The challenges and opportunities in providing end-of-life care in nursing homes

Approximately 20% of deaths in the United States occur in nursing homes. That percentage is expected to increase as the population continues to age. As a setting for end-of-life care, nursing homes provide both challenges and opportunities. This article examines factors that impede the delivery of high-quality end-of-life care in nursing homes, such as inadequate staff and physician training, regulatory and reimbursement issues, poor symptom management, and lack of psychosocial support for staff, residents, and families. In addition to discussing hindrances to providing end-of-life care, this article explores characteristics of nursing homes and their staff that support the care of terminally ill residents. Also included is an overview of models for delivering end-of-life care in nursing homes, including provision of hospice services, specialized palliative care units, and consultation services. Finally, this article discusses educational programs and current educational initiatives to enhance end-of-life care in nursing homes.     

Discharging older people from hospital to care homes: implications for nursing

This paper summarizes a research study which explored the experiences of older people being discharged from hospital to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes. While this may reflect an assumption that this form of discharge is less problematic, it is arguable that this is only the case for staff - there is a body of literature on re-location which suggests that the move to a care home is a major life event for older people. Taking a qualitative approach, this study interviewed 20 older people and 17 of their family members after discharge from hospital to a care home. We found that few people had been offered opportunities to discuss their move with nurses, and that older people tended to adopt a stoical attitude. In focus groups, interviews and written responses from 23 members of staff in the hospital and in care homes, we found that there was a lack of clarity over whose role it was to initiate such discussions. The paper concludes with some discussion of the implications for nursing practice of changing care interfaces.     

Factors influencing use of home care and nursing homes

AIM: This paper reports a study comparing the characteristics of patients who use home care services and those who are cared for in nursing homes, and identifying the factors that influence the use of these care settings. BACKGROUND: The increase in the functionally dependent older population has led to an increase in the number of nursing homes and home care agencies. It has become clear that, rather than disputing which is the better of these options, it would be better to determine the characteristics of patients who use the two long-term care services. Gaining an understanding of the unique characteristics of patients who are cared for by home care agencies and those who are cared for in nursing homes will be imperative for reforming and developing long-term care systems. METHOD: The research model was based on the Anderson Model of Health Services Utilization. Interviews were conducted with 99 stroke survivors from two home care agencies and four nursing homes, and their family members, between May and December 2001. RESULTS: The patient characteristics that predicted greater use of home care rather than nursing home services were: being married, poor physical function, impaired cognitive function, higher rates of comorbidity, various medical complications, and/or number of catheters (e.g. urinary catheter, naso-gastric tube). CONCLUSION: Contrary to the findings of previous studies conducted in countries with ageing populations, our findings indicate that in South Korea home care agencies, rather than nursing homes, provide care for severely impaired patients. This may be due to differences between countries in their long-term care systems and cultural attitudes toward end-of-life care. Our results will contribute to the development or reformation of long-term care systems in countries with ageing populations, and to the development of strategies for increasing access to these services.     

Affecting culture change and performance improvement in Medicaid nursing homes: The Promote Understanding,Leadership, and Learning (PULL) Program

A growing number of nursing homes are implementing culture change programming to create a more homelike environment in which residents and direct care staff are empowered with greater participation in care activities. Although nursing homes that have adopted culture change practices have brought about positive transformation in their settings that have improved quality of care and life, as well as increased resident and staff satisfaction, they represent a minority of all nursing homes. Nursing homes that serve primarily a Medicaid population without supplemental sources of funding have been limited in the resources to support such change processes. The purpose of this project was to gain insight into effective strategies to provide culture change and quality improvement programming to low-performing, under-resourced nursing homes that represent the population of nursing homes least likely to have implemented this programming. Factors that interfered with transformation were identified and insights were gained into factors that need to be considered before transformational processes can be initiated. Effective educational strategies and processes that facilitate change in these types of nursing homes were identified. Despite limitations to the study, there was evidence that the experiences and findings can be of value to other low-performing, under-resourced nursing homes. Ongoing clinical work and research are needed to refine the implementation process and increase the ability to help these settings utilize resources and implement high quality cost effective care to nursing home residents.     

