Changing to primary nursing in a nursing home in Finland: experiences of residents, their family members and nurses

AIM: The aim of the study was to find out how nursing home residents, their families and nurses experienced the change to primary nursing in the nursing home. BACKGROUND: This study was carried out in a nursing home in Finland. Following years of functional nursing, the change to primary nursing had started 18 months prior to data collection. The transition was preceded by staff training, planning for the change to primary nursing and discussions with staff members. Meetings were also arranged with family members to inform them of what was happening and why. Staff implemented the changeover independently with the support of the institution's management. METHODS: The data were gathered in focused interviews. There were five interview themes: change in the nursing home, the position of the resident in the nursing home, the relationship between the resident and nurse, the relationship between family member and nurse, and the role of the nurse as provider of nursing care. FINDINGS: Residents reported no major changes in nursing care or in their relationship with nurses. However, family members had noticed changes in the behaviour of the nursing staff. Staff members had become friendlier, spent more time with the residents and showed a strong job motivation. Cooperation between nurses and family members had changed very little. Some nurses in the early stages of the change tended to show signs of resistance. Others said that there had been many changes during the past year, that they acted more independently and could use their own decision-making authority more freely than before. They treated residents as individuals and gave them a greater say in decision-making. They felt responsible for the development of the workplace as a collectivity. CONCLUSIONS: Primary nursing is one way in which nurses and family members can work more closely in the best interests of older residents. The findings of this study speak in favour of making the change from functional to primary nursing and at the same time highlight certain problems and possibilities in this process.     

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions.

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values.     

Nursing intervention for grooming of elders with mild cognitive impairments in Korea

This study explores the effect of behavioral nursing intervention strategies to improve the grooming performance of elders with cognitive impairments in Korea. Eight residents with mild cognitive impairments were chosen in a special dementia care facility. A total of 21 sessions, including baseline, interventions, and postinterventions for each resident, were collected in the morning by using videotaped recordings of face-washing, toothbrushing, and hair-combing. The baselines of these activities and postinterventions were provided by nurse assistants, and the interventions were implemented by a trained nurse. The effect of Performance of Grooming Tasks (PGT) was determined. The results showed a decrease in assistance of PGT scores from 0.86, 0.77, and 0.73 at baseline to 0.60, 0.45, and 0.57 during intervention and an increase to 0.77, 0.71, and 0.71 at postintervention. The study showed a significant increase in grooming independence of elders with dementia in the nursing home when they were cared for with behavioral nursing intervention strategies.     

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse’s role in transfer decisions

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution’s mission and the nursing service’s values. (Geriatr Nurs 2001;22:313-7)     

Effects of behavioral interventions on disruptive behavior and affect in demented nursing home residents

BACKGROUND: Disruptive behaviors are prevalent in nursing home residents with dementia and often have negative consequences for the resident, caregiver, and others in the environment. Behavioral interventions might ameliorate them and have a positive effect on residents' mood (affect). OBJECTIVES: This study tested two interventions-an activities of daily living and a psychosocial activity intervention-and a combination of the two to determine their efficacy in reducing disruptive behaviors and improving affect in nursing home residents with dementia. METHODS: The study had three treatment groups (activities of daily living, psychosocial activity, and a combination) and two control groups (placebo and no intervention). Nursing assistants hired specifically for this study enacted the interventions under the direction of a master's prepared gerontological clinical nurse specialist. Nursing assistants employed at the nursing homes recorded the occurrence of disruptive behaviors. Raters analyzed videotapes filmed during the study to determine the interventions' influence on affect. RESULTS: Findings indicated significantly more positive affect but not reduced disruptive behaviors in treatment groups compared to control groups. CONCLUSIONS: The treatments did not specifically address the factors that may have been triggering disruptive behaviors. Interventions much more precisely designed than those employed in this study require development to quell disruptive behaviors. Nontargeted interventions might increase positive affect. Treatments that produce even a brief improvement in affect indicate improved quality of mental health as mandated by federal law.     

The clinical efficacy of reflexology in nursing home residents with dementia

OBJECTIVE: This experimental, repeated-measures, crossover design study with nursing home residents examined the efficacy of reflexology in individuals with mild-to-moderate stage dementia. Specifically, the study tested whether a weekly reflexology intervention contributed to the resident outcomes of reduced physiologic distress, reduced pain, and improved affect. SETTING: The study was conducted at a large nursing home in suburban Philadelphia. SAMPLE: The sample included 21 nursing home residents with mild-to-moderate stage dementia randomly assigned to two groups. INTERVENTIONS: The first group received 4 weeks of weekly reflexology treatments followed by 4 weeks of a control condition of friendly visits. The second group received 4 weeks of friendly visits followed by 4 weeks of weekly reflexology. OUTCOME MEASURES: The primary efficacy endpoint was reduction of physiologic distress as measured by salivary alpha-amylase. The secondary outcomes were observed pain (Checklist of Nonverbal Pain Indicators) and observed affect (Apparent Affect Rating Scale). RESULTS: The findings demonstrate that when receiving the reflexology treatment condition, as compared to the control condition, the residents demonstrated significant reduction in observed pain and salivary alpha-amylase. No adverse events were recorded during the study period. CONCLUSIONS: This study provides preliminary support for the efficacy of reflexology as a treatment of stress in nursing home residents with mild-to-moderate stage dementia.     

