"We're just winging it". Identifying targets for intervention to improve the provision of hearing support for residents living with dementia in long-term care: an interview study with care staff

PURPOSE

Hearing loss and dementia are common in long-term care home (LTCH) residents, causing communication difficulties and worsened behavioural symptoms. Hearing support provided to residents with dementia requires improvement. This study is the first to use the Behaviour Change Wheel (BCW) to identify barriers and propose interventions to improve the provision of hearing support by LTCH staff.

METHODS

Semi-structured interviews with 10 staff members were conducted. Transcripts were analysed according to the BCW's Theoretical Domains Framework alongside reflective thematic analysis. Relevant intervention functions and exemplar interventions were proposed.

RESULTS

Staff believed hearing support to be beneficial to residents (Beliefs about Consequences) but lacked knowledge of hearing loss management (Knowledge). Poor collaborations between LTCHs and audiology (Environmental Context and Resources), led to despondency, and apprehension about traditional hearing aids for residents (Optimism). Despite feeling responsible for hearing support, staff lacked personal accountability (Social/Professional Role and Identity).

CONCLUSIONS

Future interventions should include staff Training (on hearing support), Education (on the consequences of unsupported hearing loss), Enablement (dementia-friendly hearing devices), Incentivisation and Modelling (of Hearing Champions) and Environmental Restructuring (flexible audiology appointments to take place within the LTCH). Interventions should be multi-faceted to boost the capabilities, opportunities and motivations of LTCH staff.

Sensory Health for Residents with Dementia in Care Homes in England: A Knowledge, Attitudes, and Practice Survey

BACKGROUND

Most residents with dementia (RwD) in long-term care (LTC) facilities experience hearing and vision problems, yet these sensory deficits, which are associated with poor outcomes, are frequently under-recognized or incompletely managed.

OBJECTIVE

We investigated the knowledge, attitudes, and practice (KAP) of LTC facility staff in England regarding sensory-cognitive health of RwD.

DESIGN

A cross-sectional survey using self-administered online or mail-in questionnaires.

SETTING AND PARTICIPANTS

The study included 117 LTC facilities throughout England, involving 887 staff of different grades (managers, n=79; nurses/allied health professionals, n=160; care workers, n=648).

METHODS

Using a sampling frame of all LTC facilities nationwide, we included a stratified random selection of facilities, surveying staff regarding KAP of sensory-cognitive health. Analysis was descriptive, followed by a regression model for predictors of overall KAP capacity of staff, based on a Rasch analysis of survey items.

RESULTS

Staff of all grades reported high knowledge and awareness of sensory-health concerns amongst RwD, but training opportunities were infrequent and most front-line staff felt they lacked the skills necessary to support the use of hearing and vision aids. The most reported reason for poor use of hearing aids/glasses related to lack of maintenance and care procedures (ie, broken and lost devices), and poor adherence support (ie, not tolerating the devices). Staff willingness to receive training was high. Most managers reported that training in communication skills and "sensory-friendly" environments was not provided. Finally, higher overall KAP capacity of staff was predicted by smaller facility size and public, rather than private, facility type.

CONCLUSIONS AND IMPLICATIONS

Training and practice of sensory health care in RwD in LTC in England is lacking. To improve sensory-cognitive care for LTC RwD, there is a clear need for (1) practice recommendations and (2) multifaceted interventions that include staff training, tailored sensory support, and environmental modification.

The Prevalence, Incidence, and Correlates of Fecal Incontinence Among Older People Residing in Care Homes: A Systematic Review

OBJECTIVE

Older people resident in care homes often rely on staff for support relating to their activities of daily living, including intimate care such as continence care. Managing fecal incontinence can be challenging for both residents and care staff. We conducted this review to describe the prevalence, incidence, and correlates of fecal incontinence among care home residents.

DESIGN

Systematic literature review.

SETTING AND PARTICIPANTS

Older care home residents (both nursing and residential care) aged 60 years and older.

MEASURES

We defined double incontinence as the presence of fecal plus urinary incontinence, isolated fecal incontinence as fecal incontinence with no urinary incontinence, and all fecal incontinence as anyone with fecal incontinence (whether isolated or double). The CINAHL and MEDLINE databases were searched up to December 31, 2017, to retrieve all studies reporting the prevalence and/or incidence and correlates of fecal incontinence.

RESULTS

We identified 278 citations after removing duplicates, and 23 articles met the inclusion criteria. There were 12 high-quality studies, 5 medium-quality studies, and 6 low-quality studies. The medians for prevalence (as reported by the studies) of isolated fecal incontinence, double incontinence, and all fecal incontinence were 3.5% [interquartile range (IQR) = 2.8%], 47.1% (IQR = 32.1%), and 42.8% (IQR = 21.1%), respectively. The most frequently reported correlates of fecal incontinence were cognitive impairment, limited functional capacity, urinary incontinence, reduced mobility, advanced age, and diarrhea.

CONCLUSIONS/IMPLICATIONS

Fecal incontinence is prevalent among older people living in care homes. Correlates included impaired ability to undertake activities of daily living, reduced mobility, laxative use, and altered stool consistency (eg, constipation or diarrhea) which are potentially amenable to interventions to improve fecal incontinence.

