Staff perceptions of residents across the long-term care landscape

AIMS: This paper reports a study to determine how facility-, resident-, family- and staff-level indicators are empirically associated with staff members' perceptions of residents in nursing homes (NHs), assisted living facilities (ASLs) and family care homes (FCHs). BACKGROUND: While various efforts have described the ramifications of staff-resident interactions in nursing homes (NHs), few studies identify the factors that potentially influence staff members' perceptions of residents in multiple long-term care settings. METHODS: The participants were 41 care staff located in five NHs, five ASLs, and 16 FCHs randomly selected in Kentucky, United States of America. Face-to-face and telephone interviews were conducted with care staff, residents in their care, family members of residents, and administrators of participating facilities. Telephone interviews measured staff perceptions of residents on two domains: cohesion (perceived feelings of closeness between staff and residents) and knowledge of residents' personal lives and care needs. RESULTS: Regression models found that staff who were married, reported more positive attitudes towards family members, and worked in smaller facilities reported greater staff-resident cohesion. In addition, staff who cared for a higher percentage of residents with learning difficulties indicated greater knowledge of residents. CONCLUSION: The findings emphasize the need to consider elements of staff-family relationships when considering staff perceptions of residents. They also imply that clinical interventions designed to enhance social relationships in NHs can be extended across the long-term care landscape to influence the staff-resident-family triad positively.     

Does geriatric nursing staff burnout predict well-being of LTC residents?

Nursing staff in residential settings are exposed to a large number of stressors. This study examined the relationship between geriatric nursing staff (GNS) burnout and the well-being of residents in long-term care (LTC) facilities. Data were obtained concerning 590 older residents who were served by 315 GNS in 172 LTC facilities in Taiwan, using multilevel modeling. The depersonalization (DP) dimension of burnout in GNS was consistently related to various resident well-being outcomes. Higher DP among GNS was associated with lower residential satisfaction and perceived quality-of-life, as well as more depressive symptoms among older LTC residents. The findings support the claim that DP among GNS has a greater role in determining LTC resident well-being than other dimensions of burnout. Efforts should be made to mitigate the emergence of DP among GNS. Support and education are also needed to enable GNS to foster positive interactions and relationships with LTC residents.     

Exploring the applicability of interdependence theory to CNA-resident relationships

This study explored the quality of certified nurse assistant (CNA)-resident relationships. Of interest was the extent to which interdependence theory could be used to code CNAs' responses to questions about their relationships with residents and factors that promoted or limited these relationships. Interdependence theory defines closeness in terms of outcome interdependence and provides an account of how trust and commitment can develop. Seventeen socially skilled CNAs from nine long-term care facilities participated in structured personal interviews. All of the CNAs said they had developed close relationships with some residents. CNAs' answers to interview questions indicated they were thinking "relationally" about their interactions with residents. Many CNAs made reference to commitment and pro-relationship behaviors that promoted relationships, and their responses supported the applicability of interdependence theory. Implications for training are that CNAs should be encouraged to think relationally, as well as dispositionally, and that boundary issues need to be explored.     

Family perspectives on dying in long-term care settings

Dying is a central experience in the life of a family. Yet there are few studies of dying in long-term care and the role of a family. The dynamic relationships among families, staff, and residents in long-term care facilities related to the process of dying is an area where research is needed. As part of a larger study of death and dying in long-term care settings, 11 family members who recently had experienced the loss of a relative in the long-term care setting were interviewed. The purpose of this study was to describe family perspectives on death and dying in long-term care facilities and to discuss ways staff may be helpful to families in coping with the loss of a family member. Analyzing death and dying from the family perspective offers health care providers an opportunity to expand the understanding of the phenomenon of death in long-term care facilities and to incorporate care activities that families view as helpful. Major themes emerged from this study, including the caring behaviors of staff, participating in the dying process, and providing spiritual support. The themes and practice implications are discussed in this article.     

