The impact of an educational intervention for elderly care nurses on care recipients' and family relatives' ratings of quality of care: a prospective, controlled intervention study

BACKGROUND: Low competence levels among nursing staff have been associated with lower quality of elderly care. However, interventions aimed at improving nursing staff competence have not always been evaluated for their possible impact on the quality of elderly care. An educational intervention in the form of a workplace "toolbox" was shown to have positive effects on nursing staff competence and work satisfaction. It was therefore of interest to investigate whether the intervention had any effect on residents' and/or their family members' ratings of the quality of elderly care. OBJECTIVES: The aim of this study was to evaluate the possible effects of an educational intervention for nursing staff on care recipients' and their relatives' ratings of the quality of elderly care. DESIGN: The study was a prospective, non-randomized, controlled intervention. PARTICIPANTS AND SETTINGS: Care recipients and their relatives in two elderly care organisations in Sweden. METHODS: Practical instruments and educational materials for improving staff competence and work practices were collated in a workplace "toolbox", which was introduced in the intervention organisation in February of 2003. Care recipients and their relatives' ratings of the quality of care were measured pre and post-intervention by questionnaire and compared to quality ratings in a reference organisation, where no toolbox was introduced. RESULTS: Neither care recipients' nor relatives' ratings of the quality of care changed significantly over time in the intervention organisation. Furthermore, there were no significant interaction effects over time between organisations for quality of care ratings. Methodological weaknesses, such as low response rates, may have influenced results. CONCLUSIONS: The results of this study raise questions regarding the alleged positive association between staff competence and work satisfaction and care recipients' perceptions of the quality of care.     

The impact of an educational intervention on nursing staff ratings of quality of older people care: a prospective, controlled intervention study

Background

Low competence levels among nursing staff have been associated with lower quality of older people care. However, interventions to improve staff competence have not always been evaluated for their impact on the quality of older people care. An educational intervention in the form of a workplace “toolbox” was shown to have positive effects on nursing staff competence and work satisfaction, but had no effects on care recipients’ or their family members’ ratings of quality of care. It was therefore of interest to investigate whether the intervention had any effect on nursing staff ratings of quality of care.

Objectives

The aim of the study was to evaluate the possible effects of an educational “toolbox” intervention on nursing staff ratings of quality of care.

Design

A prospective, non-randomized, controlled intervention.

Participants and settings

Nursing staff in two municipal older people care organizations in Sweden.

Methods

Practical instruments and educational materials for improving staff competence and work practices were collated in a workplace “toolbox” and introduced in the intervention organization in February of 2003. Nursing staff ratings of quality of care were measured pre- and post-intervention by questionnaire and compared to nurses’ quality ratings in a reference organization, where no toolbox was introduced.

Results

Nursing staff ratings of quality of care improved significantly over time in the intervention organization. No improvements were found in the reference organization.

Conclusions

Compared to a reference municipality, nursing staff ratings of quality of care improved in the organization where the toolbox was introduced. Competence development measures may have a positive impact on nursing staff's ratings of quality, but not on the quality ratings of care recipients and their family members. Further research is needed to understand the differences in these stakeholders’ perceptions.     

Staff-family relationships in nursing home care: a typology of challenging behaviours

Aim.  This paper draws on data from a study which investigated how Australian nursing home staff constructed staff–family relationships.
Background.  Working with the family in aged care to provide the best care possible is consistent with modern nursing philosophy which espouses holistic care. The quality and enjoyment of the experience however, is frequently fraught with problems and challenges for both the staff and the family involved.
Design.  A qualitative constructivist design as described by Guba and Lincoln [ Fourth Generation Evaluation . Sage Publications, London.] was used.
Method.  Thirty paid caregivers drawn from eight nursing homes were interviewed about their experiences of working with residents' families. A constant comparative method of data analysis was used to arrive at the findings.
Results.  This paper reports on seven themes under the category of 'unacceptable behaviours'. These themes describe a range of attitudes and behaviours exhibited by families which staff members found undesirable.
Conclusions.  Staff members found a number of family behaviours challenging. Nursing home staff perceives the family as subordinate to their needs and want to retain control of the work environment.
Relevance to clinical practice.  Nursing home staff need to move away from custodial models of care focused on 'getting the work done' and develop more family friendly work practices that are inclusive of the needs of the family and view them as equal partners in care.     

