An evaluation of the effectiveness of an educational and experiential intervention on nursing students' attitudes towards older people

Objectives.  This paper reports the results of a study that aimed to evaluate the effectiveness of an educational and experiential intervention on nursing students' attitudes towards older people.
Background.  With repeated exposure to very sick older people in hospitals or nursing homes, nursing students are at risk of adopting stereotypical views about this section of the population as frail and dependent.
Design.  A pre- and post-test design was used to conduct the study.
Methods.  Using Kogan's Attitudes Towards Old People Scale, the attitudes of nursing students were tested at the beginning of a degree programme in Adult Nursing ( n  = 130) and one year later ( n  = 94) following a series of visits to a well-older person in the community.
Results.  Nursing students reported positive attitudes towards older people and these were retained throughout the first year of their nurse training. No statistically significant differences were found associated with any of the five independent variables in either pre- or postintervention students.
Conclusions.  The attitudes of nursing students towards older people remained positive. While it is possible that the experiential and educational interventions utilized in this study may have contributed to the retention of positive attitudes, further research is required to test this hypothesis.
Relevance to clinical practice.  Nurses have a major role to play in responding to the health and social care needs of older people and their families. The cultivation of positive attitudes is a key factor in enabling practising nurses to respond to this challenge.     

Validity and reliability testing of the Oulu patient classification: instrument within primary health care for the older people

Aim.  The aim of the study was to evaluate the reliability and validity of The Oulu Patient Classification (OPC) instrument to see whether the instrument that has been developed for hospital care is valid and useful within primary health care for older people.
Background.  Although different patient classification instruments have been under development since the 1960s, this is still a very important research area today.
Method.  Inter-rater reliability testing of the OPC instrument was undertaken. The inter-rater reliability was tested through parallel classification ( n  = 1722). Validity testing was conducted as an expert validation of the manual for the OPC instrument, using a questionnaire during June and July of 2005 ( n  = 61).
Results.  The inter-rater reliability testing achieved over 70% consensus, Cohen's Kappa showed a strong consensus for OPC classifications (0.65). The reliability measured with Cronbach's Alpha was also acceptable.
Conclusion.  The results show that the OPC instrument provides a good overview of the patient's care needs and is a reliable instrument within primary health care for older people.     

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.     

Psychosocial support as a counselling in improving health-related quality of life in patients with recent multiple sclerosis in Finland

Aim.  The aim of the study was to describe and explain psychosocial support provided by nursing personnel as experienced by people with multiple sclerosis.
Background.  The goal of providing psychosocial support is to understand and improve patients' health, self-care, initiative, commitment to care, resources, deal with emotions, social interaction and circumstances.
Design and methods.  Informants were individuals ( n  = 204) diagnosed using multiple sclerosis between the years 2003–2005 in Finland. Data were collected in 2005 by a posted questionnaire. The data were analysed with cross-tabulations, correlation coefficients, mean tests, a factor analysis and multiple regression analysis.
Results.  People with multiple sclerosis need psychosocial support from nursing personnel to promote health and self-care, strengthen emotional and mental resources and maintain social relationships. The support was to include information on multiple sclerosis and related treatment options, as well as discussion, listening to the patient and supporting them in the new situation in life caused by the illness.
Conclusion.  The psychosocial support received by the patients was sufficient and corresponded to their needs. Nursing personnel have the skills to improve the health-related quality of life of people with multiple sclerosis.
Relevance to clinical practice.  The results of this research may be applied in practical nursing, such as in planning of program of neuropsychosocial rehabilitation, in developing of home care and institutional care and in planning of content of nursing education.     

Transitions in men's caring identities: experiences from home-based care to nursing home placement

Objectives.  The aim of this study is to describe, from a gender identity perspective, the experiences of older men involved in the process of caring for a partner at home and the placement into a nursing home.
Background.  Few studies have paid attention to the importance of gender when considering the social experiences of older men providing care for an ill spouse and finally placing a partner in a nursing home. Further understanding is much needed of how older men experience the process of caring for a spouse from a gender identity perspective.
Design.  A qualitative constructivist approach was adopted for this study.
Participants.  Data consists of interviews with seven men that have been informal carers and experienced the placement of their wife in a nursing home.
Methods.  Interviews were analysed with a constructivist approach.
Results.  The results indicate that men go through two transitions in their gender identity during the caregiving process and placement. From the mutual loving relationship of being a loving husband , the social responsibility of daily care of their wives changes the situation into that of being a caring husband , and finally with the move to a nursing home there is a transition from intimate care to a relationship based on friendship .
Conclusions.  The results show that older caregiving men undergo a process involving a reconstruction of gender identity. To formally recognize men's caring activities and to make them sustainable, we believe that men in an informal caring relationship need support.
Relevance to clinical practice.  Nurses need to recognize the identity struggles resulting in sadness and suffering that are related to changes in men's lives during the caregiving process. Understanding the dynamics and changes that occur when men take on a caring task is important for the development of their role as carers.     

