Use of advance care directives for individuals with dementia living in residential accommodation: A descriptive survey

BackgroundEnd-of-life decision-making for individuals living with a dementia needs to be addressed because as dementia progresses, individuals need support to make decisions about their health care, living arrangements and end-of-life care changes. Advance care directives (ACDs) provide an opportunity for individuals living with a dementia to communicate their wishes about these important issues.AimThe aim of this study was to understand how Australian registered nurses (RNs) use ACDs for individuals with a dementia living in residential accommodation.MethodsTwo hundred and thirty eight RNs working in Australian residential accommodation were recruited via social media, professional organisations and organisations providing residential accomodation. Respondents completed an online survey delivered via Survey Monkey.Findings59.7% of respondents reported commencing discussions around ACDs within the first month of individuals living with a dementia relocating to residential accommodation. However, 42.4% never or rarely completed ACDs. Only 59.3% stated that ACDs for individuals living with a dementia were always or often regularly reviewed. 53.8% identified that ACDs were always adhered to when an individuals’ circumstances changed. 62.6% felt that understanding among families about ACDs was sometimes, or often, a barrier to using ACDs.ConclusionThe implementation of ACDs in Australian residential accommodation for those living with a dementia remains sub-optimal. This study has demonstrated that ACD documentation and policies describing how they should be used exist, but gaps remain around the practical implementation of ACDs. Strategies to promote communication and collaboration between residential facilities, general practitioners and carers / families could also assist in providing cohesive, high quality care.     

Enablers and barriers to engaging in dementia-specific education: A cross-sectional survey

BackgroundPrevalence of dementia is increasing, with more than half of aged care residents having a dementia diagnosis in Australia. Aged care staff currently lack dementia-specific knowledge and skills to care for residents with dementia.AimTo examine residential aged care staff perceptions of enablers and barriers to completing dementia-specific education.MethodsA purpose-designed cross-sectional survey of staff (n=179) from 36 of the 177 Victorian public sector residential aged care facilities across metropolitan, regional, and rural Victoria, Australia.FindingsStaff were most commonly motivated to complete dementia-specific education by intrinsic factors such as a desire to provide better care to residents, and to develop or improve their skills. Availability of education online, readily accessible information about education opportunities, workplace resources, and management support were key enablers. Difficulty with access, lack of time, high workload, and lack of awareness were significant barriers. Cost, location, and mode of delivery were cited as both enablers and barriers.DiscussionResidential aged care staff require accessible education initiatives and workplace support to facilitate their participation in dementia-specific education to provide high quality, evidence-based care for people living with dementia.ConclusionFindings of this study can assist education providers, employers, and researchers to better understand participation and inform strategies and processes to increase uptake of dementia-specific education.     

Research use in the care of older people: a survey among healthcare staff

Background. Sweden has one of the largest proportions of older people in the world. To manage the healthcare needs of an aging population, there has been an alteration from hospital care to community‐based care. In these settings, the majority of staff is enrolled nurses (EN) and nurse aides (NA) without university education. Aim and design. The overall aim of this cross‐sectional survey was to explore staff perceptions of factors related to research utilization in the care of older people. Method. Questionnaires covering research utilization and demographics were sent to all staff (n = 132) working in seven units in older people care. The response rate was 67% (n = 89). The respondents consisted of ENs/NAs (n = 63), Registered Nurses (RN) and rehabilitation professionals (RP) as physiotherapists and occupational therapists (RN/RP n = 26). Results. Most of staff reported positive attitudes towards research. The RNs/RPs stated more often than the ENs/NAs that they wanted to base their practice on research (81% vs. 25%; P = 0.001). The RNs/RPs also reported a greater extent of research use in daily practice (54% vs. 17%; P = 0.001). Support from colleagues (77% vs. 22%; P < 0.001) and unit managers (73% vs. 10%; P < 0.001) for implementing research findings was also more frequently reported by the RNs/RPs compared with the ENs/NAs. The majority of the ENs/NAs stated Do not know on many items concerning attitudes towards research, support for research utilization and actual use of research. Conclusions. Despite overall positive attitudes towards research, the majority of staff did not use research findings in daily practice. This was particularly valid for the EN/NA group. Relevance to clinical practice. There is an urgent need for managers and others in the care of older people to develop strategies for implementing evidence‐based practice that involves the EN/NA group.     

How are older people’s care preferences documented towards the end of life?