Delivering ‘Gold Standards’ in end‐of‐life care in care homes: a question of teamwork?

Aim. This paper reports findings from a study which investigated the introduction of the Gold Standards Framework for improving end‐of‐life care into care homes in England. Background. The Gold Standards Framework was developed in primary care to improve the care provided for people at the end‐of‐life. Following its successful introduction to this setting it was adapted and implemented in care homes. Design. A case study approach was appropriate for this study of a care programme into a ‘real life’ setting. Method. Fourteen managers participated in an initial telephone interview. Ten of these homes participated in the case study phase and 61 staff participated in individual or group interviews. Seven residents and three relatives participated in face to face interviews. Qualitative data were analysed in line with the template approach. Survey data were also analysed and a validated Teamworking Questionnaire was used. Results. It was found that teamwork is central to the successful introduction of the Gold Standards Framework in Care Homes. Good staffing levels and management support were also perceived to be key factors in homes where the Framework became established. Conclusion. Effective teamwork was necessary for changes in end‐of‐life care to be achieved in the care homes. If end‐of‐life care and other improvements in practice are to continue, teamwork will need to be supported and developed. Relevance to clinical practice. Effective teamwork appears to be a pre‐requisite for successful implementation of new programmes of care. Organisations wishing to implement such programmes should assess the quality of teamwork and may need to address this first.     

Dealing with death: first encounters for first-year nursing students

End-of-life care, particularly for older people, is often sub-optimal in England, and the Government has introduced several initiatives to improve this care. The authors believe the twin frameworks of emotional labour and ethics of non-abandonment underpin the provision of high-quality care. This article discusses a research project that investigated first-year nursing students' encounters with patient deaths. The research found that, to the student, every death in clinical practice is a learning experience and potentially a source of emotional distress; some students reported experiencing flashbacks afterwards and were developing avoidance behaviours. Students sometimes felt unsupported by mentors and also felt that sometimes dying patients and families were inadequately cared for. The theme of abandonment was evident in the students' stories. The authors conclude that there is still room for improvement in end-of-life care. Good role modelling and pastoral care by mentors is vital to student development. Link lecturers and mentors need to be alert to student distress.     

Place and Underlying Cause of Death During the COVID-19 Pandemic: Retrospective Cohort Study of 3.5 Million Deaths in England and Wales, 2014 to 2020

ObjectiveTo describe the place and cause of death during the coronavirus disease 2019 (COVID-19) pandemic to assess its impact on excess mortality.MethodsThis national death registry included all adult (aged ≥18 years) deaths in England and Wales between January 1, 2014, and June 30, 2020. Daily deaths during the COVID-19 pandemic were compared against the expected daily deaths, estimated with use of the Farrington surveillance algorithm for daily historical data between 2014 and 2020 by place and cause of death.ResultsBetween March 2 and June 30, 2020, there was an excess mortality of 57,860 (a proportional increase of 35%) compared with the expected deaths, of which 50,603 (87%) were COVID-19 related. At home, only 14% (2267) of the 16,190 excess deaths were related to COVID-19, with 5963 deaths due to cancer and 2485 deaths due to cardiac disease, few of which involved COVID-19. In care homes or hospices, 61% (15,623) of the 25,611 excess deaths were related to COVID-19, 5539 of which were due to respiratory disease, and most of these (4315 deaths) involved COVID-19. In the hospital, there were 16,174 fewer deaths than expected that did not involve COVID-19, with 4088 fewer deaths due to cancer and 1398 fewer deaths due to cardiac disease than expected.ConclusionThe COVID-19 pandemic has resulted in a large excess of deaths in care homes that were poorly characterized and likely to be the result of undiagnosed COVID-19. There was a smaller but important and ongoing excess in deaths at home, particularly from cancer and cardiac disease, suggesting public avoidance of hospital care for non–COVID-19 conditions.     

