How do care staff in residential aged care facilities conceptualise their non-verbal interactions with residents with dementia and what relevance has this for how residents' preferences and capacity for decision-making are understood?

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.

Systemic failures in nursing home care-A scoping study

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.

METHOD

MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.

RESULT

Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.

CONCLUSIONS

The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

Professional caregivers' participation in the International Caregiver Development Programme: A qualitative study of psychosocial care in nursing homes

AIM

This paper aims to explore professional caregivers' experiences of psychosocial care for older persons living in nursing homes following the professional caregivers' participation in the International Caregiver Development Programme (ICDP).

DESIGN

A qualitative study.

METHODS

About 15 focus group interviews and 25 participatory observations of five ICDP group courses were conducted with 31 employees in nursing homes, including registered nurses, enrolled nurses and nursing aids. The findings emerged through hermeneutic analysis.

RESULTS

Main findings: (i) Adjusting the communication to the residents' psychosocial needs, (ii) Seeing the residents as individuals and (iii) Adjusting to individual interaction with the residents. The professional caregivers experienced that the residents participated more in communication, interaction and activities, in addition to be more satisfied, calm, happy and thankful in interaction with the caregivers. Furthermore, they described that the environment in the units became calmer and that they were considering psychosocial care before medication. Work-related stress seems to impact ICDP participation and may be a barrier to implementation.

Supporting autonomy for people with dementia living in nursing homes: A rapid realist review

BACKGROUND

For people with dementia living in nursing homes, autonomy is important. However, they experience difficulty with being heard as an autonomous person, as well as with expressing their preferences and choices. The question is how to support their autonomy.

OBJECTIVE

Despite extensive efforts to support autonomy in daily care for people with dementia living in nursing homes, we do not know exactly what works for whom, in which context, how and why. The objective of this realist review is to explore what is known in literature on autonomy support interventions for people with dementia in nursing homes.

DESIGN

A rapid realist review of literature.

REVIEW METHODS

To understand how autonomy is supported, a realist approach was applied that entailed identifying the research question, searching for information, performing a quality appraisal, extracting data, synthesizing the evidence and validating the findings with a panel of experts. Causal assumptions were derived from articles found in four bibliographic databases (PubMed, PsychInfo, Cochrane and CINAHL) leading to context (C)-mechanism (M)-outcome (O) configurations.

RESULTS

Data extraction from the included articles ultimately resulted in sixteen CMO configurations on four themes: a. preferences and choice: interventions for supporting autonomy in nursing homes and their results, b. personal characteristics of residents and family: people with dementia and their family being individuals who have their own character, habits and behaviors, c. competent nursing staff each having their own level of knowledge, competence and need for support, and d. interaction and relationships in care situations: the persons involved are interrelated, continuously interacting in different triangles composed of residents, family members and nursing staff.

CONCLUSION

The findings showed that results from interventions on autonomy in daily-care situations are likely to be just as related not only with the characteristics and competences of the people involved, but also to how they interact. Autonomy support interventions appear to be successful when the right context factors are considered.

A Scoping Review of Adverse Incidents Research in Aged Care Homes: Learnings, Gaps, and Challenges

Background: Adverse incidents are well studied within acute care settings, less so within aged care homes. The aim of this scoping review was to define the types of adverse incidents studied in aged care homes and highlight strengths, gaps, and challenges of this research. Methods: An expanded definition of adverse incidents including physical, social, and environmental impacts was used in a scoping review based on the PRISMA Extension for Scoping Reviews Checklist. MEDLINE, CINAHL, and EBSCOhost were searched for English language, peer-reviewed studies conducted in aged care home settings between 2000 and 2020. Forty six articles across 12 countries were identified, charted, and analyzed using descriptive statistics and narrative summary methods. Results: Quantitative studies (n = 42, 91%) dominated adverse incidents literature. The majority of studies focused on physical injuries (n = 29, 63%), with fewer examining personal/interpersonal (15%) and environmental factors (22%). Many studies did not describe the country's aged care system (n = 26, 56%). Only five studies (11%) included residents' voices. Discussion: This review highlights a need for greater focus on resident voices, qualitative research, and interpersonal/environmental perspectives in adverse event research in aged care homes. Addressing these gaps, future research may contribute to better understanding of adverse incidents within this setting.

