'You become their advocate': The experiences of family carers as advocates for older people with dementia living in residential aged care

"I feel like a caged pig in here": Language, Race, and Ethnic Identity in a Case Study Hmong Nursing Home Resident Quality of Life

Racial disparities in nursing home (NH) quality of life (QOL) are well established, yet, little is understood about actual experiences shaping QOL for Black, indigenous, and people of color (BIPOC) residents in NHs. This gap extends to BIPOC residents with limited English proficiency (LEP). Drawing on Kane's (2001) and Zubristky's (2013) QOL frameworks, this case study examined QOL experiences for Hmong NH residents, an ethnic and refugee group from Southeast Asia, in a NH with a high proportion of BIPOC residents. Methods include four months of observation, interviews with eight Hmong residents and five NH staff, and one community focus group. Thematic analysis revealed significant challenges in QOL. Exacerbated by language barriers and racism, many residents reported neglect, limited relationships, lack of meaningful activities, and dissatisfaction with food. These experiences fostered a sense of resignation and diminished QOL among Hmong residents, highlighting the need for additional supports for this group.

Ways of interdisciplinary approaches to advocating for nursing home residents with dementia

AIM

To explore how nursing home staff advocate for residents with dementia.

DESIGN

Phenomenographic qualitative research.

METHODS

Twenty nursing home staff from four disciplines (six nurses, four physical therapists, five social workers and five care workers) were purposively recruited from three different nursing homes. Data were collected through semi-structured interviews conducted from February 2023 to March 2023, and the analysis followed the sequential steps of phenomenographic analysis.

RESULTS

The analysis identified five categories of description: focusing on what happened, finding the gaps in perspectives, how to bridge for finding a common perspective, how to tailor care such that each resident receives equitable care and how to establish interdisciplinary sharing for a consistent advocative pattern. Their structural relationship was also identified as an outcome space.

CONCLUSION

The cyclical advocacy structure illustrated that nursing home staff engage in an ongoing process of advocacy during conflict situations as part of interdisciplinary care, emphasizing continuity of care rather than separate occurrences of care.

IMPLICATIONS FOR THE PROFESSION

This study revealed that, in advocating for residents with dementia, nursing home staff adopted an approach that fosters consistent care and proactive prevention, achieved through the formation of shared knowledge applicable uniformly across similar situations.

IMPACT

This study contributes significantly to the continuing education or training of interdisciplinary staff in nursing homes. The revelations of the study hold significance not only for the practical application but also for the theoretical advancement of concepts related to safeguarding the dignity, human rights and personhood of residents with dementia, with the ultimate goal of enhancing their quality of life within nursing homes.

REPORTING METHOD

Reporting complied with the COREQ criteria for qualitative research.

PATIENT OR PUBLIC CONTRIBUTION

Nursing home directors have contributed to the validation of data analysis and interpretation.

Promoting speaking-up behaviours among nurses working in the care for older people: A scoping review

AIM

To explore interventions employed to foster speaking-up behaviours of registered nurses (RNs) working in the care of older people.

DESIGN

Scoping review.

METHODS

The updated Joann Briggs Institute scoping review methodological guidelines were followed.

DATA SOURCES

CINAHL, PubMed, PsycINFO, and Scopus were searched.

RESULTS

A total of 1691 titles and abstracts were screened, resulting in 11 articles that met the inclusion criteria. Analysis focused upon intervention types, methodologies, speaking up strategies, barriers and effectiveness. Education was the most used intervention.

CONCLUSION

There is a lack of published research on successful interventions to promote speaking-up behaviours in the care of older people, particularly relating to poor care practices. Evidence of speaking-up interventions in the residential aged care setting is absent. This highlights the need to develop strategies to support the RN to lead and enable others to raise care concerns.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Developing strategies that enable staff, care recipients and their families to speak up about care concerns is a vital future area for nursing practice development. Nursing leadership of such strategies is central to improving the quality of care for older people, particularly those living in residential aged care.

