Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.

Evaluation of two fatigability severity measures in elderly adults

OBJECTIVES

To document the stability, concurrent validity, and clinical correlates of two fatigability severity measures as recommended by the American Geriatrics Society.

DESIGN

Descriptive, cross-sectional.

SETTING

Two independent living and one community senior centers.

PARTICIPANTS

Forty-three participants, with an average age 85 ± 6.

MEASUREMENTS

Perceived fatigability severity was quantified by directly asking participants to report change in energy after a standardized 10-minute walk at a self-selected pace. Performance fatigability severity was defined as a ratio of change in walking speed to total distance walked. The walk test was repeated within 2 weeks to assess stability. Total daily physical activity (PA) was measured over 7 consecutive days using a waist-worn accelerometer. Frailty was measured using the Vulnerable Elders Survey interview scale, and gait speed was measured using a standardized 25-feet walk test.

RESULTS

The perceived and performance fatigability severity measures were significantly correlated (correlation coefficient (r) = 0.94, P < .001) and stable over two assessments (r = 0.82 and 0.85, P < .001). Both fatigability severity measures were significantly correlated with PA level (r = -0.42 and r = -0.44, respectively, P = .02), frailty (r = 0.47 and 0.53, respectively, P = .001) and gait speed (r = -0.45, P = .003 and r = -0.54, P = .001, respectively).

CONCLUSION

The methodology described in this study permits the calculation of two highly correlated fatigability severity scores, which summarize the relationship between a person's change in self-reported tiredness or change in physical performance and concurrently measured PA. The fatigability severity scores are reproducible and correlated with clinical measures predictive of decline. The methods used to quantify fatigability severity can be implemented during a brief assessment (<15 minutes) and should be useful in the design and evaluation of interventions to increase PA in older adults at risk of functional decline.

Resident characteristics related to the lack of morning care provision in long-term care

PURPOSE

The purpose of this study was to examine usual long-term care (LTC) practices related to 3 aspects of morning care and determine if there were resident characteristics related to the lack of care.

DESIGN AND METHODS

Participants were 169 long-stay residents in 4 community LTC facilities who required staff assistance with either transfer out of bed, dressing, and/or incontinence care and were able to respond to structured interview questions about their morning care preferences. Trained research staff conducted standardized observations during 4 consecutive morning hours once per week per participant for 3 consecutive months during usual LTC conditions and interviewed participants about their morning care preferences using a structured interview protocol once per month during this same time period.

RESULTS

Overall, 40% of the observations showed a lack of morning care provision, including any staff-resident communication about care, during the 4-hr observation period. Participants rated by staff as more physically dependent and requiring 2 staff for transfer were more likely to not receive morning care. Even when care in a particular area was absent, the majority of participants expressed a stable preference for care to remain the "same" (range of proportions was .75 to .87 for the 3 targeted care areas) and infrequently made requests for care.

IMPLICATIONS

Efforts to promote resident-directed care should consider staffing issues related to missed care occurrences and resident issues related to level of dependency on staff as well as reduced expectations for care, which can lead to resident acceptance of low care frequencies.

The Quality of Feeding Assistance Care Practices for Long-Term Care Veterans

The primary purpose of this study was to determine the quality of feeding assistance care and identify areas in need of improvement for a sample of long-term care veterans. A secondary purpose was to compare these findings with the results of previous studies in community facilities to determine ways in which the VA sample might differ. A repeated measures observational study was conducted in two VA facilities with 200 long-stay residents. Research staff conducted standardized observations during and between meals for 3 months. There was a trend for better feeding assistance care quality during meals in the VA sample, but there were still multiple aspects of care in need of improvement both during and between meals. Higher licensed nurse staffing levels in the VA should enable effective supervision and management, but observation-based measures of care quality are necessary for accurate information about daily feeding assistance care provision.

The coach is in: improving nutritional care in nursing homes

PURPOSE

 This article describes and evaluates a long distance coaching course aimed at improving nutritional care in nursing homes (NHs). The course was structured to provide more support than traditional training programs offer. 

METHODS

 In a series of 6 monthly teleconferences led by an expert in NH nutritional care, participating NH staff received step-by-step instructions for implementing an evidence-based nutritional management program. After each session, participants were asked to implement the care step they had just learned. Coaching calls helped facilitate implementation. Staff in 18 NHs in 12 states completed the course. Evaluation data were collected using a resident data form, pre- and post-training quizzes, a participant course evaluation survey, and a supervisor's report. 