Epistemic Injustice in Late-Stage Dementia: A Case for Non-Verbal Testimonial Injustice

The literature on epistemic injustice has thus far confined the concept of testimonial injustice to speech expressions such as inquiring, discussing, deliberating, and, above all, telling. I propose that it is time to broaden the horizons of testimonial injustice to include a wider range of expressions. Controversially, the form of communication I have in mind is non-verbal expression. Non-verbal expression is a vital, though often overlooked, form of communication, particularly for people who have certain neurocognitive disorders. Dependency upon non-verbal expression is a common feature of some forms of neurocognitive disorders such as 'intellectual disabilities', autism and late-stage dementia. According to the narrow definition of testimonial injustice currently championed in the literature, people who express non-verbally are exempt from testimonial injustice. However, when we consider cases where meaningful communications from non-verbal people are dismissed or ignored in virtue of identity prejudice, there seems to be a distinct testimonial harm at play. Using late-stage dementia as a case study, I argue that the definition of testimonial injustice should be expanded to include all communicative practices, whether verbal or non-verbal, to encompass the epistemic harms inflicted upon some of the most marginalised in our society.

Emotional availability in dyads of nursing aide - resident with dementia: Old tool, new perspective

Objectives

This study examined the emotional availability of nursing aide-resident with dementia dyads in a long-term care-facility. Emotional availability refers to the nursing aide’s sensitivity toward the resident, structuring their interactions in a non-intrusive and non-hostile manner and the resident’s responsiveness to and involvement of the nursing aide. The study evaluated the reciprocity in the emotional availability of nursing aides and the residents and examined whether emotional availability varies with the level of difficulty of taking care of the residents and with the context of the interaction.

Method

The study was conducted in three wards in one long-term care-facility. Twenty nursing aides and 40 residents took part in the study. Each nursing aide was videotaped during feeding, structured and unstructured interactions, with two residents, one that was nominated by the head nurse as difficult to take care of and one that was nominated as easy to take care of. The interactions were coded using the emotional availability scales.

Results

Linear mixed-effect model analyses indicated that higher emotional availability of nursing aides was related to higher emotional availability of the residents. Nursing aides’ emotional availability did not vary between “difficult” and “easy” residents or across the three interaction contexts. “Difficult” residents involved their nursing aides less than “easy” residents.

Discussion

The study documented the reciprocal nature of the interaction between nursing aides and residents with dementia. It suggests that nursing aides have an important role in promoting residents’ responsiveness and involvement.

You can tell it works - Experiences from using the VIPS practice model in primary healthcare

INTRODUCTION

Person-centred care is a philosophy rather than a method ready for implementation and utilization in daily clinical work. Internationally, few methods for person-centred care have been widely adopted in clinical dementia care practice. In Norway, the VIPS practice model is one that is commonly used for the implementation and use of person-centred care in primary healthcare.

METHOD

Nursing home physicians, managers and leaders in the municipalities, care institutions and domestic nursing care services were eligible for inclusion if their workplace had implemented and used the VIPS practice model for a minimum of 12 months. Individual interviews were conducted via Facetime, Skype or telephone and analysed with qualitative content analysis.

FINDINGS

In all, 20 respondents were included: one manager of health and care services in the municipality, six managers and leaders working in domestic care or daytime activity centres and 10 managers/leaders and three physicians working in nursing homes. Two global categories emerged: category 1: Change in staff's professional reasoning with two sub-categories: (a) an enhanced professional level in discussions and (b) a change in focus from task to person; and category 2: Changes in the clinical work, with three sub-categories: (a) effective interventions, (b) a person-centred work environment and (c) changes in cooperation between stakeholders.

CONCLUSION

Regular use of the VIPS practice model appeared to change the work culture for the benefit of both service users and frontline staff. Increased cooperation between frontline staff, nurses, physicians and next of kin was described. Staff were more focused on the needs of the service users, which resulted in care interventions tailored to the needs of the individual with dementia, loyalty to care plans and fewer complaints from next of kin.

Dementia care from behind the mask? Maintaining well-being during COVID-19 pandemic restrictions: Observations from Dementia Care Mapping on NHS mental health hospital wards in Wales

