Examining trust in health professionals among family caregivers of nursing home residents with advanced dementia

An online intervention to improve oncology health professional self-efficacy in communicating with carers: Hybrid effectiveness-implementation evaluation of the eTRIO program

OBJECTIVES

Many oncology health professionals (HPs) report communicating with carers as complex; and receive limited carer-relevant training. We developed an online HP education program for supporting and managing carer involvement (eTRIO). We aimed to assess whether HPs' self-efficacy in carer communication, knowledge, and decision-making preferences improve following eTRIO. Satisfaction and implementation potential were assessed.

METHODS

This type 1 hybrid effectiveness-implementation study used a pre-post single arm intervention design. HPs completed baseline measures, the eTRIO online module, and measures at 1- and 12-weeks post-intervention. Measures included: self-efficacy in carer communication (13-items), applied knowledge (7-items), preference for carer involvement in decisions (1-item). Fifteen of participants completed feedback interviews which underwent thematic analysis. User analytics were collected and analysed.

RESULTS

Fifty-six HPs completed baseline measures, 42 completed post- and follow-up measures. At baseline mean self-efficacy score was 88. HPs showed a statistically significant increase in self-efficacy post-intervention (mean = 105.8, CI [12.99, 20.47]), maintained at 12-weeks (mean = 101.1, CI [8.00, 15.72]). There were no changes in knowledge or decision-making preferences. Program engagement and satisfaction were high, 86.7% participants rated eTRIO as very/extremely helpful.

CONCLUSIONS AND PRACTICE IMPLICATIONS

eTRIO provided HPs with confidence to effectively engage with carers and manage complex situations such as family dominance. These gains are noteworthy, as conflict with families/carers contributes to HP burnout.

Social Connectedness Between Family Caregivers and Older Adults Living in Long-Term Care Homes in the Context of COVID-19

The coronavirus disease (COVID-19) pandemic and resulting restrictions on physical access to long-term care homes culminated in health declines for older adults living there and their families. Knowledge gaps exist regarding maintaining social connectedness when physically separated. The study aimed to explore family members' perceptions of the impact that restrictions on physical access to long-term care homes had on the experience of social connectedness between family members and older adults living in long-term care. The method used was a qualitative description, using in-depth semi-structured interviews. Themes arising from inductive qualitative content analysis of 21 interviews with family members included: (a) lack of connection threatening mental, emotional health, and physical health; (b) navigating trust in the unknown; (c) feelings of stress and anxiety for family members; and (d) technology - an asset, but not for everyone. Study findings suggest more emphasis should be placed on supporting social connections between older adults and their families in the context of long-term care beyond COVID-19.

Trust as a Central Factor in Hospice Enrollment Disparities Among Ethnic and Racial Minority Patients: A Qualitative Study of Interrelated and Compounding Factors Impacting Trust

Background: Disparities in end-of-life (EOL) care remain among ethnic/racial minority populations. Choosing hospice care in the United States depends on goals-of-care discussions founded on trust. While studies examine hospice enrollment disparities and others explore trust in hospice settings in general, very few explicitly examine the role of trust in hospice enrollment disparities. Objectives: To explore factors impacting trust and how these might contribute to disparities in hospice enrollment. Design: A qualitative, individual interview study, based on grounded theory. Setting/Subjects: Setting: Rhode Island, USA. Participants: Multiple stakeholders in EOL care, with diverse professional and personal backgrounds. Measurements: In-depth semistructured individual interviews were audio-recorded and transcribed as part of a broader study of hospice enrollment barriers in diverse patients. Analysis: Five researchers did a secondary data analysis, focusing on trust as the central phenomenon of interest. Researchers independently analyzed transcripts, then held iterative group analysis meetings until they reached consensus regarding themes, subthemes, and relationships. Results: Twenty-two participants included five physicians, five nurses, three social workers, two chaplains, one nursing assistant, three administrators, and three patient caregivers/family. Interviews reveal that trust is multidimensional, involving personal- and systems-level trust, and both locus and degree of trust. Factors impacting trust include: fear; communication/relationships; knowledge of hospice; religious/spiritual beliefs; language; and cultural beliefs/experiences. While some are common across groups, several are more prevalent in minority populations. These factors appear to interact in complex ways, unique to individual patients/families, compounding their impact on trust. Conclusions: While gaining patient/family trust regarding EOL decision making is challenging across all groups, minority patients often experience additional compounding factors impacting trust building. More research is needed to mitigate the negative ways these interacting factors impact trust.