Resident perspectives of the determinants of quality of life in residential care in Ireland

Title.  Resident perspectives of the determinants of quality of life in residential care in Ireland.
Aim.  This paper is a report of a study conducted to identify the determinants of quality of life for older people living in residential care, including exploration of mediating factors at personal and institutional levels and to construct a model of these.
Background.  The quality of life of older people living in residential care is an under-researched area. The focus in the gerontology literature has been on quality of care rather than quality of life for these people. There is emerging consensus, however, that quality of life for older people is a complex, multidimensional concept, incorporating both subjective and objective elements, whether people live at home or in residential care.
Method.  A grounded theory study was conducted in 2005–2006. A total of 101 interviews were undertaken with older people across 12 sites, representing different types of residential care in Northern Ireland. The constant comparative technique was used to analyse data.
Findings.  Four themes having an impact on the quality of life of residents were identified: ethos of care; sense of self and identity; connectedness; and activities and therapies. Mediating and facilitating and/or constraining factors for quality of life were also identified. The core category was conceptualized as 'maximizing potential'.
Conclusion.  Achieving optimal quality of life for older people in residential care will remain elusive unless all the factors which affect on it are taken into account by practitioners and policy-makers. Improving the quality of life of older people in residential care will require action in respect of all of the domains identified in this paper.     

Sheltered housing compared to independent housing in the community

Background:  With elderly people desiring to live independently as long as possible, traditional homes for the elderly are increasingly being transformed into sheltered accommodations. In order to assess the importance of housing for frail elderly people, elderly people at risk for institutionalization were studied in two living conditions: sheltered accommodation and living independently in the community.
Methods:  A total of 317 elderly people at risk for institutionalization [91 men and 240 women, mean age = 83.3 (SD = 6.0)] were interviewed using a structured questionnaire with questions regarding home care and social service use, quality of life, subjective well-being, life satisfaction, autonomy, functional status, feelings of insecurity and loneliness.
Results:  Exactly 56.5% of the respondents were living in sheltered accommodation (n = 179) and 43.5% (n = 138) were living in regular houses. Although both groups were similar in demographic details and functional status, those in sheltered accommodation had a higher perceived autonomy, sense of security and quality of life. No differences were found with regard to subjective well-being or feelings of loneliness. Elderly people in regular houses needed more hours of housekeeping assistance. Those in sheltered accommodation participated more frequently in services like social activities and social restaurants, but made less use of day care facilities.
Conclusions:  Affordable, decent and suitable noninstitutional housing with service provision play a vital role in the lives of elderly people. Compared with independent living in the community, sheltered accommodations provide added value. Sheltered housing should therefore be an integral part of long-term care policy.     

Predicting needs for nursing home admission – does sense of coherence delay nursing home admission in care dependent older people? A longitudinal study

Objectives.  This study examined predisposing, enabling and need variables (Andersen's Behavioral Model) influencing the need for nursing home admission (NHA) in older people receiving home nursing care. In particular, the potential role of coping ability, measured as 'sense of coherence' (SOC), was studied.
Design, sample, and measurements.  A survey with baseline- and follow-up data after a 2-year period was undertaken with 208 patients aged 75+. The measures used were: gender, education, age, social visits, SOC, social provision scale (SPS), self-rated health (SRH), general health questionnaire (GHQ), clinical dementia rating (CDR), Barthel activities of daily living (ADL) index, and registered illnesses (RI). A Cox proportional model was used to examine factors that could explain risk of NHA.
Results.  Measures with predictive properties were Barthel ADL index, SPS, SRH, and gender. SOC, along with subjective health complaints, general health questionnaire, RI and social visits did not predict NHA.
Conclusions.  It is concluded that the patients' subjective evaluations of both their health and perceived social support were important predictors of future NHA needs, and should be seriously taken into consideration, along with the more commonly used objective measures of ADL and CDR.     

