District nurse involvement in providing palliative care to older people in residential care homes

Recognition of the complexity facing residential care homes: a practitioner inquiry

AimTo explore the experiences and challenges for residential care home staff when managing the healthcare needs of their residents, in particular those living with dementia. BACKGROUND: Increasing number of older people, with complex health and social care needs are living in residential care homes. Yet there is limited appreciation of why staff sometimes struggle to manage residents' healthcare needs, or understanding of their working relationship with district nurses (DNs), whose responsibility it is to provide nursing support. METHODS: This PhD study, in a metropolitan area in the United Kingdom, was conducted by an experienced DN and involved three phases. This paper focuses on the first two phases. Phase 1 data included: semi-structured interviews (n=8), reflective field notes based on non-participant observation, documentary analysis of policies, procedures and assessment tools and other contextual data from one care home (case study site). The practitioner researcher reflected on the findings from the case study, in relation to her own knowledge and experience as a DN, focusing in particular on findings that were familiar, or which surprised. In Phase 2 she fed these findings back to other care homes (n=11) to check whether the findings from the single case study were unique or resonated with others. She gathered their feedback through semi-structured interviews with senior care staff (n=14). Data were analysed using thematic data analysis.FindingsFindings highlight the complexity facing residential care homes: high levels of healthcare needs amongst residents, the demands of caring for residents living with dementia, variations in the knowledge and skill set of care staff, inequity in the level of healthcare support, the challenges of building a good relationship with DNs, and funding pressures facing care homes.ImplicationsAny, or all of these factors can prevent care home staff from managing the healthcare needs of their residents.

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background

The needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.

Objectives

The EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.

Design

Mixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.

Setting

General practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.

Participants

People with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.

Main outcome measures

Dementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.

Results

An educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.

Conclusions

A tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.

Trial registration

EVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.

Funding

This project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.

Place and cause of death in centenarians: a population-based observational study in England, 2001 to 2010

BACKGROUND

Centenarians are a rapidly growing demographic group worldwide, yet their health and social care needs are seldom considered. This study aims to examine trends in place of death and associations for centenarians in England over 10 years to consider policy implications of extreme longevity.

METHODS AND FINDINGS

This is a population-based observational study using death registration data linked with area-level indices of multiple deprivations for people aged ≥100 years who died 2001 to 2010 in England, compared with those dying at ages 80-99. We used linear regression to examine the time trends in number of deaths and place of death, and Poisson regression to evaluate factors associated with centenarians' place of death. The cohort totalled 35,867 people with a median age at death of 101 years (range: 100-115 years). Centenarian deaths increased 56% (95% CI 53.8%-57.4%) in 10 years. Most died in a care home with (26.7%, 95% CI 26.3%-27.2%) or without nursing (34.5%, 95% CI 34.0%-35.0%) or in hospital (27.2%, 95% CI 26.7%-27.6%). The proportion of deaths in nursing homes decreased over 10 years (-0.36% annually, 95% CI -0.63% to -0.09%, p = 0.014), while hospital deaths changed little (0.25% annually, 95% CI -0.06% to 0.57%, p = 0.09). Dying with frailty was common with "old age" stated in 75.6% of death certifications. Centenarians were more likely to die of pneumonia (e.g., 17.7% [95% CI 17.3%-18.1%] versus 6.0% [5.9%-6.0%] for those aged 80-84 years) and old age/frailty (28.1% [27.6%-28.5%] versus 0.9% [0.9%-0.9%] for those aged 80-84 years) and less likely to die of cancer (4.4% [4.2%-4.6%] versus 24.5% [24.6%-25.4%] for those aged 80-84 years) and ischemic heart disease (8.6% [8.3%-8.9%] versus 19.0% [18.9%-19.0%] for those aged 80-84 years) than were younger elderly patients. More care home beds available per 1,000 population were associated with fewer deaths in hospital (PR 0.98, 95% CI 0.98-0.99, p<0.001).

CONCLUSIONS

Centenarians are more likely to have causes of death certified as pneumonia and frailty and less likely to have causes of death of cancer or ischemic heart disease, compared with younger elderly patients. To reduce reliance on hospital care at the end of life requires recognition of centenarians' increased likelihood to "acute" decline, notably from pneumonia, and wider provision of anticipatory care to enable people to remain in their usual residence, and increasing care home bed capacity.