IMPACT

Older people receiving care should feel respected and be treated humanely. Evidence suggests this is often not the case. This review found a paucity of interventions to promote speaking-up about poor care practices among RNs working in the care of older people. Future research needs to address this, to empower RNs and improve the care afforded to older people.

REPORTING METHOD

The PRISMA-ScR (Tricco et al., Annals of Internal Medicine, 169, 467-473, 2018) were adhered to throughout this scoping review.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution in this review.

Challenges in recognizing and discussing changes in a resident's condition in the palliative phase: focus group discussions with nursing staff working in nursing homes about their experiences

BACKGROUND

Most nursing home residents have complex care needs, require palliative care and eventually die in these facilities. Timely recognition of changes in a resident's condition is crucial for providing appropriate care. Observations by nursing staff play a significant role in identifying and interpreting these changes.

METHODS

Focus group discussions were conducted with nursing staff from ten nursing homes in the Netherlands to explore their experiences and challenges in recognizing and discussing changes in a resident's condition. These discussions were analysed following the principles of thematic analysis.

RESULTS

The analysis of the challenges nursing staff face in identifying and interpreting changes in a resident's condition, resulted in three themes. First, that recognizing changes is considered complex, because it requires specialized knowledge and skills that is generally not part of their education and must partly be learned in practice. This also depends on how familiar the nursing staff is with the resident. Furthermore, different people observe residents through different lenses, depending on their relation and experiences with residents. This could lead to disagreements about the resident's condition. Lastly, organizational structures such as the resources available to document and discuss a resident's condition and the hierarchy between nursing home professionals often hindered discussions and sharing observations.

CONCLUSION

Nursing staff's experiences highlight the complexity of recognizing and discussing changes in nursing home residents' conditions. While supporting the observational skills of nursing staff is important, it is not enough to improve the quality of care for nursing home residents with palliative care needs. As nursing staff experiences challenges at different, interrelated levels, improving the process of recognizing and discussing changes in nursing home residents requires an integrated approach in which the organization strengthens the position of nursing staff. It is important that their observations become a valued and integrated and part of nursing home care.

Exploring the usability, user experience and usefulness of a supportive website for people with dementia and carers

PURPOSE

This study explores the usability, usefulness and user experience of the Forward with Dementia website for people with dementia and family carers, and identifies strategies to improve web design for this population.

METHODS

The website was iteratively user-tested by 12 participants (five people with dementia, seven carers) using the Zoom platform. Data collection involved observations, semi-structured interviews and questionnaires. Integrative mixed-method data analysis was used, informed by inductive thematic qualitative analysis.

RESULTS

Users of Version 1 of the website experienced web functionality, navigation and legibility issues. Strategies for desirable web design were identified as simplifying functions, streamlining navigation and decluttering page layouts. Implementation of strategies produced improvements in usability, user experience and usefulness in Version 2, with mean System Usability Scale scores improving from 15 to 84, and mean task completion improving from 55% to 89%. The user journey for people with dementia and carers overlapped, but each group had their own unique needs in the context of web design.

CONCLUSIONS

The interplay between a website's content, functionality, navigation and legibility can profoundly influence user perceptions of a website. Dementia-related websites play an important role in informing audiences of management strategies, service availability and planning for the progression of dementia. Findings of this study may assist in guiding future web development targeting this population.

The experience of entering residential aged care: The views of residents, family members and staff-an Appreciative Inquiry

OBJECTIVES

To understand resident, family and staff perspectives of older people's transition to residential aged care and initiatives that support this transition.

METHODS

A qualitative Appreciative Inquiry was undertaken with residents, family members and staff in residential aged care. It included semistructured interviews (n = 40), three focus groups (n = 17) and an organisational summit (n = 72). Each stage sought to build on the previous one, deepening understanding of the issues experienced and identifying positive strategies for change. Data were analysed thematically using framework analysis.

