Pervasive Risk Avoidance: Nursing Staff Perceptions of Risk in Person-Centered Care Delivery

Preferences and Quality of Life in Nursing Home Residents: A Mixed Methods Study

PURPOSE

Delivery of person-centered care (PCC) is the standard in nursing homes (NHs) and demonstrates a positive impact on resident quality of life (QOL). PCC inherently recognizes and prioritizes resident preferences; however, preferences, and their degree of importance among residents, demonstrate a variable relationship with QOL that remains underexplored. Therefore, the current study examined the association between preferences and QOL among NH residents.

METHOD

A mixed methods study incorporating surveys was conducted among 144 residents, with semi-structured follow-up interviews with 11 residents.

RESULTS

Findings confirm a variable relationship between resident preferences and QOL. Higher order preferences not captured within the preference assessment may influence QOL. High numbers of unimportant and can't do/no choice preferences were linked to resident acclimatization to the NH. QOL was at risk if care was not consistent with preferences.

CONCLUSION

In-depth assessments and robust measures of preferences and QOL should be integrated into care delivery and future research. [Journal of Gerontological Nursing, 50(5), 7-13.].

" I'm not a risk taker " : Risk Perceptions of Nursing Home Residents With Dementia

BACKGROUND

Persons living with Alzheimer disease and related dementia (ADRD) in nursing homes (NH) are often excluded from conversations about their health/safety. These omissions impinge on personhood and the rights to have care preferences heard and honored. While persons with ADRD maintain the ability to communicate their preferences long after their decision-making abilities are affected, little is known about how persons with ADRD understand the risks associated with their preferences.

METHODS

As part of a larger focused ethnography, in-depth interviews and an adapted risk propensity questionnaire explored the risk perceptions of NH residents with ADRD (N=7) associated with their preferences for care and activities of daily living.

RESULTS

Residents generally self-identified as risk avoiders ( M =3.2±1.84) on the risk propensity scale and were able to rate risk associated with preferences described within 5 thematic categories: 1) participation in decision-making, 2) risk awareness, 3) paying attention to safety, 4) reliance on nursing home staff and family, and 5) impacts on quality of life and quality of care.

DISCUSSION

Results suggest NH residents with ADRD can express risk surrounding their preferences and should be encouraged to participate in discussions about their health and safety.

Ambiguities in Preventing Infections in Nursing Homes: Care Workers Experiences and Implications for Future Policies

Preventing infections in nursing homes is highly challenging, given the ambiguous nature of nursing homes as care institutions and places to live. Yet, little is known about how care workers experience preventing infections in this context. Understanding the ambiguities experienced by care workers in nursing homes when enacting infection prevention is crucial to preparing for future health crises. This study investigates and identifies the ambiguities care workers faced and experienced when preventing infections during the COVID-19 pandemic. Interviews and observations were combined to capture narratives and behaviors related to infection prevention and care work. By using thematic analysis, three types of ambiguity were identified: (a) an Ambiguous sense of purpose, (b) Environmental ambiguity, and (c) Information ambiguity. The findings provide a nuanced understanding of the ambiguities care workers face and experience in nursing homes when preventing infections and indicate that such ambiguities impact their behaviors and attitudes. From this study, it is possible to conclude that policymakers must consider nursing homes' ambiguous characteristics in infection prevention programs.

Professional caregivers' perceived barriers hindering the prevention and reduction of involuntary treatment among older persons receiving long-term care: A mixed methods study

AIMS

To gain insights into the barriers towards the prevention and/or reduction of involuntary treatment in long-term geriatric care.

DESIGN

Mixed methods.

BACKGROUND

Measures to which a person resists and/or does not provide consent for are defined as involuntary treatment. The use of involuntary treatment violates the autonomy of (older) persons and causes more harm than benefit. Moreover, it contradicts the values of person-centred care. Nevertheless, its use among people living with dementia (PLWD) is still common practice.

METHODS

We conducted a cross-sectional, mixed methods study, including an online survey for professional caregivers and a semistructured focus group interview with professional caregivers.