RESULTS

 NH staff attended an average of 4.8 teleconferences, with 5 staff members typically attending each teleconference. Average quiz scores increased 30% (p < .0001) from pre- to post-training. A majority of course participants (N = 35) said they would participate in a similar course (82.9%) and would recommend the course (80%). Just under half preferred the coaching course to a more traditional 1- to 2-day conference. Nine of 12 reporting supervisors said their facility planned to continue the new nutritional care program. The 10 NHs that submitted resident data assessed an average of 5 residents using the recommended protocols. 

IMPLICATIONS

 We recommend the coaching course format. Dissemination outcomes may improve if resources currently used for short-duration training activities are used instead on coaching activities that support NHs over extended periods.

Resident-directed long-term care: staff provision of choice during morning care

PURPOSE

To develop an observational protocol to assess the quality of staff-resident communication relevant to choice and describe staff-resident interactions as preliminary evidence of the usefulness of the tool to assess current nursing home practices related to offering choice during morning care provision.

DESIGN AND METHODS

This study included 73 long-stay residents in 2 facilities. Research staff conducted observations for 4 consecutive morning hours during targeted care activities (transfer out of bed, incontinence, dressing, and dining location). Observations were conducted weekly for 12 consecutive weeks. Staff-resident interactions were measured related to staff offers of choice and residents' responses.

RESULTS

Interrater agreement was achieved for measures of staff offers of choice (kappa = .83, p < .001), type of choice provided (kappa = .75, p < .001), and resident requests related to choice (kappa = .72, p < .001). Observations over 2,766 care episodes during 4 aspects of morning care showed that staff offered residents choice during 18% of the episodes. Most observations (70%) were coded as staff offering "no choice."

IMPLICATIONS

Nursing home staff can use a simplified version of this standardized observational tool to reliably measure staff-resident interactions related to choice during morning care provision as a first step toward improving resident-directed care practice.

Cost-effectiveness of nutrition interventions in nursing home residents: a pilot intervention

OBJECTIVES

Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents' snack foods and fluids between meals to increase caloric intake.

DESIGN

Randomized, controlled trial.

SETTING

Three long-term care facilities.

PARTICIPANTS

Sixty-three long-stay residents who had an order for nutrition supplementation.

INTERVENTION

Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption.

MEASUREMENTS

Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents' caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention.

RESULTS

Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention.

CONCLUSIONS

Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.

Prevalence of constipation symptoms in fecally incontinent nursing home residents

OBJECTIVES

To determine the prevalence of constipation symptoms and the effects of a brief toileting assistance trial on constipation in a sample of fecally incontinent nursing home (NH) residents.

DESIGN

Observational study.

SETTING

Five NHs.

PARTICIPANTS

One hundred eleven fecally incontinent NH residents.

MEASURES

Research staff measured bowel movement frequency every 2 hours for 10 days. The following week, residents were offered toileting assistance every 2 hours for 2 days to determine resident straining, time required for a bowel movement, and resident perceptions of feeling empty after a bowel movement. Constipation data were abstracted from the medical record.

RESULTS

The frequency of bowel movements during usual NH care was low (mean=0.32 per person per day), and most episodes were incontinent. The frequency of bowel movements increased significantly, to 0.82 per person per day, and most episodes were continent during the 2 days that research staff provided toileting assistance. Eleven percent of residents showed evidence of straining, and 21% of the time after a continent bowel movement, residents reported not feeling empty. Five percent of participants had medical record or Minimum Data Set documentation indicative of constipation symptoms.

CONCLUSION

Low rates of bowel movements during the day that are potentially indicative of constipation were immediately improved during a 2-day trial of toileting assistance in approximately 68% of the residents, although other symptoms of constipation remained in a subset of residents who increased toileting frequency.

The accuracy of monthly weight assessments in nursing homes: implications for the identification of weight loss

BACKGROUND

The prevalence of weight loss is a quality indicator for nursing homes (NH), and monthly weight assessments are conducted by NH staff to determine weight loss.

METHODS

A longitudinal study was conducted with 90 long-stay residents in four NHs for 12 study months. Monthly weight values documented in the medical record by NH staff were compared to independent weight values collected by research staff using a standardized protocol. Weight loss was defined according to the Minimum Data Set (MDS) criterion: >or= 5% in 30 days or >or= 10% in 180 days.

RESULTS

The total frequency of weight loss episodes per person was comparable between NH and research staff weight assessments across the 12 study months. However, monthly weight values recorded by NH staff were consistently higher than values recorded by research staff, which resulted in a higher prevalence of weight loss and earlier identification of weight loss according to research staff weight values using a standardized weighing protocol.

CONCLUSIONS

A standardized weighing protocol improved the detection of weight loss among NH residents and should allow for earlier nutrition intervention.