BackgroundMeeting individuals’ preferences is essential to achieve quality care at the end of life. Documenting these preferences in the healthcare system is an essential step to achieve them.AimTo investigate the documentation of older people’s care preferences including end of life care preferences in health records.MethodsRetrospective audit of health records for the last six months of life of people aged over 74 years who died in hospitals, residential aged care facilities, or community palliative care.FindingsFifty records were audited, including 28 hospital, 12 residential aged care facilities, and 10 community palliative care records with overall 297 documented care preferences. 30% of preferences were recorded on institution-specific forms at admission which focussed on patients’ medical/healthcare needs and less on personal/lifestyle preferences. Documentation mainly included clinical care preferences (35%), resuscitation plans (28%), and place of care (20%). Preferred place of death was not documented in 70% of cases. Increased documentation occurred closer to death with 63% of preferences recorded in the last week of life.DiscussionThe low rates of recorded preferences, especially non-medical choices like preferred place of death, may indicate low rates of preference discussions and/or poor documentation of these conversations. The increase in documentation closer to death may be explained by increased care needs and higher rates of care place transitions towards the end of life.ConclusionDiscussion and documentation of older people’s care preferences needs to be further encouraged within the healthcare system. It is essential not to wait for a crisis at the end of life to begin these processes.     

Aged‐care nurses’ knowledge of nursing documentation: an Australian perspective

Aim. This study investigated registered nurses’ knowledge of documentation used in aged‐care nursing home facilities in Queensland, Australia. Background. The purpose of nursing documentation is to communicate health information, facilitate quality assurance and research, demonstrate nurses’ accountability and, within Australia, to support funding of residents’ care. Little is known about the relationship between RNs’ knowledge of nursing documentation, the documentation process within residential aged care and the outcomes of the documentation. Design. Cross‐sectional, retrospective design. Method. The study was conducted with a large sample of RNs (n = 360) located in 162 Queensland aged‐care facilities. Participants completed a postage‐return questionnaire in which they identified factors that influence their knowledge and understanding of documentation. Results. Participants reported that they have considerable knowledge of nursing documentation. They also indicated that they were most knowledgeable about policies on documentation and writing discharge instructions. However, their knowledge of nursing assessments ranked fifth and they were least knowledgeable about reading reports each shift. Conclusions. The modified version of Edelstein's questionnaire provided a valid and reliable instrument for measuring RNs’ knowledge of nursing documentation. A factor analysis of the 16 items in the Knowledge scale showed excellent reliability. The data indicated that RNs in aged‐care facilities have high levels of knowledge about documentation. Specific recommendations relate to the implementation of comprehensive documentation education programs that reflect the needs of organisations and the level of RNs’ skills and knowledge concerning documentation. Relevance to clinical practice. Accurate nursing documentation is relevant to residents’ care outcomes and to government funding allocations. Measuring RNs’ knowledge of nursing documentation can identify factors that impede and facilitate their documentation of care.     

Influencing factors that support and build aged care research capacity: Staff perspectives

BackgroundStrategic collaborative networks between care staff and researchers can be a powerful means of improving the provision of safe and quality care. Aged care staff hold vital information on research practicality and ease of implementation in the clinical setting. Aged care staff are best positioned to advise on a study’s feasibility in the clinical environment and for the particular residents in their care, regardless of the fact that they are often not involved in the research process.AimTo explore aged care staff attitudes towards research particularly the influencing factors that promote and sustain care staff participation in research in the residential aged care facility (RACF) setting.MethodsQualitative semi-structured interviews were conducted at two aged care facility sites in Sydney with 10 aged care staff before and after their participation in a randomised controlled trial on their ward. The interviews explored aged care staff perceptions of the importance of research, staff compliance and factors that influence research conducted in the RACF setting.FindingsAged care staff reported on the importance of conducting research in RACFs. The barriers to staff participation included insufficient time (50%), lack of belief in intervention effect (30%), deficits in research knowledge (40%) or support (30%). Research perceived as practical (40%) that could be conducted unobtrusively (60%), provided tailored education (70%) with effective communication (50%) between researcher and aged care staff, was more favourable for staff participation.DiscussionAged care staff recognised that findings from research when implemented was important for improving quality care provision but it was challenging to conduct research in the RACF setting. Implementing strategies that support aged care staff research time away from clinical tasks, access to research education and foster communication between academic and staff can improve care staff participation in research.ConclusionFocused strategies fostered by collaborative partnerships between aged care staff, academic researcher and industry management can promote and sustain the research capacity of staff caring for older people in RACFs.     