District nurses' experiences of providing care in residential care home settings

Little research describes the involvement and contribution of primary health care services in residential homes, despite policy and research concerns that older people in residential homes are a vulnerable population for whom care must be improved. The aim of this research was to explore the actual and potential contribution of primary care nurses in residential homes for older people, particularly district nurses. Five focus groups were held with district nurses in one county in England, to explore how participants represented their views, values and experiences of working in residential homes. Our major finding was the importance of context in shaping the experience of district nursing involvement. General practitioner attachment determined the frequency of visiting homes and affected workload. District nurses had regular contact with residential homes for discrete nursing tasks, but appropriateness of referrals and input was not agreed. The focus group discussions with district nurses revealed how problematic their work in residential homes was and a lack of consensus about their role. The data suggested that uncertainty about providing care in a setting that straddles the health and social care, public and private divide, and anxieties about managing their workload overshadowed their acknowledged concerns about the older people in residential care homes. Further research is needed to substantiate the findings, obtain residents' views and address issues of how to achieve integrated and equitable health and social care for this group.     

Striking the balance: night care versus the facilitation of good sleep

This article presents the key findings from an extensive research project aiming to identify the determinants of poor sleep in care homes. A mixed methods study was conducted in 10 care homes in South East England. This included 2-week daily diaries completed by 145 older residents and interviews with 50 care-home staff. This research demonstrated that the regular surveillance by qualified nurses and care assistants at night seriously impedes the quality of sleep experienced by older people living in care homes. However, nurses and social care workers have a duty of care, which would not be fulfilled if regular checks were not undertaken at night. There is a need for care-home staff to strike a balance between enabling older people living in care homes to have a good night's sleep and adhering to their own professional duty of care.     

Thinking falls-taking action: a falls prevention tool for care homes

Falls in older people resident within care home settings are common and serious, often resulting in injury and mortality. Yet there is no standardised approach within UK care homes to assessing the risk of falls for individuals or identifying risk factors relevant for that person. The Guide to Action for Falls Prevention Tool - Care Homes (GtACH) was developed with local care homes in Nottinghamshire. Ten care homes were selected to participate in the study, four withdrawing before data collection commenced. Fourteen care home staff across six care homes tested the tool for usability and found it quick (20 minutes) and easy to use, yet only 53% of the recommended interventions highlighted were completed. The GtACH needs further evaluation to test whether its use prompts actions which reduce the number of falls, and the barriers to these actions being taken.     

Developing relationships in long term care environments: the contribution of staff

Aims and objectives. The aim of this study was to consider how relationships in care homes influence the experience of older people, their families and staff. The main objective reported in this paper considers how these relationships are developed and the contribution that staff make to this process through the routines of care. Background. Relationships have been found to be integral to experiences of residents, families and staff in care homes but little is known about how these relationships develop. Few studies consider relationships in care homes as their main focus and there is a dearth of studies that consider relationships from the perspective of residents, families and staff within the same care home. Design. The study employed a constructivist design where the different perspectives held by participants were explored and shared to develop a joint construction of how relationships influenced their experiences. Methods. Data were collected from three care homes in England over two years between 2003–2005. Participant observation and interviews enabled a hermeneutic circle to be created between residents, families and staff. Data collection and analysis were conducted concurrently using a constant comparative method. Results. Staff adopted three approaches to care delivery and these influenced the type of relationships that were developed between residents, families and staff. The three approaches were described as individualised task‐centred, resident‐centred and relationship‐centred. Conclusion. This study progresses our understanding of the development of relationships between staff, residents and families in care homes by considering how the staff may support or constrain these relationships through their approach to care delivery. Relevance to clinical practice. These findings have implications for developing practice in care homes to improve the experience of older people and their families by encouraging staff to develop a relationship‐based approach to care routines.     