Resident complaints about the nursing home food service: relationship to cognitive status

Most nursing home (NH) residents are not interviewed about their satisfaction with the food service due to cognitive impairment. The purpose of this study was to determine the proportion of NH residents able to complete a structured interview to assess food complaints when no cognitive status criteria were used to exclude residents from interview. Eighty-nine percent of 163 residents were able and willing to complete the interview, and 65% expressed complaints about the NH food service. Residents who expressed complaints ate less of their meals, had less cognitive impairment, and had more depressive symptoms than those who did not. This study shows that the majority of NH residents are able to reliably answer questions about their satisfaction with the food service, regardless of cognitive status, and the presence of complaints is related to poor meal intake and depressive symptoms.

Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: a quality improvement project

OBJECTIVES

To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss.

DESIGN

Pre-Post intervention study.

SETTING

Two skilled nursing homes.

PARTICIPANTS

Eighteen long term care residents.

INTERVENTION

At baseline all participants had a non-specific physician's order to receive a nutritional supplement. The intervention consisted of specifying the physician's order as follows: "Give 4 oz high protein supplement at 10 am, 2 pm, and 7 pm".

MEASUREMENTS

Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period.

RESULTS

Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it.

CONCLUSIONS

Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.

Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance

OBJECTIVES

To determine the effects of a feeding assistance intervention on food and fluid intake and body weight.

DESIGN

Crossover controlled trial.

SETTING

Four skilled nursing homes (NHs).

PARTICIPANTS

Seventy-six long-stay NH residents at risk for unintentional weight loss.

INTERVENTION

Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks.

MEASUREMENTS

Research staff independently weighed residents at baseline and monthly during a 24-week intervention and 24-week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24-week period.

RESULTS

The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between-meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack.

CONCLUSION

Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.

A Preliminary Evaluation of the Paid Feeding Assistant Regulation: Impact on Feeding Assistance Care Process Quality in Nursing Homes

PURPOSE

The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality.

DESIGN AND METHODS

Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality.

RESULTS

Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents.

IMPLICATIONS

Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.

Quality Improvement for Feeding Assistance Care in Nursing Homes

Unintentional weight loss is a common problem among nursing home residents and one that can lead to adverse and costly clinical outcomes. Observational studies have shown that residents often receive inadequate and poor-quality feeding assistance during meals, and residents consume few calories between meals from oral liquid nutritional supplements or other food and fluid items. Improvements in the adequacy and quality of feeding assistance either during or between meals have been shown to improve residents' daily oral food and fluid consumption and promote weight gain. However, these feeding assistance interventions require significantly more time than nursing home staff currently spend on feeding assistance care activities. Alternative staffing models are explored through the recent federal "paid feeding assistant" regulation and an observational tool is described for use in practice to improve feeding assistance care.

What Do Family Members Notice Following an Intervention to Improve Mobility and Incontinence Care for Nursing Home Residents? An Analysis of Open-Ended Comments

PURPOSE

The purpose of this study was to evaluate the sensitivity of family members' responses to open-ended interview questions about an intervention to improve incontinence and mobility care for their relative in a nursing home.

DESIGN AND METHODS

The study was a randomized, controlled intervention trial with incontinent nursing home residents (N = 145), wherein research staff provided toileting and walking assistance of sufficient intensity to significantly improve continence and mobility outcomes in the treatment group. Interviewers posed open-ended interview questions to family members after 8 weeks of intervention to assess if they noticed a difference in care.

RESULTS

Family responses to open-ended questions showed that, compared to the control group, the intervention group noticed significant overall improvement in incontinence and mobility care and in residents' outcomes in mobility.

IMPLICATIONS

Families' responses to open-ended questions were sensitive to improvements in incontinence and mobility care and may provide evidence for important care quality differences that would be missed if only direct satisfaction and discrepancy-based closed-ended questions were asked.

Nursing Home Staff Delivery of Oral Liquid Nutritional Supplements to Residents at Risk for Unintentional Weight Loss

OBJECTIVES

To describe nursing home (NH) staff delivery of oral liquid nutritional supplements to residents with an order to receive supplementation.

DESIGN

Descriptive.

SETTING

Six skilled NHs.

PARTICIPANTS

One hundred thirty-two long-stay residents.

MEASUREMENTS

Research staff conducted direct observations for 2 days during and between meals and documented NH staff delivery of supplements, amount consumed (fluid ounces), and amount of assistance (minutes) provided by staff to encourage consumption.

RESULTS

Eighty-eight percent had an order to receive a supplement one to three times daily (mode = 3); 12% had an order to receive a supplement four to six times daily. Fewer than 10% received the supplement consistent with their orders during the 2 observation days. On average, NH staff provided a supplement less than once per participant per day during or between meals. When a supplement was provided, residents consumed an average+/-standard deviation of 4.91+/-2.19 fluid ounces during meals with 6.16+/-7.46 minutes of staff assistance and 3.98+/-2.60 fluid ounces between meals with less than 1 minute of staff assistance. Participants with orders that specified time of delivery received the supplement at a significantly higher frequency between meals.