Evaluation of nursing manpower allocation in a nursing home

The subjects of this study encompassed the nursing staffs (nurses and nursing aids) and residents of a public hospital-based nursing home. By intensive sampling, this study explored the differences in actual times that nurses spent caring for residents. We assessed the functional status of nursing home residents of various illness severities as well as measured the actual nursing manpower needed to meet the residents' care needs using Typology of the Aged with Illustration (TAI). Results showed that current nursing manpower levels in nursing homes was adequate, although some units had excessive manpower allocation. As a result, this study suggests the establishment of a resident classification system for use in long-term care (LTC) facilities to assist with manpower allocation and reasonable utilization of resources within the facility. Adequate nurse staffing will enhance the quality and accessibility of care for the residents with severe illnesses in LTC facilities.     

Are nursing homes adequately staffed? The silent epidemic of malnutrition and dehydration in nursing home residents. Until mandatory staffing standards are created and enforced, residents are at risk

Providing care to produce positive resident outcomes is an ethical duty of nursing home staff. Research has shown that inadequate staffing levels present an increased health risk to nursing home residents. Nursing home residents may experience dehydration and malnutrition caused by inadequate staffing. Continued research in the area of nutrition and dehydration in nursing home residents may positively influence changes in staffing levels at nursing homes. Currently, residents living in understaffed nursing homes and not receiving proper care are the victims. It is time for nurses to forcefully lobby for national mandatory nurse staffing standards.     

The influence of understanding diagnostics on perceived stress of nurses caring for nursing home residents with dementia

Health services for nursing home residents with dementia require the expertise of highly trained nursing staff. In addition, dealing with challenging behaviour of people with dementia is often stressful for nurses and causes major difficulties for them. Being a part of the general nursing guidelines, ?understanding diagnostics? enables nursing staff to deal with challenging behaviour of persons with dementia. The primary focus of the concept is to understand the behaviour. The aim of the study was to implement and evaluate ?understanding diagnostics? through structured case conferences and the application of the 'Innovative dementia-oriented Assessment system' (IdA) in nursing homes for the first time. Nursing staff of 15 nursing homes in North- Rhine Westphalia were trained about the content and implementation of ?understanding diagnostics?. Nurses' perceived level of stress was measured before (n = 106) and after (n = 71) the intervention (9 months). The study results show positive effects on the nurses' perceived level of stress. They support the use of structured case conferences and the IdA assessment in order to understand the behaviour of nursing residents with dementia. The implementation of ?understanding diagnostics? allows nursing staff to deal with challenging behaviour of nursing home residents with dementia.     

The experiences of the registered nurse caring for the person dying of cancer in a nursing home

This paper reports on research that set out to identify and describe the experiences of the registered nurse caring for the resident dying of cancer in a nursing home. The research method used was a qualitative single case study involving five registered nurses in one nursing home. Thematic analysis of data from unstructured interviews and reflective journals was used to explicate the nurses' experiences. Four major themes were extracted from the data. These themes were the exclusivity of the relationships, difficulties in the management of pain, the expectations of the registered nurse and the impact of caring. The nurses' experiences were loving, fascinating, compelling and rich. The overarching experience of the nurses came from the relationship they formed with the residents. A crucial finding in this study was that these registered nurses valued the elderly resident and developed meaningful relationships with them. All aspects of the relationships were unique and profound. However, the emotional involvement with the resident, multiple death losses, confrontation of personal losses, limited workplace support such as counselling, potentially places these registered nurses at emotional risk from burnout and complicated bereavement. The implications of these findings for nursing practice, education and research are discussed.     

Audio presence intervention for decreasing agitation in people with dementia

Researchers have demonstrated the utility of various nonpharmacologic interventions in decreasing or preventing agitation in elderly nursing home residents with dementia. Auditory intervention strategies are one behavioral approach. We tested a modified version of simulated presence therapy called audio presence intervention (API). In 28 episodes of agitation among seven residents, API produced a significant decline in agitation level as measured by four items from the Haycox Rating Scale. However, in six episodes (four residents), agitation stayed the same or worsened. The results of this study pose more questions than answers and should stimulate nurse researchers to further investigate auditory intervention for control of agitation elders with dementia.     