Factors affecting caregivers' perceptions of residents' oral health in long-term care facilities in taiwan

The purpose of this study was to investigate the differences between resident oral care policies provided by 2 types of long-term care (LTC) institutions. The study also investigated factors affecting LTC institutional caregivers' perceptions of the residents' oral health. Overall, 103 completed questionnaires were returned. Of these, 44 were from senior citizen welfare institutions, and 59 were from nursing homes. The variables affecting these perceptions included institution type and whether the residents attended hospital dental clinics or consulted a hospital doctor regarding oral health problems. The research results showed that institution type and whether an oral care-related professional was available in an institution were correlated with an increase in institutional caregivers' perceptions of oral care.     

‘I feel like a salesperson’: the effect of multiple‐source care funding on the experiences and views of nursing home nurses in England

The difficulties faced in the recruitment and retention of nursing staff in nursing homes for older people are an international challenge. It is therefore essential that the causes of nurses’ reluctance to work in these settings are determined. This paper considers the influence that multiple‐source care funding issues have on nursing home nurses’ experiences and views regarding the practice and appeal of the role. The methodology for this study was hermeneutic phenomenology. Thirteen nurses from seven nursing homes in the North East of England were interviewed in a sequence of up to five interviews and data were analysed using a literary analysis method. Findings indicate that participants are uncomfortable with the business aspects that funding issues bring to their role. The primary difficulties faced are: tensions between care issues and funding issues; challenges associated with ‘selling beds’; and coping with self‐funding residents’ changing expectations of care. The findings of the study suggest that multiple‐source care funding systems that operate in nursing homes for older people pose challenges to nursing home nurses. Some of these challenges may impact on their recruitment and retention.     

Job control,work-family balance and nurses’ intention to leave their profession and organization: A comparative cross-sectional survey

BackgroundThe shortage of nurses is a problem in many countries. In Japan, the distribution of nurses across different care settings is uneven: the shortage of nurses in home healthcare and nursing homes is more serious than in hospitals. Earlier research has identified numerous factors affecting nurses’ intention to leave work (e.g., job control, family-related variables, work-family conflict); however, these factors’ levels and effect size may vary between nurses in hospitals, home healthcare, and nursing homes.ObjectivesThis study measured job control, family-related variables, and work-family conflict among nurses in hospitals, home healthcare, and nursing homes, and compared these variables’ levels and effect size on nurses’ intention to leave their organization or profession between these care settings.DesignThe research design was cross-sectional.MethodsParticipating nurses from hospitals, home healthcare facilities, and nursing homes self-administered an anonymous questionnaire survey; nurses were recruited from the Kyushu district of Japan. Nurses from nine hospitals, 86 home healthcare offices, and 107 nursing homes participated. We measured nurses’ intention to leave nursing or their organization, perceived job control, family variables and work-family conflict. We analyzed 1461 participants (response rate: 81.7%).ResultsThe level of job control, family variables, and work-family conflict affecting nurses varied between hospitals, home healthcare, and nursing homes; additionally, these variables’ effect on nurses’ intention to leave their organization or profession varied between these care settings. Work-family conflict, family variables, and job control most strongly predicted nurses’ intention to leave their organization or profession in hospitals, home healthcare, and nursing homes, respectively.ConclusionsInterventions aiming to increase nurse retention should distinguish between care settings. Regarding hospitals, reducing nurses’ work-family conflict will increase nurse retention. Regarding home healthcare, allowing nurses to fulfill family responsibilities will increase nurse retention. Regarding nursing home nurses, increasing nurses’ job control will increase nurse retention.     

Survey of continuing professional education within nursing homes

This article reports a survey of qualified nurses employed in nursing homes in a large city in the north of England. The aim of the study was to describe nurses' experiences and perceptions of continuing professional education (CPE), and their views on the development of their knowledge and skills through formal and informal education. Findings revealed that nurses in nursing homes perceived the value of educational programmes but had limited opportunities to attend formal education programmes. They faced a number of barriers and challenges in accessing formal education. Various informal ways of learning were used, including reading professional journals, watching videotapes and television programmes and accessing the Internet. However, respondents appeared not to use fully opportunities for sharing knowledge with colleagues. Although this study is based on a small sample, the findings support those of other studies in this field. Collectively, these studies suggest an urgent need to develop a range of approaches to CPE within care homes, both formal and informal, if the standards outlined within recent policy initiatives are to be achieved.     