WHAT IS KNOWN ON THE SUBJECT?: Coronavirus disease 2019 (COVID-19) is a new infectious disease that has spread across the world and infected a large number of people many of whom have died. People with moderate to severe dementia are at very high risk of becoming infected as the disease mainly impacts on older people with other health problems and once infected the person with dementia is more likely to become seriously ill than other people. To prevent infection, people are required to wear masks and isolate from contact with others. It is believed that these measures can reduce the quality of life and general well-being of people with moderate to severe dementia in hospital or social care. This belief has not yet been demonstrated by research. WHAT DOES THIS PAPER ADD TO THE EXISTING KNOWLEDGE?: We show that people with moderate to severe dementia receiving care on mental health hospital wards and subject to strict infection prevention measures can still achieve high levels of well-being. We show that mental health nurses alter the focus of their care to deliberately overcome the challenges and particularly the restrictions on visiting by families. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: We believe that the changes in practice we observed can occur in other healthcare and social care settings and that whilst restrictions remain in place care staff can protect and possibly enhance well-being for people with moderate to severe dementia. ABSTRACT: Introduction The effect of coronavirus (COVID-19) on people living with dementia is potentially severe in its clinical impacts. More widely, for this vulnerable group, the social restrictions to limit the spread of infection may be emotionally and psychologically damaging. Aim To explore the impact of restrictions on well-being for people with moderate to severe dementia in acute mental health hospital care. Method "Dementia Care Mapping" was the observational tool used to determine well- or ill-being. Observations were undertaken in two mental health hospital wards during a time of restrictions and the use of personal protective equipment. Results We report levels of well-being that are higher than might be expected alongside a change in the focus of psychological care delivered through mental health nursing interventions aimed at enhancing well-being. Discussion-We postulate that mental health nurses faced with an unprecedented challenge respond by changing practice to mitigate for infection prevention measures and to compensate for family absence. Implications for practice We suggest that the desirable enhancing actions by nursing staff which raise well-being in these hospital settings are readily transferable to other settings that are aiming to maintain well-being but also practising under COVID-19 restrictions.

Aged care residents' prioritization of care: A mixed-methods study

Background

Eliciting residents’ priorities for their care is fundamental to delivering person‐centred care in residential aged care facilities (RACFs). Prioritization involves ordering different aspects of care in relation to one another by level of importance. By understanding residents’ priorities, care can be tailored to residents’ needs while considering practical limitations of RACFs.

Objectives

To investigate aged care residents’ prioritization of care.

Design

A mixed‐methods study comprising Q methodology and qualitative methods.

Setting and participants

Thirty‐eight residents living in one of five Australian RACFs.

Method

Participants completed a card–sorting activity using Q methodology in which they ordered 34 aspects of care on a pre‐defined grid by level of importance. Data were analysed using inverted factor analysis to identify factors representing shared viewpoints. Participants also completed a think‐aloud task, demographic questionnaire, post‐sorting interview and semi‐structured interview. Inductive content analysis of qualitative data was conducted to interpret shared viewpoints and to identify influences on prioritization decision making.

Results

Four viewpoints on care prioritization were identified through Q methodology: Maintaining a sense of spirituality and self in residential care; information sharing and family involvement; self‐reliance; and timely access to staff member support. Across the participant sample, residents prioritized being treated with respect, the management of medical conditions, and their independence. Inductive content analysis revealed four influences on prioritization decisions: level of dependency; dynamic needs; indifference; and availability of staff.

Conclusions

Recommendations for providing care that align with residents’ priorities include establishing open communication channels with residents, supporting residents’ independence and enforcing safer staffing ratios.

Using branching path simulations in critical thinking of pain management among nursing students: Experimental study

BACKGROUND

Nursing education has to promote nursing students' critical thinking skills especially those who are going to work with people with dementia suffering from pain. Therefore, nursing education needs to incorporate new and effective teaching methods in nursing curricula for critical thinking skills promotion. Branching path simulation is an interactive learning tool which helps students; (1) to make decisions about treatment options for patients and get feedback immediately and (2) to demonstrate and promote their critical thinking skills in a safe and supported environment before dealing with complex and real-life case scenarios.

OBJECTIVES

The present study aimed to examine the effectiveness of branching path simulation in promoting the critical thinking skills of undergraduate nursing students.

METHODS

This an equivalent control group pretest-posttest experimental study was done in 2019 on 102 undergraduate nursing students who had registered in both practical and theoretical courses of Advanced Adult Health Nursing. A pretest posttest experimental design with concurrent control group and random assignment to the treatment/nontreatment variable was used and a convenience sample of 102 nursing students was recruited in this study. The students were randomly assigned and divided into two equal intervention and control groups and each group attended different training sessions. The control group was trained by traditional lectures while the intervention group was trained by branching path simulation. The researcher used a demographic questionnaire and the Critical Thinking Self-Assessment Scale (CTSAS) for data collection.

RESULTS

After the training sessions, the mean scores of the CTSAS and its subscales domain in the intervention group were significantly higher than the control group.

CONCLUSIONS

Branching path simulation is an effective teaching method to promote students' critical thinking skills. Future studies are recommended to examine the effect of branching path simulation on other nursing students learning outcomes.