RESULTS

The transition experience was characterised by grief and guilt felt by family members and the challenges they faced in participating in a decision to admit a relative to residential aged care. Residents found the transition challenging but stressed the need to adjust to the situation. Family members struggled with trusting others to provide appropriate care and both residents and relatives reported challenges in communicating with staff. Initiatives were recommended by the organisational summit to assist in the transition to residential aged care. These included developing a service navigator role, co-designing new systems and resources with residents and relatives, and ensuring more consistent staffing.

CONCLUSIONS

Improved communication strategies and resources are needed to support the resident's identity, build trust in the organisation and support transition to residential aged care. Staff should continue to value the contribution family members play in the life of the resident and the culture of the aged care community.

Roles and experiences of informal caregivers of older adults in community and healthcare system navigation: a scoping review

OBJECTIVE

Informal caregivers are playing a vital role in improving the degree to which older adults access community and healthcare systems in a more seamless and timely manner, thereby fulfilling their complex needs. It is critical to understand their experiences and perspectives while navigating these systems. This review aimed to identify and organise the research findings on the roles and experiences of informal caregivers of older adults while navigating community and healthcare systems.

DESIGN

This scoping review was undertaken according to the Joanna Briggs Institute's Reviewer manual. Four databases were used: AgeLine, PsycINFO, CINAHL and Medline to capture literature with a focus on informal caregivers whose care recipients are aged 55 years or older. Articles were included if they focused on examining the experience, perspective and/or role of informal caregivers in providing care for their older care recipients, while articles were excluded if they only focused on healthcare professionals or older adults.

RESULTS

A total of 24 studies were identified that met the study inclusion criteria. This review elucidated the roles of caregivers as a primary system navigator and as an advocate for older adults. Numerous challenges/barriers in system navigation were uncovered, such as lack of consistency in fragmented systems, as well as facilitators, including interface/coordination roles. Finally, recommendations for better system navigation such as caregiver engagement and integration of continuity of care services were identified.

CONCLUSION

The need to raise the visibility of the roles and experiences of informal caregivers in system navigation was highlighted. Further research needs to focus on implementing interventions for informal caregivers incorporating a care coordinator to fill the care gap within community and healthcare systems. This review has the potential to foster greater integration of community and healthcare systems.

Quality of interaction between the nursing personnel and the informal caregivers of people with memory disorders: A systematic review and metasummary of qualitative studies

AIM

To explore the factors that affect the quality of interactions between nursing personnel and the informal caregivers of people with memory disorders.

DESIGN

Systematic review and metasummary of qualitative empirical research.

METHODS

The literature search targeted studies concerning the professional care interactions between nursing personnel and the informal caregivers of people with progressive memory disorders. The search in PubMed, CINAHL, PsycINFO and Scopus covered records from the earliest possible date up to December 2020. The data were summarised using a qualitative metasummary method. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist was used to validate the reporting process.

RESULTS

Ten articles were included. As presented in 33 statements, the factors affecting the quality of interactions were related to (1) expectations, (2) memory disorders, (3) interaction strategies, (4) time and place of interactions and (5) organisational aspects. Meeting the individual interactional needs of informal caregivers is recommended. The results provide guidance for improving the quality of interactions between nursing personnel and informal caregivers.

Assessing implementation fidelity of an on-site pharmacist intervention within Australian residential aged care facilities: A mixed methods study

BACKGROUND

An on-site pharmacist (OSP) intervention was implemented which sought to improve medication management within residential aged care facilities (RACFs) in the Australian Capital Territory, Australia. The objectives of this mixed methods study were to evaluate the implementation fidelity of the OSP intervention and to determine the moderating factors which influenced delivery of this intervention.

METHODS

This convergent parallel mixed methods study was underpinned by Hasson's conceptual framework for implementation fidelity. Implementation fidelity for seven intervention RACFs was quantitatively assessed using three quantitative data sets: (1) range of OSP intervention activities delivered; (2) random sample of 10% of medication reviews assessed for quality; (3) proportion of residents who received at least one medication review. Semi-structured interviews (n = 14) with managers and OSPs across the intervention RACFs were conducted to identify moderating factors which may have influenced OSP intervention delivery.