Nursing Diagnoses of Burned Patients and Relatives' Perceptions of Patients' Needs

PURPOSE.  The aims of this study were to identify the nursing diagnoses of burn patients in the period 1 week before hospital discharge and to determine whether their relatives had similar perceptions of the patients' problems.
METHODS.  A qualitative case study was conducted with 10 burn patients and 10 family members. One week before hospital discharge, the nursing diagnoses of the patients and the relatives' perceptions of the patients' were identified and compared.
FINDINGS.  Thirty different diagnoses related to physical and psychosocial aspects were identified. The family members reported concerns mainly related to physical care, specifically wound care and prevention of infection, and psychosocial aspects, while patients were primarily concerned with the latter.
CONCLUSIONS.  Nursing diagnoses for these patients and their relatives' perceptions frequently overlapped; however, the emphasis of the families' attention was on the physical aspects.
IMPLICATIONS FOR NURSING PRACTICE.  Anticipating family members' perceptions about the patients' problems is important in order to promote strategies that will improve patient care after hospital discharge.     

Nursing staff competence, work strain, stress and satisfaction in elderly care: a comparison of home-based care and nursing homes

Abstract Aims. The aims of this study were to: (1) compare older people care nursing staff's perceptions of their competence, work strain and work satisfaction in nursing homes and home‐based care; and (2) to examine determinants of work satisfaction in both care settings. Background. The shift in older people care from hospitals to community‐based facilities and home care has had implications for nursing practice. Lack of competence development, high levels of work strain and low levels of work satisfaction among nursing staff in both care settings have been associated with high turnover. Few studies have compared staff perceptions of their competence and work in nursing homes as opposed to home‐based care. Design. A cross‐sectional questionnaire survey. Methods. Nursing staff perceptions of their competence, work strain, stress and satisfaction were measured by questionnaire in 2003 in two older people care organizations in Sweden. Comparisons of all outcome variables were made between care settings both within and between the two organizations. Multiple regression analysis was used to determine predictors of work satisfaction in home care and nursing homes respectively. Results. In general, staff in home‐based care reported significantly less sufficient knowledge compared with staff in nursing homes. However, home care staff experienced significantly less physical and emotional strain compared with staff in nursing homes. Ratings of work‐related exhaustion, mental energy and overall work satisfaction did not differ significantly between care settings. In both care settings, work‐related exhaustion was the strongest (inverse) predictor of work satisfaction. Conclusions. Future interventions should focus on counteracting work‐related exhaustion and improving competence development to improve work satisfaction among older people care nursing staff in both care settings. Relevance to clinical practice. Work‐related exhaustion and lack of competence development may have significant negative implications for work satisfaction among older people care nursing staff in both home care and nursing homes.     

A communication intervention for nursing staff in chronic care

Title.  A communication intervention for nursing staff in chronic care.
Aim.  The paper is a report of a study conducted to evaluate the effect of a brief, focused educational intervention on the quality of verbal interactions between nursing staff and patients in a chronic care facility.
Background.  Positive nurse–patient communication in chronic care is crucial to the quality of life and well-being of patients. Despite this, patients are dissatisfied with these interactions and nursing staff indicate the need for additional training.
Method.  A repeated-measures design was used to collect data between April 2003 and February 2004, by audiotaping verbal interactions between nursing staff and patients during morning care. Baseline data were analysed and an educational intervention was developed based on the results of the pretest. Five months after the educational intervention, interactions between the same nursing staff and patients were audiotaped. Twenty-seven randomly chosen patients and selected nursing staff participated in the study. Data were analysed using a qualitative comparative method, and a quantification technique was developed to compare the quality of the interactions before and after the intervention.
Findings.  Preintervention interactions were task-oriented, superficial and dominated by nursing staff. Results statistically significantly improved after the intervention was implemented. Nursing staff were less authoritative, used more solution-focused communication and interactions had a statistically significantly higher positive ratio.
Conclusion.  Brief interventions can change nursing staff's communication practice and they realized the importance of effective communication as a fundamental component to deliver patient-focused care.     

Evaluation of an educational "toolbox" for improving nursing staff competence and psychosocial work environment in elderly care: results of a prospective, non-randomized controlled intervention

BACKGROUND: Lack of professional development opportunities among nursing staff is a major concern in elderly care and has been associated with work dissatisfaction and staff turnover. There is a lack of prospective, controlled studies evaluating the effects of educational interventions on nursing competence and work satisfaction. OBJECTIVES: The aim of this study was to evaluate the possible effects of an educational "toolbox" intervention on nursing staff ratings of their competence, psychosocial work environment and overall work satisfaction. DESIGN: The study was a prospective, non-randomized, controlled intervention. PARTICIPANTS AND SETTINGS: Nursing staff in two municipal elderly care organizations in western Sweden. METHODS: In an initial questionnaire survey, nursing staff in the intervention municipality described several areas in which they felt a need for competence development. Measurement instruments and educational materials for improving staff knowledge and work practices were then collated by researchers and managers in a "toolbox." Nursing staff ratings of their competence and work were measured pre and post-intervention by questionnaire. Staff ratings in the intervention municipality were compared to staff ratings in the reference municipality, where no toolbox was introduced. RESULTS: Nursing staff ratings of their competence and psychosocial work environment, including overall work satisfaction, improved significantly over time in the intervention municipality, compared to the reference group. Both competence and work environment ratings were largely unchanged among reference municipality staff. Multivariate analysis revealed a significant interaction effect between municipalities over time for nursing staff ratings of participation, leadership, performance feedback and skills' development. Staff ratings for these four scales improved significantly in the intervention municipality as compared to the reference municipality. CONCLUSIONS: Compared to a reference municipality, nursing staff ratings of their competence and the psychosocial work environment improved in the municipality where the toolbox was introduced.     