Community nurses', home carers' and patients' perceptions of factors affecting venous leg ulcer recurrence and management of services

AIM: This study examines the feasibility of utilizing social service home carers (SSHC) to provide a collaborative approach with community nurses for the provision of leg ulcer aftercare in four National Health Service (NHS) Trusts. The purpose of this study was to gain insight into what community nurses and people with healed venous leg ulcers felt influenced leg ulcer recurrence. BACKGROUND: Studies have demonstrated that provision of community-based leg ulcer clinics has improved healing rates of venous leg ulcers, yet recurrence remains a problem. The reasons for this are far from clear, and further research is required before unequivocal support can be given to one approach to the provision of care for this client group. Collaborative approaches to the provision of leg ulcer aftercare are beginning to receive more attention. It has been recognized that social service health carers could be co-opted to provide essential aftercare once healing has occurred, although the logistics of this approach have not been fully explored. METHODS: This study was conducted in four NHS Trusts. Stage one used focus groups to explore the perceptions of district nurses (n = 15) and social service health carers (n = 15) of a leg ulcer shared care project and to gain insight into factors that they felt influenced recurrence. The second stage used semistructured interviews (n = 12) to explore the perceptions that people with healed leg ulcers have about factors influencing ulcer recurrence. FINDINGS: Key themes emerging from this study were: health promotion is perceived by community nurses and patients to be ineffective and leg ulcer aftercare services are fragmented. Organizational factors such as time constraints and limited resources were cited by community nurses and home carers as being responsible for high leg ulcer recurrence rates. Community nurses expressed a desire to delegate preventative aspects of leg ulcer care to home carers rather than participate in health promotion strategies to support healing behaviours. CONCLUSIONS: A strategy aimed at supporting healing behaviour in elderly people has the potential to reduce the recurrence of leg ulceration and improve quality of life. The findings suggest that such a strategy needs to rationalize delivery of leg ulcer aftercare to provide seamless care. It needs to improve carers' and patients' understanding of factors influencing leg ulcer recurrence and facilitate development of a more balanced professional--patient relationship.     

Social support and networks in health promotion of older people: a case study in Brazil

Aim.  This research aimed at identifying social support for older people and their families.
Background.  The Brazilian National Policy for Older People's Health, created in 1998, is based on the promotion of healthy ageing, aiming at encouraging older people to remain in their environment and independently exert their functions in society. Nursing has engaged in this process, seeking to provide integrated care to the older person and family.
Method.  A case study with multiple participants was carried out. The inclusion criteria were families of older people over 70 years old who attended a Family Health Unit in the interior of the State of Minas Gerais, Brazil. Data were collected between April and June, 2007. In-depth interviews, genograms and ecomaps were used to collect data, which were categorized by thematic content analysis.
Results.  Three families participated in this study, totalling seven participants.
Conclusions.  The older people's families depend on institutional networks for their health maintenance. Spirituality and religion are mixed and are very expressive sources of support.
Relevance to clinical practice.  Assessing social support and networks can favour nursing interventions in order to intensify social interactions, promote leisure and help the families of older people to cope with life changes.     

Keeping carers healthy: the role of community nurses and colleagues

Carers form a substantial proportion of the patients seen by primary care professionals, but their health needs are often overlooked. By recognizing and addressing the needs of the carer as well as the patient, primary care staff (including practice, community and district nurses) can protect the physical and mental health of both. Staff can start by developing simple systems for identifying and recording both patients who are carers, and patient who have carers. Primary health professionals may be able to identify specific opportunities for checking on carers' health, e.g. at general health checks or clinics for older people or those with chronic disease. Community nurses should ensure that they use their home visits to keep an eye on the health of the carer as well as the patient. Much of this input can be integrated into the everyday activities and priorities of the primary care team.     

Support needs of carers of dependent adults from a Bangladeshi community

AIM: This paper reports a study identifying the health and social care needs of informal carers for dependent adult relatives from a Bangladeshi community in South Wales and their views on the acceptability and appropriateness of formal support services provided by statutory, private and voluntary sectors. BACKGROUND: Within the next 20 years in the United Kingdom the proportion of older people from black and ethnic minority communities will dramatically increase and there will be an increased demand for carers. Asian carers, particularly Bangladeshi carers, are one of the most neglected and invisible groups. As carers are fundamental to the success of community care and their importance is increasingly recognized, caregiving within Asian communities needs further exploration. METHODS: A qualitative study with individual focused interviews was conducted with 20 Bangladeshi carers, using a combination of purposive and snowball sampling. Maxwell's dimensions of acceptability and appropriateness of quality of care were applied to aid understanding of the findings. FINDINGS: Families primarily cared for Bangladeshi dependent adults and viewed the experience positively, although they were providing care under challenging circumstances. There was a lack of awareness of the health and social services available to assist carers, and limited involvement of community nursing and social services. A tension was identified in accepting some types of formal support, and ethnocentrism in service provision was evident. CONCLUSION: Institutional barriers to accessing formal support, such as the inability to meet religious and cultural needs, must be addressed if Bangladeshi carers are to be provided with services which are acceptable to them. Primary care providers, including community nurses and health visitors, need to work in partnership with the Bangladeshi community if services are to be acceptable and appropriate for meeting the needs of these hidden carers.     