RESULTS

The OSP intervention was generally delivered as intended with overall medium levels of implementation fidelity. This delivery was supported by a range of facilitation strategies with most participants perceiving that the intervention was delivered to a high standard. RACF managers and OSPs were mostly well engaged and responsive. A number of potential barriers (including the part-time OSP role, COVID-19 pandemic, RACFs spread out over a large area with significant distance between resident dwellings) and facilitators (including the pharmacist support meetings, OSPs who took time to establish relationships, RACF managers who actively supported OSPs and worked with them) for OSP intervention delivery were identified which have potential implications for the roll out of OSPs within Australian RACFs.

CONCLUSION

In this study, the implementation fidelity of OSP intervention delivery was assessed with overall medium levels of fidelity found across the intervention RACFs. This suggested that the OSP intervention can generally be delivered as intended in real world RACFs. OSP intervention delivery was influenced by a range of moderating factors, some of which posed barriers and others which facilitated the OSP intervention being delivered as intended.

Staff Perceptions of the Impact of the COVID-19 Pandemic on Older Adults Living in a Residential Long-Term Care Facility

Older adults residing in long-term care facilities (LTCFs) were an at-risk group during the coronavirus disease 2019 (COVID-19) pandemic. Actions to prevent transmission in LTCFs included visitation restrictions, suspension of group activities, and isolating residents in their rooms. Despite these measures, this vulnerable cohort experienced high levels of infection and mortality. The current article reports RNs' and health care assistants' perceptions of the impact of COVID-19 on residents in a LTCF. Using a descriptive qualitative design, semi-structured interviews, which were conducted with seven RNs and four health care assistants, were thematically analyzed. Three themes emerged: Impact on Daily Routine, Disruption to Relationships With Staff, and Vulnerability. Staff perceived residents were negatively impacted physically, emotionally, and socially as a direct consequence of COVID-19 and by strategies introduced to protect them contracting the virus. It is recommended that the long-term impact of the COVID-19 pandemic on this cohort be evaluated from the perspective of all stakeholders (i.e., residents, staff, and families) using a longitudinal research design. [Journal of Gerontological Nursing, 49(10), 44-50.].

Discussing physical restrictions in care plan meetings between family members of residents with dementia and nursing home staff

In long-term dementia care, caregivers face a dilemma. On the one hand, they need to respect the residents' right to self-determination, but on the other hand, they sometimes rely on physical restraints to deal with potential violence and self-destructive behavior. The issue of self determination is further complicated by residents often depending on family members as advocates in decision-making. In this article, we examine 15 care plan meetings to identify the professional practices of discussing the physical restrictions posed to residents with severe dementia. Our method is conversation analysis. Our analysis demonstrates that staff members' practices involve informing, accounting, and agreeing on the goals rather than on the methods of physical restraining. Staff members tend to first inform family members about the principles of restraining and then account for the use of restraints. Accounts highlight the problems that can be avoided and the benefits that can be achieved by limiting residents' actions. Consequently, the family members' role in the discussion is to accept the decision that has already been approved by authorities. As the staff members highlight the aim of protecting the well-being of the resident, the family members tend to respond with overt agreement and even promote the use of restraints. Current negotiation practices provide insufficient opportunities for family members to advocate for residents. Therefore, we recommend involving family members in decision-making about restraining at an earlier stage, adjusting the protocol in care plan meetings, and engaging the family in minimizing and preventing restraints. In general, staff members should pay more attention to the residents' experiences and the family members' lifeworld knowledge of the residents.

Interprofessional collaboration between prescribers, managers, nursing staff and on-site pharmacists within residential aged care facilities: a mixed-methods study

BACKGROUND

A new on-site pharmacist (OSP) intervention within residential aged care facilities (RACFs) is being investigated to help improve medication management. Interprofessional collaboration amongst prescribers, nursing staff and pharmacists is critical to improving RACF medication management.