Factors affecting Australian aged care facility workers in administering oral medication to residents with swallowing difficulties

Swallowing difficulties are common in older people and can complicate the administration of oral medications. The aim of this study was to explore factors affecting healthcare workers in their practices of oral medication administration to aged care residents with swallowing difficulties. A purposeful sample of 17 healthcare workers composed of clinical/care managers, registered nurses (RNs), enrolled nurses (ENs), and assistants in nursing (AINs) from three aged care facilities in Queensland, Australia participated in semi-structured interviews. Leximancer was used for quantitative content analysis. The responses centered on three main factors. Participants discussed workprocess-related factors including time, workload, and stress and frustrations resulting from work processes. Medication-related factors included strategies to facilitate medication administration, uncertainties around modifying medications, availability/cost of alternatives, multidisciplinary medication management, prescribing considerations, and polypharmacy. Resident-related factors were discussed around individualized needs of residents especially those with dementia-associated swallowing difficulties. Ideas differed among the four groups of participants. Managers discussed workprocess-related factors pertaining to staff and facility. RNs focused on how clinical aspects of the medication practices were affected by work processes. ENs were task-oriented and their responses focused on work processes. AIN responses centered on reliance on RNs in performing medication tasks. The findings suggest that healthcare workers' practices of medication administration to residents with swallowing difficulties are affected by various factors associated with work processes, medications, and resident characteristics. Although these factors affect all levels of healthcare workers, the needs of each group vary depending on their level of training and responsibilities.     

Challenges for professional care of advanced dementia

Qualitative methodology based on action research identified challenges when caring for persons with advanced dementia, as perceived by key professional providers. Data collection was via five focus groups (total n  = 24) and 20 follow-up individual interviews. Participants included palliative care, aged care and dementia specialist nurses, medical specialists from an area health service, residential aged care staff and general medical practitioners. Responses emphasized the need for improved knowledge and skills, and clearer policy. Concerns included accurate assessment, especially of pain, owing to the inability of people with advanced dementia to communicate their symptoms. Assessment, managing physical and behavioural symptoms, and communicating with family presented as further challenges. Conclusions are that the need for a palliative approach to care in advanced dementia should be recognized. Aged care staff can deliver palliative care to people with advanced dementia only if the staff receive relevant education and training beyond their generalist competencies.     

Enrolled nurse trainees in acute care

Enrolled nurses (ENs) play a pivotal role in the health workforce in Australia and the role is expanding in many practice settings. An EN traineeship was introduced in an acute medical/surgical setting at St Vincents & Mercy Private Hospital (STVMPH) a large metropolitan private hospital in Victoria, in 2005. Since then there has been a significant increase in the EN workforce across all clinical areas within the organisation. With consideration of skill mix the current percentage of 18.3% of the nursing workforce is ENs. This review shows the viability of such a program in relation to workforce planning and recruitment. Enrolled nurses are a valuable source in the health care environment. The latest figures indicate there are 230,192 registered nurses (RNs) and 52, 895 ENs (Australian Institute of Health and Welfare, 2010). Enrolled nurses account for approximately 23% of the nursing workforce. The common setting for education (clinical placement) and employment for ENs is aged care. Education and employment of ENs in acute hospital settings is necessary to broaden the skill mix of nursing staff in an acute environment. The acute medical setting encourages ENs to develop and advance their clinical skills to practice acute nursing care within their scope of practice.     

Implementation of Sustainable Evidence-Based Practice for the Assessment and Management of Pain in Residential Aged Care Facilities

Pain is common in residential aged care facilities (RACFs). In 2005, the Australian Pain Society developed 27 recommendations for good practice in the identification, assessment, and management of pain in these settings. This study aimed to address implementation of the standards and evaluate outcomes. Five facilities in Australia participated in a comprehensive evaluation of RACF pain practice and outcomes. Pre-existing pain management practices were compared with the 27 recommendations, before an evidence-based pain management program was introduced that included training and education for staff and revised in-house pain-management procedures. Post-implementation audits evaluated the program's success. Aged care staff teams also were assessed on their reports of self-efficacy in pain management. The results show that before the implementation program, the RACFs demonstrated full compliance on 6 to 12 standards. By the project's completion, RACFs demonstrated full compliance with 10 to 23 standards and major improvements toward compliance in the remaining standards. After implementation, the staff also reported better understanding of the standards (p < .001) or of facility pain management guidelines (p < .001), increased confidence in therapies for pain management (p < .001), and increased confidence in their training to assess pain (p < .001) and recognize pain in residents with dementia who are nonverbal (p = .003). The results show that improved evidence-based practice in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce via this implementation program has shown improvements in staff self-efficacy and practice.     