Family caregivers' experience of communication with nursing home staff from admission to end of life during the COVID-19 pandemic: A qualitative study employing a transitional perspective

OBJECTIVES

Family caregivers' (FCs) caregiving in nursing home (NH) moves across 3 main phases: transitioning relatives to long-term care, worsening of a relative's conditions, and end of life; each phase brings specific challenges that FCs must confront. Moreover, during the COVID-19 pandemic, strict mandatory visitor restrictions affected communication modalities. This study explored FCs' experience of communication with NH staff during the COVID-19 pandemic from admission to end of life.

METHODS

A descriptive qualitative study with inductive content analysis was performed in 7 Italian NHs from May to June 2021. NH managers purposively identified 25 FCs at different phases of their caregiving trajectory: transitional (i.e., admission in the previous 8 weeks, n = 8), deterioration-in-condition (i.e., acknowledged changes in care needs of their relative after trigger events, n = 10), and end-of-life phase (i.e., death expected in the next weeks or a few months, n = 7), who were interviewed.

RESULTS

Regardless the phase of caregiving trajectory, what mattered most to FCs was the opportunity to have regular and sensitive discussions with health-care professionals. The need of in-person communication increased nearing death. The COVID-19 pandemic enhanced FCs' need to interact with health-care professionals they trusted. Knowledge of residents' preferences mitigated FCs' turbulent emotions throughout the overall caregiving trajectory.

SIGNIFICANCE OF RESULTS

Findings suggest that in-person contacts should be prioritized and facilitated when possible, particularly at the end of life; nonetheless, meaningful communication can occur also through remote modalities. Investments in training health-care professionals about effective long-distance communication and supportive skills can help trusting relationships to be established. Open discussions about residents' care preferences should be encouraged.

Measuring relatives' perceptions of end-of-life communication with physicians in five countries: a psychometric analysis

The Family Perceptions of Physician-Family Caregiver Communication scale (FPPFC) was developed to assess quality of physician-family end-of-life communication in nursing homes. However, its validity has been tested only in the USA and the Netherlands. The aim of this paper is to evaluate the FPPFC construct validity and its reliability, as well as the psychometric characteristics of the items comprising the scale. Data were collected in cross-sectional study in Belgium, Finland, Italy, the Netherlands and Poland. The factorial structure was tested in confirmatory factor analysis. Item parameters were obtained using an item response theory model. Participants were 737 relatives of nursing home residents who died up to 3 months prior to the study. In general, the FPPFC scale proved to be a unidimensional and reliable measure of the perceived quality of physician-family communication in nursing home settings in all five countries. Nevertheless, we found unsatisfactory fit to the data with a confirmatory model. An item that referred to advance care planning performed less well in Poland and Italy than in the Northern European countries. In the item analysis, we found that with no loss of reliability and with increased coherency of the item content across countries, the full 7-item version can be shortened to a 4-item version, which may be more appropriate for international studies. Therefore, we recommend use of the brief 4-item FPPFC version by nursing home managers and professionals as an evaluation tool, and by researchers for their studies as these four items confer the same meaning across countries.

Reimagining Family Involvement in Residential Long-Term Care

Although descriptions of family involvement in residential long-term care (RLTC) are available in the scientific literature, how family involvement is optimized in nursing homes or assisted living settings remains underexplored. During the facility lockdowns and visitor restrictions of the COVID-19 pandemic, residents experienced social deprivation that may have resulted in significant and adverse health outcomes. As with so many other critical issues in RLTC, the COVID-19 pandemic has magnified the need to determine how families can remain most effectively involved in the lives of residents. This article seeks to better understand the state of the science of family involvement in RTLC and how the COVID-19 pandemic has expedited the need to revisit, and reimagine, family involvement in RLTC.

The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home

BACKGROUND

Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care.

AIMS

To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication.

METHOD

This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed.

FINDINGS

Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory.

CONCLUSION

Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.

Trust of Nursing Home Staff Caring for Residents with Advanced Dementia: A Qualitative Descriptive Study of Family Caregivers' Perspectives

BACKGROUND/OBJECTIVES

Studies of interpersonal trust within nursing homes (NHs) is limited. This study aimed to describe the perspectives of interpersonal trust in NH staff among family caregivers of residents with advanced dementia. Additionally, comparisons of Black and White caregivers' perspectives were also explored.

DESIGN

We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives.

PARTICIPANTS

Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis.

RESULTS/CONCLUSIONS

While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

DESIGN

We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives.

PARTICIPANTS

Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis.