Effective health care for older people resident in care homes: the optimal study protocol for realist review

BACKGROUND

Care homes in the UK rely on general practice for access to specialist medical and nursing care as well as referral to therapists and secondary care. Service delivery to care homes is highly variable in both quantity and quality. This variability is also evident in the commissioning and organisation of care home-specific services that range from the payment of incentives to general practitioners (GPs) to visit care homes, to the creation of care home specialist teams and outreach services run by geriatricians. No primary studies or systematic reviews have robustly evaluated the impact of these different approaches on organisation and resident-level outcomes. Our aim is to identify factors which may explain the perceived or demonstrated effectiveness of programmes to improve health-related outcomes in older people living in care homes.

METHODS/DESIGN

A realist review approach will be used to develop a theoretical understanding of what works when, why and in what circumstances. Elements of service models of interest include those that focus on assessment and management of residents' health, those that use strategies to encourage closer working between visiting health care providers and care home staff, and those that address system-wide issues about access to assessment and treatment. These will include studies on continence, dignity, and speech and language assessment as well as interventions to promote person centred dementia care, improve strength and mobility, and nutrition. The impact of these interventions and their different mechanisms will be considered in relation to five key outcomes: residents' medication use, use of out of hours' services, hospital admissions (including use of Accident and Emergency) and length of hospital stay, costs and user satisfaction. An iterative three-stage approach will be undertaken that is stakeholder-driven and optimises the knowledge and networks of the research team.

DISCUSSION

This realist review will explore why and for whom different approaches to providing health care to residents in care homes improves access to health care in the five areas of interest. It will inform commissioning decisions and be the basis for further research. This systematic review protocol is registered on the PROSPERO database reference number: CRD42014009112.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

Understanding residential home issues to meet health-care needs

The needs of individuals in residential care homes have risen over time. Residential care homes were originally set up to provide accommodation for those requiring limited support, but today residents often have high levels of both health and social care needs, which often go unmet. The suggestion often made is that more staff training and improved support are needed. This is an oversimplification, as a number of other factors have a significant impact on care provision. It is suggested that residents will continue to receive suboptimal care until the issues are acknowledged and tackled.

Palliative care provision for older people in care homes

There is a paucity of research in relation to district nurses' (DNs) experiences of palliative care provision in adult care homes (CHs) despite their substantial involvement. The aim of this study was to demonstrate the current involvement of DNs in CHs and identify the potential implications for future practice in providing palliative care in this setting. The findings suggested that even experienced DNs, wanted support and education about when to commence palliative care. They also wanted earlier involvement with CH residents who have a life-limiting condition and CH managers were seen as being essential contributors towards planning care. There was concern among DNs as to how the Liverpool Care Pathway could be introduced into CHs with untrained carers and finally, DN alignment to CHs was shown to improve continuity of care for residents and produce more effective partnership working between DNs, general practitioners and CH staff.

Dignity as experienced by nursing home staff

Aims and objectives.  To explore nursing home staff members' experiences of what dignity in end of life care means to older people and to themselves. Background.  Dignity is a concept often used in end-of-life care, but its meaning is rarely clarified. Design.  Qualitative descriptive study. Methods.  Content analysis. This study is based on interviews with 21 staff members in four different nursing homes in Sweden. Findings.  The results show that staff members balanced between providing for the older person's physical needs while wishing to be able to deliver a 'deeper' level of care. The older people's dignity is presented in the main theme: Feeling trust - Showing respect. The staff members' dignity is presented in the main theme: Maintaining self-respect - Being shown respect. Threats to dignity are presented in the main theme: conflicts between the ideal and the reality. Conclusions.  The results reveal that nursing home staff members deal with a moral conflict between what they are able to deliver and what they would like to provide in the care of older people. Relevance to clinical practice.  To promote older people's dignity, there is a need to take account of staff members' work situation. Supervision and continuous education could be one way of achieving this.

The palliative care education needs of nursing home staff

BACKGROUND

Palliative care is delivered in a number of settings, including nursing homes, where staff often have limited training in palliative care.

AIM

We explored the level of palliative care knowledge among qualified staff delivering end-of-life care in nursing home settings, to inform the development of an appropriate education and training programme.

DESIGN

An audit of the educational needs assessment was performed using an anonymous postal questionnaire sent to 528 qualified nursing staff within 48 nursing homes.

FINDINGS

In total, 227 questionnaires were returned giving a response rate of 43%. Results indicated that less than half the sample had obtained formal training in the area of pain assessment and management and less than a quarter had obtained training in non-malignant conditions. Registered nurses in this study reported a lack of awareness of palliative care principles or national guidelines.

CONCLUSION

Qualified nursing home staff agree that palliative care is a valuable model for care in their setting. There are clear opportunities for improvement in nursing home care, based on education and training in palliative care. Results also support the need for enhanced liaison between nursing homes and specialist palliative care services.