Personal and Interpersonal Factors and Their Associations With Advance Care Planning Documentation: A Cross-sectional Survey of Older Adults in Australia

ContextPersonal and interpersonal factors may be influential in a person's decision to engage in advance care planning (ACP), including completion of ACP documentation.ObjectivesTo conduct a cross-sectional survey of older adults accessing Australian general practices, hospitals, and residential aged care facilities, with the aim of describing associations between personal and interpersonal factors and self-reported ACP documentation completion.MethodsEligible participants included in a national health record audit were approached to complete a survey measuring demographic and health characteristics, preferences for care, worries about the future, and experiences talking with others about ACP and completing ACP documentation.ResultsOf 1082 people eligible to participate in the survey, 507 completed the survey (response rate = 47%; median age 82 years) and 54% (n = 272) reported having completed ACP documentation. Having ever discussed ACP with other people (anyone) or a doctor were both significant predictors of ACP documentation completion, whereas having previously spoken specifically to a partner about ACP, currently living with children compared to living alone, and being aged 55–69 versus 90–99 years were associated with reduced odds of ACP documentation completion.ConclusionApproximately half the participants reported having completed ACP documentation. The strongest predictor of ACP documentation completion was having spoken to anyone about ACP followed by having spoken to a doctor about ACP. These findings suggest that discussions about ACP are an important part of the process of completing ACP documentation.     

Communication between residential aged care facilities and the emergency department: A review of the literature

BackgroundWestern countries have encountered an increase in elderly patients transferred from residential aged care facilities to emergency departments. This patient cohort frequently experiences impaired physical and cognitive function. Emergency department staff require important clinical and personal patient information to provide quality care. International studies show that documentation and handover deficiencies are common.ObjectiveThe purpose of this literature review was to explore transitional communication practices, and to consider the specific patient information deemed essential for the management of residents in the emergency department.MethodsA literature review was conducted to examine the studies exploring the documentation accompanying elderly people who were transferred from residential aged care facilities to emergency departments. Scopus, OVID Medline and Cinahl Plus data bases were searched using combinations of the following key words: ‘nursing home’, ‘long-term care’, ‘skilled nursing facility’, ‘aged care facility’, ‘communication’, ‘documentation’, ‘emergency department’, ‘emergency room’, ‘hospital’, ‘acute’, ‘transfer’, and ‘transition’. Additional data was located with the use of Google Scholar. Review of titles and exclusion of duplicates identified 69 relevant studies. These 69 papers were independently reviewed by three members of the research team for eligibility for inclusion in the review, and seven papers were retained.ResultsThere is currently no consensus regarding what information is essential when residents are transferred from aged care facilities to emergency departments, and practices vary. Key information which should accompany the resident has been reported by various authors and include the reason for transfer, past medical history, current medications, cognitive function and advance directives. Some authors also suggest that facility contact details are essential. Without agreement by key stakeholders as to what constitutes ‘essential transfer information’, clinical practices will continue to vary and resident care will be affected.ConclusionThis paper identifies frequent communication deficits in the information provided to the emergency department from aged care facilities. There is an imperative to identify suitable items of information which health care professionals agree are essential. Future research should focus on methods to improve the transfer of information between facilities, including consensus regarding what information is essential transfer data.     

Prevalence of disruptive behaviour displayed by older people in community and residential respite care settings

The aim of this study was to determine the prevalence of disruptive behaviour displayed by older people in community and residential respite care settings. The specific objectives were to (i) obtain an estimate of the frequency of disruptive behaviour displayed by older people in the community setting before residential respite care; (ii) characterize older people being admitted for residential respite care; and (iii) obtain an estimate of the frequency of disruptive behaviour displayed by older people in residential respite care. A quantitative approach using a cross-sectional survey was employed in the community and in the residential aged care facilities. The older people (n = 100) had a mean age of 81.8 years (range 66-96 years). The older people were being admitted from their homes for booked respite care at residential aged care facilities in a regional Australian city. Home caregivers and nurses rated disruptive behaviour using the Dementia Behaviour Disturbance Scale (DBDS). Reliability data for the DBDS are provided. As expected, in both community and residential respite settings, older people with dementia (29%) scored significantly higher on the DBDS than people without dementia. In addition, DBDS scores were unexpectedly higher in the community setting than in the respite setting. These findings should be taken into consideration by primary health-care professionals when offering treatment options to the home caregivers and by staff in the residential aged care facilities that offer respite.     