Violence experienced by nurses' aides in nursing homes: an exploratory study.

1. The growing aged population in the United States will result in an increase in nursing home patients, and in numbers of employees in these homes providing care to patients. Nurses' aides, an employee group that has not received much attention, will be the primary providers of this patient care. 2. In this preliminary study the abuse experienced by nurses' aides in nursing homes was both a psychosocial and ergonomic stressor, because it had emotional and psychological components, as well as actual physical injury. 3. Nurses' aides, like other workers, deserve a safe and healthful workplace. A large scale study should be done to determine the extent of abuse/violence directed toward nursing home employees. 4. If abuse is validated as a problem, aides should receive training in handling abusive patients. In addition, it is important to identify the factors related to patients' abusive behaviors and to test mechanisms for reducing these behaviors.     

Clinical prioritizations and contextual constraints in nursing homes – a qualitative study

Scand J Caring Sci; 2010; 24; 533–540
Clinical prioritizations and contextual constraints in nursing homes ‐ a qualitative study Aim: The aim of the study was to describe nurses’ and physicians’ experiences of prioritization factors in nursing homes. Background: What are the experiences of health care personnel when prioritizing treatment and care for elderly residents in nursing homes? Little research has been done in this area, yet with the growing elderly population and limited health care budgets there can be little doubt about its relevance. Method: The study was conducted through semi‐structured interviews with 13 physicians and nurses in six nursing homes. The interviews were analysed by manifest content analysis based on first‐ and second‐level categories describing relevant factors. The categories were developed after preliminary readings of the texts. Results: This study revealed that there was a complex set of contextual constraints which influenced the care provided. There were three main findings: (i) some overall challenges related to providing good care to nursing home residents; these in turn influenced (ii) prioritizing dilemmas and (iii) factors influencing prioritization decisions. Discussion: Contextual constraints and higher level prioritizations seem to play a key role in clinical prioritizations in nursing homes. The combination of implicit rationing and the factors described as most predominant in the clinical prioritizations in nursing homes may result in inadequate and unjust health care services for some of the nursing home residents. In particular, those patients who do not speak up or do have comprehensive needs are at risk of being neglected.     

A comparative study of the financing, provision and quality of care in nursing homes. The approach of four European countries: Belgium, Denmark, Germany and the Netherlands

A comparative study of the financing, provision and quality of care in nursing homes. The approach of four European countries: Belgium, Denmark, Germany and the Netherlands As result of an increase in the numbers of frail elderly people, most European countries are facing problems with the financing and provision of services by nursing homes. At the same time, the expectations of quality of these services continue to rise. The main question investigated in this study was that of how countries approach the problems of financing and service provision by nursing homes and, at the same time, attempt to increase the quality levels in these institutions. The study was conducted in Belgium, Denmark, Germany and the Netherlands. A study was made of the relevant literature and questionnaires were sent to experts in each country. The four countries are addressing the problems of financing and sufficient service provision by controlling the use of nursing home services. In addition, financial problems are approached by extending co-payments, encouraging cheaper forms of care and putting pressure on nursing homes to operate at lower costs. Problems in the provision of care are addressed by applying more selective admission criteria and offering alternative forms of care outside the nursing home. As a result nursing home beds are used for those with the greatest care-dependency. Nursing home services are adjusted to rising quality expectations by offering a greater range of provision, decreasing the number of residents per room, improving comfort and improving the training of nursing staff. Another way to increase the quality of care is to separate the housing and service functions. Many nursing homes nowadays collaborate intensively with other facilities for the elderly to cope with all these problems and changes. The workload for nursing home staff has increased because of the increasing care-dependency of residents, the demand for higher quality of services and the financial problems.