The relationship between staffing and quality in long-term care facilities: exploring the views of nurse aides

Research on staffing and quality of care in long-term care facilities confirms that adequate staffing levels are important to ensuring quality but few studies have examined how the two are linked. The research reported in this article used participant observation and indepth interviewing to explore how nurse aides (NAs) understand the link between staffing and quality. The findings show that NAs deem their relationships with residents to be the central determinant of quality of care as well as an important outcome in itself. Adequate staffing is essential to allowing NAs to nurture these relationships.     

Spiritual care at the end of life in long-term care

BACKGROUND: There is growing attention given to the spiritual needs of dying patients and long-term care (LTC) facilities are common settings in which patients receive care as they approach death. OBJECTIVES: To describe the sources of support, the structure and processes of spiritual care in LTC, and examine the relationship between these components and family ratings of overall care. RESEARCH DESIGN: After-death interviews of family members of decedents. SUBJECTS: Family members of 284 decedent residents from a stratified sample of 100 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. MEASURES:: Interview items included sources of spiritual support, processes of spiritual care, and the impression of overall care (4 = very good, 3 = good, 2 = fair, 1 = poor) for decedents. Facility-level data included demographics, counseling by clergy, on-site religious services, hospice services, and hospice unit. RESULTS: Most decedents (87%) received assistance with their spiritual needs and those who received spiritual care were perceived by family members to have had better overall care (3.59 vs. 3.25, P = 0.002). Family ratings of care ratings were higher for those who received spiritual support or care from facility staff when compared with those who did not (3.76 vs. 3.49, P < 0.001) and better care was associated with the facilitation of individual devotional activities (3.87 vs. 3.53, P = 0.001). CONCLUSIONS: Spiritual support and care are associated with better overall care at the end of life for LTC residents, and interventions to improve this type of care may best target interactions between residents and facility staff.     

The Experience to Implement Palliative Care in Long-term Care Facilities: A Grounded Theory Study of Caregivers

PurposeThe purpose of this study was to explore the experiences of caregivers in long-term care facilities as they implement palliative care. Although palliative care has been available in Taiwan for more than 30 years, it is often provided in hospitals, few models in the long-term care facilities.MethodsSemi-structured interviews using grounded theory methodology and purposive sampling. Two small long-term care facilities that had performed well in palliative care were selected from eastern Taiwan. A total of 12 caregivers participated in in-depth semi-structured face-to-face interviews.ResultsFour major stages in the implementation of palliative care were identified: (1) feeling insecure, (2) clarifying challenges, (3) adapting to and overcoming the challenges, and (4) comprehending the meaning of palliative care. The core category of these caregivers as “the guardians at the end of life” reflects the spirit of palliative care.ConclusionThis study demonstrates that successful palliative care implementation would benefit from three conditions. First, the institution requires a manager who is enthusiastic about nursing care and who sincerely promotes a palliative care model. Second, the institution should own caregivers who possess personality traits reflective of enthusiasm for excellence, unusual ambition, and a true sense of mission. Third, early in the implementation phase of the hospice program, the institution must have the consistent support of a high-quality hospice team.     

Female caregivers' experiences of exposure to violence in nursing homes

Although earlier studies have examined caregivers' experiences of exposure to violence, few have investigated female caregivers working in nursing homes with a specific focus on experiences throughout the entire scenario of a violent situation. This study illuminates female caregivers' experiences of being exposed to violence in nursing homes. Twenty caregivers working in three nursing homes located in northern Sweden were asked to narrate about a situation in which they had been exposed to violence. Their narratives were analysed by using qualitative content analysis. We found that the caregivers had preconceived ideas about violent behaviour, that they experienced a loss of control over the situation, and that they then strove to regain control. Experiences such as these may influence caregivers' interactions with residents who display violent behaviour. As a result of violent interactions, caregivers may distance themselves from the residents, an attitude that may decrease the quality of care. There is a risk that violence in nursing homes is accepted and normalized as a part of the job and hence persists.     

A survey of breast cancer detection methods in long-term care facilities

The majority of women residents in long-term care facilities are at high risk for the development of breast cancer. Routine breast cancer detection methods are indicated but not used for women in long-term care facilities on Long Island, New York. There appears to be an age-related bias concerning breast cancer detection of long-term care residents among health-care providers. There is no literature that addresses the need for breast cancer detection among residents in long-term care facilities.     