OBJECTIVE

To explore the extent of interprofessional collaboration and the nature of the working relationships between OSPs and prescribers, managers and nursing staff.

METHODS

A mixed-methods study was undertaken within the context of a 12-month cluster randomised controlled trial. Semi-structured interviews were conducted with data analysed using framework analysis, and a survey based upon the Physician-Pharmacist Collaboration Index (PPCI) was distributed at two time points (T1 at 3 months and T2 at 9 months after OSP commencement) across seven intervention RACFs.

RESULTS

The qualitative data (n = 33 interviews) findings related to the processes supportive of these relationships e.g. on-site proximity, OSP personality and perceived (or beneficial) benefits of OSPs working with health care team members (such as OSPs being trusted and providing reassurance to RACF health care team members). The PPCI survey mean scores at T1 (n = 33) and T2 (n = 19) suggested that OSPs were able to establish positive working relationships at 3 months and that positive relationships also existed at 9 months. The integrated findings suggested that the working relationships between OSPs and health care team members were generally positive.

CONCLUSIONS

This study is the first to explore interprofessional collaboration between OSPs and health-care team members in RACFs. The findings suggest that OSPs can positively contribute to interprofessional collaborative care within RACFs.

Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

BACKGROUND

The prescription of psychotropic medication to older people living with dementia in residential aged care has become an increasing concern. The use of prescription medication is often prefaced as a way of preventing harm to self and others. However, the use of such medications has been considered a way of managing some of the behavioural and psychological symptoms of dementia. Using a large secondary data set, this study aimed to identify the precursors and mediating factors that influence the use of chemical restraint of older people in residential aged care.

METHODS

Publicly available documents from the Australian Royal Commission into Aged Care Quality and Safety were used as the data corpus for this study. Keywords were used to search over 7000 documents to extract a set of topic-related content. We identified the cases of seven people in respite or permanent residential aged care who had been prescribed or administered psychotropic medication under circumstances that appeared to demonstrate chemical restraint. All documents relating to the cases were collated for our data set. A descriptive case study approach to analysis was taken.

RESULTS

Four key descriptive patterns were identified: labelling and limits to tolerance, pushing prescription as a solution, coverups and avoiding consent, and family's fight for liberty. Triangulation across the data and academic literature supports the findings.

CONCLUSION

Our findings provide some insight into how chemical restrain happens. Featuring throughout the cases were reports of a lack of workforce capacity to care for and support residents exhibiting dementia behaviours. Prescription of psychotropic medications featured as a "first resort" care solution. Family and friends found such approaches to care unacceptable and frequently challenged the practice. Where consent for prescription was explicitly denied, more covert approaches are demonstrated. Family awareness, presence, and advocacy were key to challenging the practice of chemical restraint. Shortfalls in the capacity of the current workforce come into play here. However, workforce shortcomings can no longer mask this ubiquitous practice. Just as importantly the spotlight needs to be turned on the prescribers and the providers.

Keeping the Connection Alive With Tender Care and Common Sense: A Phenomenological Study on Daughters' Experiences of Having a Mother in a Nursing Home

The relationship between mother and daughter is exceptional when it comes to closeness and its impact on their whole life. Thus, a mother's move to a nursing home is pivotal for both of them. The aim of this interpretative phenomenological study, using the Vancouver School of Doing Phenomenology, was to explore daughters' experience of having a mother in a nursing home, its impact on the maternal relationship, and the daughters' need for education and support. Data were collected by 21 semi-structured interviews with 12 women who had mothers living in a nursing home. Keeping the connection alive with tender care and common sense encapsulates the interrelation between the daughters' urge to hold on to the mother-daughter relationship and the rare consideration of education and support from health professionals. Responsibility and sense of duty paired with relief because the mother is in a safe place were accompanied by the daughters' need for confirmation that the mother is well taken care of.