amount of time all residents spend in bed, and to evaluate whether residents who spend more time in bed are different from those who spend less time in bed according to functional measures. METHODS: A cohort design used medical records, resident interviews, and direct observation data to compare 15 nursing homes (n = 451 residents) on the proportion of bedfast residents, the amount of time residents spent in bed, the frequency of activity, and the scores on six activity and mobility care process indicators. RESULTS: Significant differences were found between upper (i.e., higher prevalence of bedfast residents) and lower quartile nursing homes in the proportion of time residents were observed in bed (43% vs. 34%, respectively; p =.007), and in the proportion of residents who spent more than 22 hours in bed per day (18% vs. 8%, respectively; p =.002). All nursing homes underestimated the number of bedfast residents. The residents of upper quartile homes showed more activity episodes and reported receiving more walking assistance than the residents of lower quartile homes. DISCUSSION: Minimum Data Set bedfast quality indicator identified nursing homes in which residents spent more time in bed, but did not reflect differences in activity and mobility care. In fact, upper quartile homes provided more activity and mobility care than lower quartile homes. Across all the nursing homes, most of the residents spent at least 17 hours a day in bed. Further study of activity and mobility care and bedfast outcomes in nursing homes is needed, and nurses need to note the amount of time nursing home residents spend in bed.     

Nutritional status and health outcomes for older people with dementia living in institutions

AIM: This paper is a report of a study to determine changes over a 3-month period among older people with dementia living in long-term care settings, related to: (1) changes in body mass index, and (2) health outcomes and associated factors. BACKGROUND: Nutritional deficiencies are common problems among older people, but frequently unrecognized, both in long-term care settings and in the community. METHOD: A cross-sectional design with repeated measures of body weights and medical record reviews was adopted. The study was conducted in 2003 in two long-term care facilities for older people with dementia in Taiwan. Fifty-five residents participated in the study. RESULTS: Eighteen percent of the residents were under-nourished (body mass index <18.5). There was a trend toward decreasing body mass index over the 3-month study period. Residents with low body mass index tended to need assistance at mealtimes. Nineteen residents, many receiving naso-gastric tube-feeding, experienced adverse health events during the study period. Dependency in eating was the major factor differentiating residents with normal or low body mass index values, and also in distinguishing those who experienced adverse health outcomes. CONCLUSION: Assessment of eating ability, mode of feeding and measurement of body weight can be used by nurses in long-term care settings for early identification of the nutritional status of older people with dementia.     

Predictors and correlates of the frequency and the length of verbal communications between nursing staff and elderly residents in geriatric care facilities

Aim: The present study was conducted to clarify the type and frequency of verbal communication between caregivers and elderly residents in geriatric care facilities. The relationship of this verbal communication was studied in terms of the caregivers talking to elderly residents and the utterances issued by the elderly residents. The attributes of the elderly residents were also studied. Methods: There were 35 eldery residents living in three metropolitan geriatric care facilities. Observations were made of caregivers talking to elderly residents and of elderly residents talking to caregivers in order to conduct a content analysis that categorized the types of verbal communication observed. A statistical analysis of the relationship between the frequency and duration of verbal communication and attributes of the elderly residents was carried out. Results: There were two category types of talking to elderly residents by a caregiver: ‘talking to elicit the ‘activities of daily living (ADL)‐related behavior/performance or physical functioning’ (type I: instrumental communication) and ‘talking to facilitate psychosocial life activities’ (type II: affective communication), of which the former accounted for 75.9%. The number of spontaneous utterances from elderly residents was very low, with most utterances being responses to caregivers talking to them. There was a tendency for utterances from the elderly residents to increase as the total time of being talked to by caregiver increased (r = 0.47, P < 0.01). The total amount of time a caregiver spent talking to elderly residents was longer for people with low versus high mobility and for people with dementia versus people without dementia (t = 3.4, P < 0.01). Conclusion: The correlation between type II communication and the mean frequency of utterances by elderly residents was high (r = 0.72, P < 0.01) compared with type I, suggesting that the former type of communication is more likely to elicit utterances by elderly residents.     

Managing change in nurse education: the introduction of Project 2000 in the community

The United Kingdom Central Council's proposals for nurse education (Project 2000: A New Preparation for Practice) were implemented in 13 demonstration districts in England in 1989. In 1991, as part of an English National Board-funded research study, the author conducted 15 interviews with first line managers from three of these demonstration districts. The data were reinterpreted in 1995; the experience of implementing educational change in the community setting was discovered to be a complex and difficult process for the managers involved. They found themselves confronted with sometimes conflicting responsibilities; their perception of their role encompassed the meeting of a range of needs, which are presented in this paper within three categories. Firstly, the managers felt they had an obligation to meet the needs of students and of education in general in order both to provide an adequate experience for each individual student and to safeguard standards in community nursing in the long term. Secondly, they were confronted with the need to mitigate the pressures Project 2000 placed on'their'staff. The new educational programme meant that community nurses spent much more time with students than formerly, and the difficulties they encountered were exacerbated by uncertainty about their role with these students. Finally, and most importantly, managers were responsible for ensuring that clients'needs were met. In particular, they saw it as their role to ensure that the presence of large numbers of students in the community for long periods of time did not compromise standards in the delivery of community nursing services.     

Resident Educational Time Study: A Tale of Three Specialties

Abstract. Objectives : To compare amounts of in-hos-pital time use by PGY1 residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery. This article reports the general study methodology and focuses on the educational aspects of residency time use. Methods : A cross-sectional, observational study of the activities of EM PGY1 residents was performed while the residents were on duty during the 3 specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical/service, educational, and personal areas. A time-blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. Results : Twelve PGY1 residents were observed for a total of 166 hours on surgery, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical 2-week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service-oriented activities, 24% on educational activities, and 19% on personal activities. The proportions of time devoted to the 3 major areas were similar for the 3 rotations. In all 3 rotations, the largest proportion of time was spent on patient-focused education (81% to 92% of total educational time). Only 2% to 11% of educational time was devoted to self-education. Within the patient-focused education category, proportionately less resident time with faculty occurred on the surgery rotation than on the EM and IM rotations (18% vs 30% and 27%, respectively). Conclusion : The general breakdowns of clinical/service, educational, and personal time use by PGY1 residents are proportionately similar for the 3 service rotations. Patient-focused education is the primary mode of education for all services. In-hospital, self-education time is limited. Clinical teaching is largely by nonfaculty. The educational implications of these findings are discussed.     

DO SMALLER HOMES RESULT IN INCREASED INTEGRATION?

One of the best publicised consequences of the policy of community care is the resettlement of people with a mental handicap from large institutions into homes in the community. Normalisation dictates that smaller residences have greater potential for integration than larger ones. The aim of this study was to investigate whether there is a difference in the number of community contacts made by residents with a mental handicap living in small and large community units. Community contacts of 40 individuals with a mental handicap were recorded by care staff for a period of four weeks. Twenty one of the subjects lived in three flats, with seven, ten and eight beds respectively and the remaining 19 lived in a large unit with 24 beds. Results show that people residing in the smaller units experienced significantly more community contacts than those in the large unit (p < 0.05). Areas for further study are identified.