Communicative barriers and resources in nursing homes from the enrolled nurses’ perspective: A qualitative interview study

Background and objectivesManaging communicative disability is a pervasive issue in long-term care facilities. The aim of this study was to explore how enrolled nurses experience their everyday interactions with residents in nursing homes, particularly focusing on interactions with residents with communicative disability.DesignA qualitative exploratory design including content analysis was used.Participants and settingEight individuals working at six nursing homes in western Sweden were interviewed.MethodThe interviews were semi-structured with questions about the participants’ experiences in communicating with residents, feelings associated with interactions involving residents with communicative disability, meaning ascribed to interactions, and factors influencing interactions. The interviews were analysed using content analysis.ResultsA dynamic interplay between interpersonal relations, daily interactions and the managing of communicative disability was revealed. The enrolled nurses had good knowledge of supportive strategies and an awareness of the importance of the development of personal relationships with residents in order to facilitate interaction. However, factors in the environment presented barriers to communication.Conclusions/implicationsThe organisation and physical environment of nursing homes prevent the enrolled nurses from taking full advantage of the communicative resources they have in interaction with residents with communicative disability, hence affecting staff–resident relationships and the delivery of person-centred care.     

Management of patients with Alzheimer's disease in long-term care facilities

The care of residents with AD in long-term care facilities presents a number of challenges to nursing staff. The institutionalized person with AD displays a number of behaviors that are difficult to manage on traditional, integrated nursing units. In these units, behaviors such as wandering and falling are often managed by chemical and physical restraints. Multiple, complex stimuli, common on integrated units, contribute to the confusion and disorientation experienced by residents with AD. An alternative setting, the special-care unit designed specifically to meet the needs of residents with AD, has been described. Special-care units modify the environment of the traditional nursing unit to promote the safety of demented residents. The units are an attempt to reduce or control the amount of sensory stimulation in order to prevent catastrophic behaviors in the residents and maximize patient functioning. Staff on special-care units are selected specifically for their commitment to the unique care demands required by residents with AD. Ordinarily, staff in long-term care settings need specialized education to provide this care. A research project designed to evaluate the effectiveness of a special-care unit was also described. This research is valuable to residents with AD, their families, managers, and policy makers of long-term care institutions concerned with the effective use of resources. Considerable costs are involved in the construction and staffing of special-care units. However, the potential costs and threats to quality of care associated with care of residents with AD on traditional units make it imperative to evaluate the effectiveness of special-care units. With the increasing number of persons expected to develop AD, nurses, managers of long-term care facilities, and policy makers are faced with the difficult prospect of determining the most effective means of caring for these residents. Because there have been no definitive, comprehensive studies of special care units, there is an absence of empiric support for the many proposed advantages. Few studies have used systematic measurement techniques or measures with established reliability and validity. Given the growing number of elderly persons in the United States and the expected growth in the number of nursing home residents with AD, it is important to establish the value of special treatment units for residents with AD.     

As individual as death itself: a focus group study of terminal care in nursing homes

One in four Americans who reach the age of 65 will die in a nursing home, yet little research exists to define the end of life care needs of this population. We used focus groups with experienced nursing home staff and physicians to: (1) define a good death in a nursing home and (2) describe factors that promote or prevent good care for the dying in this setting. We audiotaped 11 focus groups with 77 participants. Discussions were structured around 3 questions: "How does someone die in the nursing home?" "What makes the difference between a good death and a bad death?," and "What can aides, nurses, or physicians do to help ensure that when someone dies it is a good death?" Participants described lack of training, regulatory emphasis on rehabilitation, and a resource-poor setting as important barriers to high quality care of the dying in nursing homes. They affirmed the value of their experience and personal relationships with residents as the basis for good care. Three major themes emerged to define a good death in a nursing home: highly individualized care based on continuity relationships with caregivers, effective teamwork by staff, physicians and family, and comprehensive advance care planning that addresses prognosis, emotional preparation, and appropriate use of medical treatments. The significance of these themes may be tested in the design of interventions to improve care of the dying in long-term care.     