Effects of an environmental manipulation emphasizing client-centred care on agitation and sleep in dementia sufferers in a nursing home

This study was designed to determine whether a change from a task-oriented care approach to a client-oriented care approach affects (a) the level of agitation and (b) 24-hour sleep in residents suffering from dementia in a nursing home The levels of dementia and sleep of 33 nursing home residents were measured four times over 12 weeks (twice before and twice after the change in care approach) using the Cohen-Mansfield agitation inventory and the dementia mood assessment scale Verbal agitation levels significantly decreased 6 to 8 weeks following the change, whereas more infrequent agitated behaviours, which were classified as 'other', significantly increased Daytime sleep increased initially after the change but then returned to baseline levels after 6 weeks While the main focus of the study was on residents 'behaviour following an environmental manipulation, anecdotal observations of staff members interactions with residents indicated that they felt less rushed and were more tolerant of residents' behaviour following the intervention     

Medical decision-making in the nursing home: a comparison of physician and nurse perspectives

The purpose of this study is to clarify the perspectives of physicians and nurses in the medical decision-making process at the time of status change events in nursing home residents. The decision-making processes studied involved 28 cognitively impaired nursing home residents in a large suburban nursing home. In interviews, the authors ascertained the personal opinions of physicians and the nurses related to the status change event and the decision-making process using the Medical Decision-Making During a Status Change Event Questionnaire. Nurses reported a greater degree of familiarity with the family's and resident's wishes than did physicians. Physicians reported considering more treatment options and choosing more treatments for residents than nurses. Both physicians and nurses reported that the physicians had a major role in decision-making and that nurses did not, yet the gap in reported roles was greater based on physicians' reports in comparison to nurse reports. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed. These findings reflect a division of roles and perspectives of nurses versus physicians in the medical decision-making process. This study demonstrates the ability of the questionnaire to reveal several key differences in perceptions of care. This information could be useful in developing forums for communication among the professionals to enhance mutual understanding.     

Family satisfaction with care provided by nurse practitioners to nursing home residents with dementia at the end of life

The purpose of this study was to examine family satisfaction with care provided by nurse practitioners (NP) to nursing home (NH) residents with dementia. A survey was mailed to 239 family members of nursing home residents who died with dementia. One open-ended question was added to provide comment about the care provided by the NP. A total of 131 surveys were returned (response rate 55%). The study revealed that 98% of family members agreed that they were satisfied with the end-of-life care provided by the NP. Survey responses were used to analyze the associations of communication, comfort, and satisfaction with NPs to total satisfaction with end-of-life care. Pearson's correlations demonstrated that overall satisfaction was significantly associated with NP-family communication, resident comfort, and satisfaction with NP care. Findings suggested that NPs using a model of care that emphasizes advance care planning, communication, and comfort results in high satisfaction of family members.     

Delirium in the hospitalized elder and recommendations for practice

Delirium is a mental disorder of acute onset and fluctuating course, characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior. It occurs in up to 50% of elderly hospital inpatients, many with preexisting dementia, and is associated with significant increases in functional disability, length of hospital stay, rates of death, and health care costs. Despite its clinical importance, delirium often remains undetected or misdiagnosed as dementia or other psychiatric illness. Awareness of the etiologies and risk factors of delirium should enable nurses to focus on patients at risk and to recognize delirium symptoms early. Knowledge of pharmacological and nonpharmacological treatments for delirium will provide the nurse with an arsenal of potential interventions in the care of the delirious hospitalized elder.     

RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care

OBJECTIVE: A clear link has been demonstrated between lower nurse staffing levels in hospitals and adverse patient outcomes, but the results of studies of such relationships in long-term care facilities haven't been as clear. This study explored the time nurses spent in direct care and how it affected outcomes in long-stay (two weeks or longer) nursing home residents. METHODS: In a retrospective study of data collected as part of the National Pressure Ulcer Long-Term Study (NPULS), we analyzed data on 1,376 residents of 82 long-term care facilities whose lengths of stay were 14 days or longer, who were at risk of developing pressure ulcers but had none at study entry, and who had a Braden Scale score of 17 or less. Primary data came from residents' medical records during 12-week periods in 1996 and 1997. Dependent variables included development of pressure ulcer or urinary tract infection (UTI), weight loss, deterioration in the ability to perform activities of daily living (ADLs), and hospitalization. Independent variables included resident demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time. RESULTS: More RN direct care time per resident per day (examined in 10-minute increments up to 30 to 40 minutes per resident per day) was associated with fewer pressure ulcers, hospitalizations, and UTIs; less weight loss, catheterization, and deterioration in the ability to perform ADLs; and greater use of oral standard medical nutritional supplements. More certified nursing assistant and licensed practical nurse time was associated with fewer pressure ulcers but did not improve other outcomes. CONCLUSIONS: The researchers controlled for important variables in long-stay nursing home residents at risk for pressure ulcers and found that more RN direct care time per resident per day was strongly associated with better outcomes. There's an urgent need for further research to confirm these findings and, if confirmed, for improving RN staffing in nursing homes to decrease avoidable adverse outcomes and suffering.     

Specialized care unit: family and staff perceptions of significant elements

Specialized care units (SCUs) for nursing home residents with dementia are increasingly prevalent. Although reported to promote positive resident outcomes, the specific characteristics of SCUs most likely to yield these outcomes have not yet been identified. This article presents the findings of a qualitative study that investigated the perceptions of family members and staff about SCU characteristics that contribute to positive outcomes for residents with dementia. All family and staff members interviewed agreed that the SCU fostered feelings of personal space, personhood, and an unforced routine. These findings are discussed and provide specific direction for care of nursing home residents with dementia.