RESULTS/CONCLUSIONS

While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust, trust for certain staff members and mistrust of others. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

Family involvement with care homes following placement of a relative living with dementia: a review

This review updated a previous review [Gaugler JE (2005) Family involvement in residential long-term care: a synthesis and critical review. Aging and Mental Health9, 105–118] and focused on dementia. Fourteen years of development in family involvement with care homes following placement of a relative was explored. The review aimed to investigate two questions: (1) What types of involvement do families have with care homes following placement of people living with dementia? (2) Which factors influence family involvement with care homes? PsycINFO, MEDLINE and CINAHL Plus were searched for publications between January 2005 and December 2018. Thirty-three papers representing 30 studies were included. Papers were appraised using a quality rating tool designed for use with mixed study designs. Studies were of a reasonable quality though some weaknesses included single-site samples, high attrition rates and poor reporting. Twenty-eight papers highlighted types of involvement including collaboration, family–staff relationship development, decision making and visiting. Twenty-five papers pertained to factors influencing involvement, which included outcome of care quality evaluation, wish for recognition and sense of integration into the care team. Type of family involvement has changed over time with increased emphasis on families’ desire for partnership, to be active rather than passive advocates, and to focus on care monitoring and evaluation. Seven themes of family involvement activities are featured and a non-linear process is proposed. When compared to patient and family-centred care principles, an analysis of family involvement types found good fit overall and potential for framework improvements. Over 30 diverse factors influence inter-family variation in the level and nature of family involvement. Consideration of these factors and resolution of the gaps in evidence, including intergenerational and cultural concerns, can improve care home facilitation of family participation. This dementia-specific review is a comprehensive timely complement to Gaugler's seminal work about older adults in care.

Family Caregivers' Conceptions of Trust in Home Health Care Providers

Trust is important to family caregivers of older adults receiving home health care (HHC). Caregivers rely extensively on nurses, home health aides, and other providers to manage complex care tasks. The current study examined how family caregivers conceive of trust in HHC providers. Directed content analysis methods were applied to 40 qualitative interviews conducted with caregivers of HHC patients aged ≥65 years. Results indicated that caregivers invested trust in providers who displayed competencies in caring for patients with chronic conditions and functional difficulties, willingness to foster frequent and open communication with room for questions and feedback, confidence in their ability to be present and alert for patients, and fidelity to a variety of tasks contributing to holistic care. Caregivers' conceptions of trust in providers are affected by interpersonal aspects of their interactions with providers as well as the broader systems of care within which they participate. [Research in Gerontological Nursing, 14(4), 200-210.].

VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans

The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.

Motivations for Family Members' Visits to Nursing Home Residents With Dementia in Taiwan: A Qualitative Study

PURPOSE

The purpose of this study was to explore what motivates family members to visit a relative with dementia who has been transferred to a nursing home in Taiwan.

DESIGN AND METHODS

Data were collected for this qualitative descriptive study using audiotaped, semi-structured, in-depth, face-to-face interviews. A total of 20 family members of elderly nursing home residents participated in the study. Nursing home residents were from four nursing homes in Taiwan and had been diagnosed with probable or possible dementia by a psychiatrist or neurologist. Transcribed audiotaped interviews were analyzed using thematic analysis.

FINDINGS

Most family members were the children of the residents (n =17, 85%). The theme describing the core motivation for family members' visits to nursing home residents was "to maintain the unforgotten family affection." This motivation comprised four relevant categories: hoping to slow degeneration, providing a congruous environment, honoring filial and karmic duty, and ensuring the quality of care.

CONCLUSIONS

Motivations for Taiwanese family members' visits to nursing home residents with dementia were similar to those in Western cultures. However, "hoping to slow degeneration" and "providing a congruous environment" were unique categories.

CLINICAL RELEVANCE

Nurses and policymakers could use these findings to design interventions that might increase holistic care for both family members and nursing home residents with dementia. Providing programming focused on family members' unique priorities could address swallowing difficulties, management of dementia symptoms, nutritional needs, and selection of residents' roommates. These programs could improve the quality of family members' visits as well as the quality of staff-family relationships.

A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home

BACKGROUND

With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly.

AIM

To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents.

DESIGN

A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted.

RESULTS

Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences.

CONCLUSION

This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.

Conceptualising trust in aged care

This article calls for a sociological understanding of the importance of trust to aged care. It connects existing theories of trust to empirical evidence from gerontology and nursing research. Trust is defined as a response to and management of social vulnerability. It is argued this makes trust a fundamental concept for understanding human service and social care institutions, including aged care. In light of Australia's Royal Commission into Aged Care Quality and Safety, as well as generational shifts in consumer expectations and care ethics, the article highlights four distinct yet interrelated forms of trust: interpersonal, institutional, organisational and public trust. All of these forms are shown to be critical in conceptualising and evaluating the perceived trust deficit facing contemporary aged-care systems, and existing evidence shows how these forms of trust can reinforce, conflict and misalign with each other. Efforts to rebuild trust in aged care at an organisational and institutional level should ensure mechanisms facilitate rather than hinder the formation of interpersonal trust relations between individual service users, their families and aged care staff. Broader social policy reforms must also consider and address the way cultural understandings of ageing, and media representations of aged care, have diminished the public's trust in the sector, and how the cycle of scandals, reviews and piecemeal reforms contributes to this.