Development of a caregiver-reported measure to support systematic assessment of people with dementia in long-term care: The Integrated Palliative care Outcome Scale for Dementia

BACKGROUND

Symptom burden is common for long-term care residents with dementia which if untreated compromises quality of life. Measurement tools can support assessment of symptoms and problems but are not widely used in long-term care settings. We developed the Integrated Palliative care Outcome Scale for Dementia derived from the Palliative care Outcome Scale, Palliative care Outcome Scale-Symptom and Integrated Palliative care Outcome Scale.

AIM

To examine the content validity, acceptability and comprehension of Integrated Palliative care Outcome Scale for Dementia for routine use in long-term care settings for people with dementia and to refine Integrated Palliative care Outcome Scale for Dementia.

DESIGN

A multi-method qualitative study consisting of focus groups, semi-structured interviews and cognitive interviews.

SETTING/PARTICIPANTS

Three residential long-term care settings in London, UK. Focus group and semi-structured interview participants included caregiver staff, family, general practitioners and district nurses. Caregiver staff were sampled purposively for cognitive interviews.

RESULTS

A total of 26 respondents participated in the focus groups ( n = 21) or semi-structured interviews ( n = 5) and 10 caregiver staff completed cognitive interviews. Additional symptoms and problems included agitation, wandering, sleep problems, communication problems and diarrhoea. Refinements or lay terms were required to improve comprehension and consistency of item response for nausea, drowsiness, delusions/hallucinations, agitation, loss of interest, communication problems and interaction. A video presentation was required to support comprehension of instructions and assessment of verbally compromised residents.

CONCLUSION

Integrated Palliative care Outcome Scale for Dementia is a comprehensive and acceptable caregiver-reported measure to detect symptoms and problems in dementia. It is suitable for caregiver staff without professional training as it has been refined and tailored to maximise caregiver expertise, ready for further psychometric testing.

The challenges of implementing a multi-centre audit of end-of-life care in care homes

AIMS

This article aims to share the experience of a hospice in facilitating a multi-centre audit of end-of-life care in care homes, particularly noting the challenges and enablers of carrying out the audit.

METHODS

The audit was a retrospective multi-centre survey of bereaved relatives/next of kin of residents who died in the care home, using an anonymous, validated questionnaire: the Family Perception of Care Scale. Questionnaires were sent 3-months after bereavement. Returned questionnaires were analysed using SPSS and Excel. The care homes were in areas encompassing outer and inner city populations.

FINDINGS

The team identified eight challenges to the audit process, in particular, embedding procedures within the care homes, non-responses and developing action plans for improvement.

CONCLUSION

Overall, the audit provided an indication of where improvements could be made and where care was already excellent, built confidence and increased expertise in the care-home staff.

Perceived needs for support among care home staff providing end of life care for people with dementia: a qualitative study

OBJECTIVE

The aim of the current exploratory study was to investigate the impact on care home staff when working with people with dementia at the end of life and to explore how they cope with this aspect of their work. With UK policy encouraging death in the place of residence, rather than hospital, more people with dementia are dying in care homes.

METHOD

A qualitative approach was employed; 20 care home staff working in five English care homes were interviewed. Thematic Analysis was used to analyse the data.

RESULTS

Care home staff found the external demands on them and difficulties associated with interacting with people with dementia sometimes challenging, stressful and anxiety-provoking, particularly as residents approached end of life. Emotional aspects of caring for dying residents were sometimes heightened by close attachments with residents and their families. Staff were able to recognise these unmet needs and identified a need for further training and emotional support to manage these stressors.

CONCLUSIONS

This study revealed rich and complex understandings of the practice dimensions of caring for people with dementia at the end of life and the impact these have on staff. There is a need to develop effective psychosocial interventions that focus on emotional support for care home staff. There will be challenges in providing this in employment settings that are generally low paid, low status, have high turnover and are reliant on temporary or migrant staff, where training is not rewarded, mandatory or culturally valued. Copyright © 2016 John Wiley & Sons, Ltd.

Ethnographic process evaluation of a quality improvement project to improve transitions of care for older people

OBJECTIVES

Quality improvement projects to address transitions of care across care boundaries are increasingly common but meet with mixed success for reasons that are poorly understood. We aimed to characterise challenges in a project to improve transitions for older people between hospital and care homes.

DESIGN

Independent process evaluation, using ethnographic observations and interviews, of a quality improvement project.

SETTING AND PARTICIPANTS

An English hospital and two residential care homes for older people.

DATA

32 hours of non-participant observations and 12 semistructured interviews with project members, hospital and care home staff.

RESULTS

A hospital-based improvement team sought to reduce unplanned readmissions from residential care homes using interventions including a community-based geriatric team that could be accessed directly by care homes and a communication tool intended to facilitate transfer of information between homes and hospital. Only very modest (if any) impacts of these interventions on readmission rates could be detected. The process evaluation identified multiple challenges in implementing interventions and securing improvement. Many of these arose because of lack of consensus on the nature of the problem and the proper solutions: while the hospital team was keen to reduce readmissions and saw the problems as lying in poor communication and lack of community-based support for care homes, the care home staff had different priorities. Care home staff were unconvinced that the improvement interventions were aligned with their needs or addressed their concerns, resulting in compromised implementation.

CONCLUSIONS

Process evaluations have a valuable role in quality improvement. Our study suggests that a key task for quality improvement projects aimed at transitions of care is that of developing a shared view of the problem to be addressed. A more participatory approach could help to surface assumptions, interpretations and interests and could facilitate the coproduction of solutions. This finding is likely to have broader applicability.