Nurses in municipal care of the elderly act as pharmacovigilant intermediaries: a qualitative study of medication management

Objective: To explore registered nurses’ experience of medication management in municipal care of the elderly in Sweden, with a focus on their pharmacovigilant activities. Design: A qualitative approach using focus-group discussions was chosen in order to provide in-depth information. Data were analysed by qualitative content analysis. Setting: Five focus groups in five different long-term care settings in two regions in Sweden. Subject: A total of 21 registered nurses (RNs), four men and 17 women, aged 27–65 years, with 4–34 years of nursing experience. Results: The findings reveal that RNs in municipal long-term care settings can be regarded as “vigilant intermediaries” in the patients’ drug treatments. They continuously control the work of staff and physicians and mediate between them, and also compensate for existing shortcomings, both organizational and in the work of health care professionals. RNs depend on other health care professionals to be able to monitor drug treatments and ensure medication safety. They assume expanded responsibilities, sometimes exceeding their formal competence, and try to cover for deficiencies in competence, experience, accessibility, and responsibility-taking. Conclusion: The RNs play a central but also complex role as “vigilant intermediaries” in the medication monitoring process, including the issue of responsibility. Improving RNs’ possibility to monitor their patients’ drug treatments would enable them to prevent adverse drug events in their daily practice. New strategies are justified to facilitate RNs’ pharmacovigilant activities.

• Key points

• This study contributes to the understanding of registered nurses’ (RNs’) role in medication management in municipal care of the elderly (i.e. detecting, assessing, and preventing adverse drug events or any drug-related problems).

  • RNs can be considered to be “vigilant intermediaries” in elderly patients’ drug treatments, working at a distance from staff, physicians, and patients.

  • RNs occasionally take on responsibilities that exceed their formal competence, with the patients’ best interests in mind.

  • In order to prevent adverse drug events in municipal care of the elderly, new strategies are justified to facilitate RNs’ pharmacovigilant activities.

     

Dementia palliative care: A multi-site survey of long term care STAFF’S education needs and readiness to change

Many people with dementia reside in long-term care, where limited staff knowledge of dementia palliative care has been identified, along with poor awareness that a palliative approach can assist in identifying unmet care needs. Evidence-based guidance in palliative care for people with dementia is available however, implementing this guidance requires staff engagement and a tailored educational approach. This pre-implementation situational analysis informed a tailored staff education intervention to support the implementation of national guidance on dementia palliative care in long term care. Using a cross-sectional study design, underpinned by the Consolidated Framework for Implementation Research, survey data were collected on site profile, staff demographics, learning needs, and readiness-to change at three residential care sites for older people in Ireland. In total, 69 staff (predominantly nurses and healthcare attendants) completed the surveys. Medication management and management of pain were the most frequently identified learning needs. Staff were confident in their ability to implement change but de-motivation and powerlessness were substantial factors as only one-third of staff were “ready for change”. Staffing levels, managing risk during change and perceived reluctance in others were common barriers. These results informed an educational intervention to address the specific care context, staff learning needs and barriers to change prior to implementation.     

Staff outcomes from the caring for aged dementia care resident study (CADRES): a cluster randomised trial

BackgroundDementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched.ObjectivesThe impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions.DesignA cluster-randomised, controlled trial.SettingsThe study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care.Participants194 consenting managers, nurses, therapists and nurse assistants working in the participating sites.MethodsIntervention care sites received training and support in either person centred care (n = 5) or dementia care mapping (n = 5); control sites continued with usual dementia care (n = 5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias.ResultsThe Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Post-hoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p = 0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (r_s = 0.26, p = 0.004, n = 122) and less depersonalisation (r_s = 0.21, p = 0.023, n = 122), but not for any of the other outcome measures.ConclusionsThis study has shown that person centred approaches of care, in particular with dementia care mapping, may contribute to reducing staff job related burnout. The findings also highlight a potentially important role of managerial support and a whole of system approach.