Selecting the Best Instrument to Measure Family Perceptions of End-of-Life Communication in Intensive Care Units

BACKGROUND

Good communication with the family is a clinical imperative for high quality end-of-life (EOL) care in intensive care unit (ICU). Many interventions aim to improve EOL communication, and the choice of an outcome instrument has important implications for evaluating interventions. The purpose of this project is to search and review available instruments' psychometric properties and determine which best measures family-clinician communication in the ICU.

METHOD

A stepwise method was used by searching 2 databases (PsycInfo and Web of Science) to identify instruments and articles that provide information about scale psychometric properties.

INSTRUMENTS

Three instruments were identified, including Family Inpatient Communication Survey, Family Perception of Physician-Family Caregiver Communication, and Quality of Communication (QOC).

RESULTS

Reliability estimates were high (≥ 0.79) in all 3 instruments. The QOC's convergent validity estimates exceed its discriminant validity values, and the QOC is an intervention-sensitive measure used to examine families' treatment response in randomized control trials.

CONCLUSION

Quality of Communication is the most suitable instrument to measure family's perceptions of EOL communication in the ICU. Quality of Communication scores provide a deeper understanding of family-clinician communication and data about how to improve EOL care in ICUs.

Families' Experiences With End-of-Life Care in Nursing Homes and Associations With Dying Peacefully With Dementia

OBJECTIVES

To examine family caregivers' experiences with end-of-life care for nursing home residents with dementia and associations with the residents dying peacefully.

DESIGN

A secondary data analysis of family caregiver data collected in the observational Dutch End of Life in Dementia (DEOLD) study between 2007 and 2010.

SETTING AND PARTICIPANTS

Data were collected at 34 Dutch nursing homes (2799 beds) representing the nation. We included 252 reports from bereaved family members of nursing home residents with dementia.

MEASURES

The primary outcome was dying peacefully, assessed by family members using an item from the Quality of Dying in Long-term Care instrument. Unpleasant experiences with end-of-life care were investigated using open-ended questions. Overall satisfaction with end-of-life care was assessed with the End-of-Life Satisfaction With Care (EOLD-SWC) scale, and families' appraisal of decision making was measured with the Decision Satisfaction Inventory. Associations were investigated with multilevel linear regression analyses using generalized estimating equations.

RESULTS

Families' reports of unpleasant experiences translated into 2 themes: neglect and lack of respect. Neglect involved facing inaccessibility, disinterest, or discontinuity of relations, and negligence in tailored care and information. Lack of respect involved perceptions of being purposefully disregarded, an insensitive approach towards resident and family, noncompliance with agreements, and violations of privacy. Unpleasant experiences with end-of-life care were negatively associated with families' perceptions of the resident dying peacefully. Families' assessment of their relative dying peacefully was positively associated with satisfaction with end-of-life care and decision making.

CONCLUSIONS/IMPLICATIONS

Families' reports of unpleasant experiences with end-of-life care may inform practice to improve perceived quality of dying of their loved ones. Humane and compassionate care and attention from physicians and other staff for resident and family may facilitate recollections of a peaceful death.

The meanings of the unlicensed assistive personnel role in nursing homes: A triadic job analysis perspective

AIM

This study described and analyzed how older residents, professional nurses and unlicensed assistive personnel (UAP) perceive the meaning and content of the job carried out by UAP in nursing homes (NHs), as a basis for job analysis.

BACKGROUND

Increasing numbers of NH beds and financial restraints have led UAP to become a significant part of the long-term care service system, yet in numerous contexts, the UAP job remains misunderstood and underexplored.

METHOD

The research employed a qualitative phenomenological methodology. Data were collected from 50 semi-structured in-depth interviews with 18 UAP, 15 certified nurses and 17 older NH residents.

RESULTS

We identified six content dimensions in the participants' descriptions regarding the meanings of the roles and duties of the UAP: (a) care for the physical environment, (b) bodily-physical care, (c) psycho-social interpersonal care, (d) professional hierarchy and boundaries, (e) UAP personal traits and (f) UAP skills, or the need for training and professional education.

CONCLUSIONS

Future job definition and formal regulation of UAP should place more focus on the personal characteristics of UAP, as a prerequisite to enter the job.

IMPLICATIONS FOR NURSING MANAGEMENT

The study takes a step forward toward better defining the professional boundaries delineating the meaning of the UAP position.