Differences in plans for living at home between temporary residents of a health-care facility for the elderly and their family caregivers in Japan

Aim: Older residents in Japan requiring rehabilitation often reside in health‐care facilities for the elderly (HCFE) prior to being discharged to home. The return home can be very stressful for both the elder and family caregiver. The purpose of this study was to clarify the differences in plans for home life between the residents of a HCFE who were scheduled for discharge home and their family caregivers. Method: Semistructured interviews were conducted with eight pairs of elders and caregivers. Results: Differences were seen in several areas, including dietary preferences, recognition of the elder’s independence, preconceptions or not knowing about the elder’s pleasurable activities, and the way of care. Conclusions: Differences with regard to enjoyable activities for the elderly arose from a lack of understanding of the lives of the elderly on the part of their families.     

A comparison of wandering behavior in nursing homes and assisted living facilities

Wandering, a challenging behavior associated with dementia, affects many residents of long-term care facilities and can result in elopement, injury, and death. Most studies of wandering have taken place in nursing homes (NH). Expansion of the long-term care sector over the last 2 decades has resulted in a surge in options such as assisted living facilities (ALF). This study compared wandering behavior of residents (N = 108) in 21 long-term care facilities (15 NH, 6 ALF). Staff used the Revised Algase Wandering Scale-Nursing Home Version (RAWS-NH) to quantify wandering. While there were some differences in demographic variables (i.e., race, motor ability) between NH and ALF participants, no significant differences were found in either RAWS-NH overall or any of the 6 subscale scores. This suggests that the expression of wandering is similar in long-term care residents across all dimensions of the RAWS-NH regardless of facility type. Findings are of concern for those involved in the safe management and protection of residents at risk for wandering, particularly in long-term care facilities with underregulated staffing and training requirements.     

Geriatric mental health education in Canada SKIPs into the 21st century

The Skills Immersion Program (SKIP) provides an educational opportunity for staff nurses who face the challenge of caring for residents who present with psychiatric and behavioral problems in long-term care (LTC) facilities within British Columbia, Canada. With the aging population and an increase in the number of individuals waiting for placement in care facilities, care providers are in substantial need of advanced education and training in the field of geriatric psychiatry nursing. Nurses working in LTC facilities in Canada are not prepared to manage the changing acuity levels and complex needs of their residents. The SKIP was developed by nurses, primarily for nurses, at St. Vincent's Hospital in Vancouver, British Columbia, Canada. Nurses who participate in the SKIP acquire an enhanced knowledge base in geriatric psychiatry nursing and gain access to assessment tools that will assist staff to increase the quality of care for their residents.     

Education to promote verbal communication by caregivers in geriatric care facilities

Aim: Our previous study divided the verbal communication between caregivers and elderly residents at geriatric care facilities into Type I communication (to elicit activities of daily living) and Type II communication (conversation that occurs in normal social life) and found that Type II communication promotes utterances by elderly residents. This study conducted an education intervention to promote Type II talking by caregivers and evaluated the results. Methods: At three geriatric care facilities, 243 caregivers who might care for 36 elderly residents experienced training involving lectures and group discussion to understand the importance of Type II talking and how to apply it to their daily work. A statistical comparison was applied to the changes in Type II talking duration from before the intervention, 1 week after the intervention, and 3 months after the intervention to evaluate the effect of the educational intervention. Results: At two facilities, the Type II talking duration increased significantly from before the educational intervention to 1 week after the intervention and remained higher after 3 months. However, the educational intervention's effect was not clear at one facility. There was no significant difference in the elderly persons' total utterance duration, but it increased from before the intervention to 1 week after the intervention. Conclusion: After the educational intervention, the amount of Type II talking by the caregivers increased significantly 1 week after the intervention for two facilities, but although the amount of Type II talking was higher at 3 months than before the intervention, it was not as high as 1 week after the intervention.