The challenge of providing palliative care in the nursing home: part 1 external factors

One impact of the baby boom generation and improved medical care is that nursing homes will be the place of care and site of death for growing numbers of frail, older persons dying of chronic progressive illnesses. The nursing home settings may appear to be an appropriate environment wherein residents could receive palliative care, but the literature suggests that provision of such care is replete with challenge. Some of these challenges are external to the nursing home environment and are beyond the setting's control, others have internal origins and to some extent may be under the home's control. In part I of this two-part article, we review and critically analyse the primary external factors identified in the literature -- characteristics of the residents -- as they impact on the ability of care homes to deliver palliative care.

Where older people die: a retrospective population-based study

BACKGROUND

Palliative medicine services have invested in the community to support people dying at home. To develop end-of-life care for older people, we need to know where they die.

AIM

To examine trends in age and location of death over the last 20 years.

DESIGN

Retrospective death certificate review.

METHOD

All Wales death certificates from 1981 to 2001 were examined. Place of death and age were noted.

RESULTS

Total deaths decreased from 35,015 in 1981 to 32,966 in 2001, and mortality decreased from 12.45 per 1000 population in 1981 to 11.33 in 2001. Deaths in the community decreased from 37.6% (n = 13,155) to 22.1% (n = 7293) (p < 0.001); deaths increased in hospital from 56.7% (n = 19,871) to 61.7% (n = 20,334) (p < 0.001) and in care homes from 5.7% (n = 1989) to 16.2% (n = 5339) (p < 0.001). Between 1981 and 2001, deaths in those aged 65-74 years dropped from 9752 to 6361, but increased in the over-85s from 5661 to 9779. Deaths amongst 75-84-year-olds remained stable at around 11,000. The biggest rise in hospital and care-home deaths was in those over 85: hospital deaths increased from 2928 in 1981, to 5438 in 2001; care-home deaths increased from 941 to 3141.

DISCUSSION

The last 20 years have seen a significant shift in location of death from the community to hospitals and care homes. Those aged over 85 years account for the biggest rise in hospital and care-home deaths. End-of-life needs for older people need to be addressed in hospital and care homes, not just in the community.

Palliative care in Irish nursing homes: the work of community clinical nurse specialists

AIM

to assess the current level of input from community-based clinical nurse specialists in palliative care into nursing homes in the Republic of Ireland.

METHOD

a national survey was undertaken with questionnaires distributed via the National Council for the Professional Development of Nursing and Midwifery database. The total population was 114 community-based clinical nurse specialists in palliative care.

FINDINGS

63 completed questionnaires were returned achieving a 55% response rate. All respondents had undertaken work with nursing homes. The main focus of interactions with nursing homes was on pain and symptom management and this was often provided by telephone. The majority of nurses were involved exclusively in care of patients with cancer, although 40% of respondents cared for patients with non-malignant diseases.

CONCLUSIONS

As populations age and more people end their lives in residential care settings, this area of care has increasing relevance. The dissemination of palliative care best practice would ensure that all patients, regardless of their diagnosis, receive the benefits of palliative care at the end of life. Clinical nurse specialists are ideally placed to provide education and support to nursing homes and other residential care settings for older people.

Families in home care--a resource or a burden? District nurses' beliefs

BACKGROUND

Caring for families in home care is a growing part of Swedish district nurses' professional work. District nurses' facilitative and constraining beliefs about families guide the extent to which families are acknowledged and engaged in the care.

AIMS AND OBJECTIVES

The aim of the study was to explore district nurses' beliefs about families in home care.

DESIGN

Explorative, descriptive.

METHODS

Five district nurses participated in focus group interviews on three separate occasions. Each interview lasted approximately 90 minutes, was audio taped and transcribed verbatim. A thematic content analysis was used for analyses of the data.

RESULTS

The result revealed two underpinning beliefs held by the district nurses towards families in home care: families are a resource and Families are a burden. Families could be a resource for the patient, for the other family members as well as for the district nurses themselves. Families could be a resource for the patient both practically and emotionally by e.g. being present and listening. Being open in communication with other family members and district nurses was also considered as a resource. The district nurses considered families as a burden when they were experienced as demanding in various ways, for example, when family members did not act in a way that pleased the district nurses or when family members showed their suffering.

CONCLUSIONS

This study highlight some facilitating and constraining beliefs held by district nurses: families can be both a resource and a burden.

RELEVANCE TO CLINICAL PRACTICE

It is important that district nurses are aware of what beliefs they hold as their beliefs guide their actions towards the families.