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.     

Staffing adequacy, supervisory support and quality of care in long-term care settings: staff perceptions

Title. Staffing adequacy, supervisory support and quality of care in long‐term care settings: staff perceptions Aim. This paper is a report of a study to explore relationships between perceived care quality, self‐assessed professional skills, and the perceptions of the quality‐related factors. Background. The work in long‐term care is more demanding than in the past. The quality of care is strongly related to the well‐being and job satisfaction of staff. Those emerge in part through a perception of resources allocated to caring and also through a perception of the quality achieved. Method. Data were collected in Finland in 2002 using a questionnaire sent to the nursing staff working in 112 wards in 40 long‐term care institutions monitoring their care with the Resident Assessment Instrument System. Institutions were invited to participate the survey. The response rate was 70·2% (n = 1262). The respondents represented 3·8% of nursing personnel working in long‐term care institutions. Findings. Staff members who perceived staffing levels as inadequate and supervisory support as insufficient had lower perceptions of their own professional skills and the quality of care. Perceptions of empowering support behaviour were more strongly associated to self‐assessed skills and to perceived care quality than perceptions of skills‐oriented support activities. Staff members with short professional training, older staff members and staff members with long work experience in the unit had lower perceptions of their professional skills than other groups. Conclusion. The perception of adequate staffing and of sufficient supervisory support, especially empowering support increases the probability of perceiving the care quality as good. If supervisors concern themselves with staff members’ perceptions, they can better identify the staffing needs and also the support needs of personnel.     

Staff attitudes towards older patients with cognitive impairment: need for improvements in acute care

nilsson a., lindkvist m., rasmussen b.h. & edvardsson d. (2012) Journal of Nursing Management  20, 640–647 Staff attitudes towards older patients with cognitive impairment: need for improvements in acute care Aim To explore the attitudes held by staff working in acute care units towards patients aged 70 years or older with cognitive impairment, and to explore factors associated with negative attitudes. Background Hospital staff attitudes towards older patients with cognitive impairment are of concern as older people are the main hospital users, and because staff attitudes influence care quality and uptake of evidence-based care. Method A cross-sectional survey design was used to collect data from staff (n = 391). Results Staff attitudes were not explicitly negative. However, higher perceived strain in caring for older patients with cognitive impairment, higher perceived prevalence of these patients in the ward, being younger and working as an assistant nurse were associated with negative attitudes. A majority of staff reported that these patients received the best possible care, but few reported formally assessing cognitive status or working with evidence-based care protocols. Conclusion Staff characteristics associated with negative attitudes were described and staff perception that patients received best hospital care, despite limited cognitive assessments and care guidelines, indicate areas for improvement. Implications for nursing management Supporting young staff and assistant nurses, and implementing cognitive assessments and evidence-based guidelines can promote positive attitudes and best practice.     

Using gaming workshops to prepare nursing students for caring for older people in clinical practice

mclafferty e., dingwall l. & halkett a. (2009)   Using gaming workshops to prepare nursing students for caring for older people in clinical practice. International Journal of Older People Nursing   5 , 51–60
doi: 10.1111/j.1748-3743.2009.00176.x
Background.  Older people are the least satisfied with the care they receive when they are acutely ill. Furthermore, within nurse education, nursing older people has been submerged rather than embedded in the acute focus of nursing curricula. Lecturers designed a 1-day gaming workshop to stimulate interest in nursing older people.
Aim.  To explore the influence of gaming workshops on undergraduate nursing students' learning about nursing older people.
Methods.  Both quantitative and qualitative methods were used. A survey questionnaire was distributed pre- and postgaming workshops to a cohort of second year nursing students ( n  = 100, 86% response rate). Students ( n  = 9) were invited to participate in a semi-structured interview on completion of their placement.
Findings.  Responses were significantly more positive for the questionnaire postworkshop when compared with the responses of preworkshop. Five themes were identified from the interviews, they included teacher interaction; level of student engagement with the topic; the effect of the teaching method; influence of the workshops on practice; working with older people.
Implications for practice.  Nursing students preferred this novel teaching method to lectures. They learned about appropriate and relevant care of older people, however, they seem to struggle to apply concepts related to caring for older people in the acute settings.     