CONCLUSION

Oral liquid nutritional supplements are not provided consistent with orders in NH practice. Staff spends little time promoting supplement consumption during or between meals. The specificity of the order related to time of delivery may influence when and how often supplements are provided to residents.

Improving the quality of nursing home care and medical-record accuracy with direct observational technologies

Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and ability of providers to identify areas for improvement. Observational protocols designed for use by survey and quality-assurance staff can provide the independent information necessary for improving both medical record accuracy and residents' quality of life. Unfortunately, observational protocols currently used in survey and quality-assurance activities are not designed in a manner that is consistent with the scientific principles that guide observational measurement. The purpose of this article is to describe the steps to develop a standardized and scientifically defensible observational system to assess nursing home care quality.

Feeding assistance needs of long-stay nursing home residents and staff time to provide care

OBJECTIVES

To describe the staff time requirements to provide feeding assistance to nursing home residents who require three different types of assistance to improve oral food and fluid intake (social stimulation, verbal cuing, or both; physical guidance; or full physical assistance) and to determine whether physically dependent residents require more staff time, as defined in the national Resource Utilization Group System (RUGS) used for reimbursement.

DESIGN

Descriptive.

SETTING

Six skilled nursing homes.

PARTICIPANTS

Ninety-one long-stay residents with low oral intake who responded to improved feeding assistance.

MEASURMENTS

Research staff conducted direct observations of usual nursing home care for 2 consecutive days (total of six meals) to measure oral food and fluid consumption (total percentage eaten) and staff time spent providing assistance (minutes and seconds). Research staff then implemented a standardized graduated-assistance protocol on 2 separate days (total of six meals) that enhanced residents' oral food and fluid intake.

RESULTS

Staff time to provide feeding assistance that improved food and fluid consumption was comparable across different levels of eating dependency. Across all levels, residents required an average of 35 to 40 minutes of staff time per meal; thus, residents who needed only supervision and verbal cuing required just as much time as those who were physically dependent on staff for eating.

CONCLUSION

The current RUGS system used for reimbursement likely underestimates the staff time required to provide feeding assistance care that improves oral intake.

A standardized quality assessment system to evaluate pain detection and management in the nursing home

CONTEXT

Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain.

OBJECTIVE

Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain.

DESIGN

Descriptive.

SETTING

Thirty nursing homes (NHs).

PARTICIPANTS

Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator.

MEASUREMENTS

Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware.

RESULTS

Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview.

CONCLUSIONS

Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

Direct observations of nursing home care quality: Does care change when observed?

OBJECTIVES

Recent research demonstrates that care recorded by nursing home (NH) staff is often inaccurate. Direct observations of care may therefore be of critical importance in assessing and improving care in this setting. Unfortunately, despite their apparent use in several types of quality assurance activities, there is little written information about the reliability or accuracy of observational procedures in NHs. This paper provides information about one important measurement issue (reactivity) that is often cited as a limitation of observational procedures in measuring usual care practices accurately.

DESIGN

Descriptive.

SETTING

Seven nursing homes.

PARTICIPANTS

Staff and residents.

MEASUREMENTS

Direct observational time in bed; repositioning and feeding assistance.

RESULTS

Observational measures of care quality were stable over multiple observation periods and consistently detected quality problems even on the first and last days of observation.

CONCLUSION

Direct observations of care provided to residents do not appear to change provider behavior.

The effect of staff care practices on nursing home residents' preferences: implications for individualizing care

PURPOSE

To examine the effect of staff care practices on nursing home residents' preferences for dining location.

METHODS

A cross-sectional study was conducted with 304 long-stay residents in six skilled nursing homes. Research staff conducted direct observations during meals for two days and interviewed residents on the same two days about their preferences for dining location for each scheduled meal (breakfast, lunch and dinner).

RESULTS

Staff care practices were significantly related to residents' preferences to eat in the dining room for all meals after adjusting for resident characteristics and nurse aide staffing level. For each unit increase in the proportion of residents taken to the dining room for meals by staff, residents' preferences to eat in the dining room also significantly increased by approximately three to four percent for each mealtime period.

DISCUSSION

Staff care practices may influence residents' reported preferences for dining location. Daily care practices may be inappropriately justified by residents' preferences, which are shaped by their nursing home care experience and reduced expectations. In efforts to individualize resident care, nursing home staff should consider the influence of established care practices on residents' reported preferences for daily care.