Unmet expectations: why nursing home staff leave care work

Background.  The shortages of healthcare professionals have been a common topic in care of older people.
Aim and objectives.  The aim of the present study was to illuminate what caused the nursing home caregivers to decide to leave their employment.
Design.  A two-year intervention study was performed in three nursing homes in Sweden.
Method.  This qualitative interview study was conducted with 18 caregivers who decided to leave their employment during the first year. Content analysis was the method used to analyse the interviews.
Result.  The caregivers' decisions to leave their work in care of older people could be encompassed in one main category: 'Unmet Expectations'. Their experiences were lack of encouragement and trust and professional development. Feelings of insecurity, different opinions on the care delivered, being disregarded and betrayed followed as did thoughts of leaving work and pursing other opportunities.
Conclusion.  The main findings indicated that organizational work pressure with information about pending financial cutbacks caused the caregivers to leave the nursing homes.
Relevance to clinical practice.  The study's results show the value of meeting the needs of caregivers, as caregivers consider that they meet the needs of the older people. Optimal use of caregivers' skills, experiences, competence and respect for their aspirations is also likely to result in cost-efficient care.     

Urinary incontinence and use of pads--clinical features and need for help in home care at 11 sites in Europe

Aim:  The aim of this study was to obtain evidenced-based knowledge about older persons in home care; we conducted a population-based study at 11 sites in Europe (2001/2002). This article focuses on urinary incontinence and need for help in home care.
Methods:  A sample of 4010 respondents 65 years or older were assessed by the Resident Assessment Instrument for Home Care. Urinary incontinence was defined as leakage once a week or more including use of catheters.
Results:  A total of 1478 individuals had urinary incontinence, 45% men and 47% women. The use of pads ran from 29% to 52% between the sites. The associates of urinary incontinence were: moderate or severe cognitive impairment, dependency in toileting and other activities of daily living compared with less impaired; urinary infections, obesity and faecal incontinence. Caregivers to persons with urinary incontinence reported burden or stress more often then carers to nonurinary incontinence individuals (OR = 2.2, 95% CI 1.8–2.7).
Conclusions:  To enable older people with incontinence to stay at home with a better quality of life, they need caring assistance during toileting on a regular basis.     

Risk management dilemmas in dementia care: an organizational survey in three UK countries

Aims and objectives.  The overall project aimed to understand the variability of the construction of risk in dementia care from the perspective of the person with dementia, family carers and practitioners with the intention of developing negotiated partnerships in risk management. This paper focuses on the objective of identifying the understandings of risk by practitioners.
Background.  Risk management can result in a 'safety first' approach to care practices, but this may be disempowering for people with dementia.
Design.  This paper describes the results of the first stage of the study: a survey to service managers or equivalent in health, social and voluntary sector care organizations in three countries of the UK.
Methods.  Data from this stage was collection by postal questionnaire ( n  = 46).
Results.  Risk was portrayed as a multidimensional concept and clustered around three themes: (1) Risk and Independence, (2) Risk and Resource, and (3) Organizational Risk Management.
Conclusions.  Very wide understandings of risk are identifiable, ranging from avoidance of physical harm through to managed risk taking to improve quality of life, and to an appreciation of the impact of organizational and professional patterns of behaviour resulting in harm to the person with dementia.
Relevance to clinical practice.  Obtaining information about the perspectives of others may help to illuminate some of the dilemmas experienced by staff in this study, and the development of risk assessment frameworks may assist staff to resolve some of these.     

Managing the optimal workload by the PAONCIL method – a challenge for nursing leadership in care of older people

Aim  The aim of the study was to test the ability of the professional assessment of optimal nursing care intensity level (PAONCIL)-method to establish the optimal nursing intensity (NI) per care giver within the care of older people by testing whether the method's prerequisites for hospital settings can be fulfilled within the care of older people as well.
Background  The PAONCIL method is included in the RAFAELA system as a method for calculating personnel resources based on NI.
Method  The PAONCIL assessments were collected through questionnaires (n = 3512). The data was analysed by simple linear regression analysis.
Results  It can be stated that the prerequisites for the PAONCIL method were fulfilled and that the optimal NI-level could be determined on seven participating units.
Discussion  It can be stated that the RAFAELA system is a useful system for measuring NI within the care of older people, but additional research is needed, especially within the home care setting.
Conclusion  Although an instrument never provides a complete overview of the patient's care needs and need satisfaction, it provides information about the daily situation as well as gives guidelines for long-term strategic planning.