RESULTS

A total of 218 participants completed the questionnaire. The percentage of participants who perceived barriers in one of the 22 survey items ranged from 15% to 42%. Lack of time, the experienced need to use involuntary treatment, uncertainty about responsibilities of stakeholders and a lack of knowledge on methods to prevent and/or reduce the use of involuntary treatment were most seen as barriers. Nursing staff perceived a lack of time hindering them in the prevention or reduction of involuntary treatment more often than other professional caregivers. Working in home care and having no former experience with involuntary treatment usage increased perceived barriers. Participants of the focus group interview confirmed these findings and added that professional caregivers in general lack awareness on the concept of involuntary treatment.

CONCLUSIONS

One out of four professional caregivers experiences barriers hindering prevention and/or reduction of involuntary treatment. More research is needed to gain a better understanding of how professional caregivers can be supported to remove barriers and, consequently, prevent and/or reduce the use of involuntary treatment.

RELEVANCE TO CLINICAL PRACTICE

Professional caregivers experience many barriers towards the prevention and reduction of involuntary treatment. Future initiatives should aim to remove the perceived barriers.

Assessment of Nursing Staff Learning Needs Around Person-Centered Risk Management in Nursing Homes

The purpose of the current study was to describe nursing home (NH) staff's perceived learning and practice competency needs to facilitate effective delivery of person-centered care (PCC) when older adult residents' care preferences involve perceived risks. This needs assessment included a survey of NH staff and leaders (N = 87) and two focus groups (FGs) (N = 14). Results indicated staff were most confident handling preferences related to medication refusal (mean item rating = 4.1) and least confident in preferences related to smoking (mean item rating = 2.4). Staff were challenged in denying residents' preferences (mean item rating = 3.6) and worried about risk outcomes for residents or themselves (71.6%), reporting lack of policy and procedures to support them (48.1%). Survey results were enriched by FG themes: Establishing Person-Centered Values, Navigating Risk, and Operational Characteristics. Together, this information informed the development of a practice protocol to improve nursing competence in situations involving negotiation of resident and/or NH risks in care delivery. [Journal of Gerontological Nursing, 49(2), 7-12.].

Nursing Staff Perceptions of Outcomes Related to Honoring Residents' "Risky" Preferences

Nursing homes (NHs) are challenged to consistently deliver person-centered care (PCC), or care based on residents' values and preferences. NH staff associate certain resident preferences with risk. However, there are limited evidence-based person-centered risk management strategies to assist NH staff with risky resident preferences. The purpose of the current study was to explore NH staff perceptions of health and safety outcomes associated with honoring NH residents' risky preferences to inform intervention development. This descriptive, qualitative study used sequential focus groups and content analysis, revealing that nursing staff perceive negative and positive outcomes for staff and residents when seeking to honor residents' risky preferences. This finding is supported by three themes: Potential Harms to Staff, Potential Harms to Residents, and Positive Shared Outcomes. These results contribute a set of nurse-driven quality of life and quality of care outcomes for NH staff and residents associated with PCC delivery in NHs. [Research in Gerontological Nursing, 15(6), 271-281.].

What is and what ought to be: A meta-synthesis of residential aged care staffs' perspectives on quality care

BACKGROUND

As places of both residence and work, what constitutes "good quality care" in residential aged care requires consideration of staffs' perspectives.

OBJECTIVE

A meta-synthesis of the qualitative literature was conducted exploring residential aged care staff perspectives on "quality of care."

METHODS

Six electronic databases were searched for articles that met the screening inclusion criteria. This meta-synthesis was informed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, and included studies were critically appraised using JBI SUMARI. Two independent reviewers conducted thematic network mapping and analysis of included articles, with oversight from three additional reviewers.

RESULTS

Forty-seven articles were included, with findings summarised into four organising themes and nine basic themes. The four organising themes about quality care from staff perspectives include direct care, professional values and competence, the care environment and organisational/regulatory factors.

CONCLUSION

Staff describe a wide range of factors that they perceived to influence the quality of care. Some may feel motivated to leave employment in aged care, due to organisational pressures that make staff unable to uphold what they perceive as an acceptable standard of care. There is tension between professional values and organisation/regulatory factors-regulation should be enacted at a level that supports good practice and staff's moral integrity.

RELEVANCE TO CLINICAL PRACTICE

This review found that while person-centred care is now well established as the benchmark of quality care in residential aged care homes, achieving it in reality remains challenged by limitations on staff members' time, resources and sometimes their competencies and the regularity of their employment.