Moving forward together: evaluation of an action group involving staff and relatives within a nursing home for older people with dementia

Background.  This paper describes the implementation and evaluation of an action group within a nursing home for older people with dementia. Over a two-year period, researchers worked with staff, residents and relatives on a series of initiatives aimed at improving experiences of living and working within the home. The action group, involving staff, residents and their relatives was the vehicle through which a number of important changes were achieved. The project was underpinned by ideas about relationship-centred care and the Senses Framework.
Methods.  A constructivist methodology informed both the initial development and the evaluation of the project. This paper reports findings from interviews with staff and relatives and process recordings of group discussions.
Findings.  Data from the evaluation provide evidence of ways in which the project has contributed to creating the senses (security, significance, belonging, purpose, continuity and achievement) for each of the key stakeholder groups. Factors supporting and hindering the project were also identified.
Conclusions.  The development approach using the Senses Framework adopted within the project is a useful model for partnership working in settings providing continuing care for older people.
Relevance to clinical practice.  Findings from this small-scale but intensive project suggest that staff within care homes should seek to engage with a range of stakeholders in order to improve experiences for all involved in long-term care. Academic staff within schools of nursing should consider innovative, action-oriented approaches to supporting developments within care homes.     

Impact of community care in enabling older people with complex needs to remain at home

Aim.  This aim of the study was to explore the impact of community care in enabling older people with complex needs to remain at home.
Background.  Changing demographic trends and successive government policies have led to an increase in the number of older people with complex needs residing in the community.
Design.  A qualitative approach using semi-structured interviews was used to collect data from older people ( n  = 17) and carers ( n  = 14).
Method.  Social workers were asked to identify community dwelling older people (65+ years) with multiple needs requiring interventions from a range of health and social care practitioners.
Results.  Community care enabled older people with complex needs who would otherwise have required residential or nursing home care to remain in their own homes. This was the expressed wish of both the older people and carers interviewed.
Conclusions.  The provision of high-quality community care for older people is a globally significant challenge and one that requires creative solutions, both at a local and strategic level.
Relevance to clinical practice.  Nurses and other health and social care professionals need to understand the significance of 'home' for older people and take steps to ensure that additional and appropriate resources are targeted towards community care.     

Missed nursing care: a concept analysis

Title.  Missed nursing care: a concept analysis.
Aim.  This paper is a report of the analysis of the concept of missed nursing care.
Background.  According to patient safety literature, missed nursing care is an error of omission. This concept has been conspicuously absent in quality and patient safety literature, with individual aspects of nursing care left undone given only occasional mention.
Method.  An 8-step method of concept analysis – select concept, determine purpose, identify uses, define attributes, identify model case, describe related and contrary cases, identify antecedents and consequences and define empirical referents – was used to examine the concept of missed nursing care. The sources for the analysis were identified by systematic searches of the World Wide Web, MEDLINE, CINAHL and reference lists of related journal articles with a timeline of 1970 to April 2008.
Findings.  Missed nursing care, conceptualized within the Missed Nursing Care Model, is defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed. Various attribute categories reported by nurses in acute care settings contribute to missed nursing care: (1) antecedents that catalyse the need for a decision about priorities; (2) elements of the nursing process and (3) internal perceptions and values of the nurse. Multiple elements in the nursing environment and internal to nurses influence whether needed nursing care is provided.
Conclusion.  Missed care as conceptualized within the Missed Care Model is a universal phenomenon. The concept is expected to occur across all cultures and countries, thus being international in scope.     

Elderly peoples' experience of nursing care after a stroke: from a gender perspective

Title.  Elderly peoples' experience of nursing care after a stroke: from a gender perspective.
Aim.  This paper is a report of a study conducted to explore, from a gender perspective, older people's experiences of nursing care after a stroke.
Background.  Little attention has been given to gender differences in nursing care. The majority of people who have a stroke are older. Improving knowledge of the gender perspectives of older men and women regarding nursing care after stroke is crucial.
Method.  This was a qualitative study based on interviews with five women and five men between 66 and 75 years of age, who had received nursing care at a ward for stroke rehabilitation. The data were collected in 2006. Qualitative content analysis of the interviews was carried out.
Findings.  A main theme and five categories, all common to both men and women, were identified. The main theme, to promote recovery of the body, encompassed the categories. There were, however, gender differences in how the nursing care received was experienced. The ways patients experienced nursing care seemed to be linked with their lives as women and men before they had the stroke. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ.
Conclusion.  Nurses need to increase their awareness and knowledge concerning the similarities and gender differences in the experiences and needs of older people, both men and women.     

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.