Evidence behind The Green House and similar models of nursing home care

Utilizing the physical green care environment to support activities of daily living for nursing home residents: a focused ethnographic case study

BACKGROUND

The nursing home residents' ability to carry out Activities of Daily Living (ADLs) is influenced by the physical care environment. One emerging area of interest in scientific research is the green care environment within nursing home care, where agricultural activities such as gardening and animal care are integrated alongside daily care. Previous research has neglected to explore how these environments can be employed to enhance ADL performance. This study, therefore, explores how a green care environment, specifically one with an animal shelter, can be used to support nursing home residents in their ADLs.

METHODS

A focused ethnographic case study was conducted in one nursing home. Data was collected employing participatory observations, informal conversations, and semi-structured interviews, which we analyzed by employing a thematic analysis.

RESULTS

Overall, 25 residents were observed for a total time of 89h, and interviews were conducted with 10 staff members. The nursing home integrates activities in the green care environment into daily care for a broad scope of residents. The analysis revealed four themes: (1) The (in)visibility of ADL, (2) Reciprocal care dynamics: Fostering ADL performance through connection and teamwork, (3) Seized and missed opportunities for meaningful integration of ADL in the physical green care environment, and Theme (4) Professional fulfillment and ADL task obligation: Views from staff and management.

CONCLUSIONS

This physical green care environment carries the potential to enhance the residents' daily activities and foster better staff-resident relationships. Yet, there are varying views among staff and management regarding its integration into the residents' lives and care.

Assessment of innovative living and care arrangements for persons with dementia: a systematic review

BACKGROUND

Alternative forms of housing for persons with dementia have been developed in recent decades. These concepts offer small groups of residents familiar settings combined with efforts to provide normal daily life. The aim of this systematic review is to collate and analyze these more innovative forms of housing regarding residents' quality of life, behavioral aspects, as well as functional, cognitive and emotional aspects.

METHODS

Searches were conducted in PubMed, EMBASE and PsycInfo in November 2020. Studies comparing traditional and more innovative living environments for persons with dementia were eligible. Concepts are described based on the results of additional searches. Risk of bias of included studies was assessed using checklists from the Joanna Briggs Institute.

RESULTS

A total of 21 studies corresponding to 11 different concepts were included, namely Green Houses (USA), Group Living (Sweden), Cantou (France), Group Homes (Japan), Small-scale Group Living (Austria), Special Care Facilities (Canada), Shared-housing Arrangements (Germany), Residential Groups (Germany), Residential Care Centers / Woodside Places (USA/Canada), Small-scale Living (Netherlands/ Belgium), and Green Care Farms (Netherlands). The concepts are broadly similar in terms of care concepts, but partly differ in group sizes, staff qualifications and responsibilities. Several studies indicate that innovative forms of housing may encourage social behavior, preserve activity performance and/or positively influence emotional status compared to more traditional settings, while other studies fail to demonstrate these effects. Some studies also show increased behavioral and psychological symptoms of dementia (BPSD) in residents who live in more innovative housing concepts. The effect on cognition remains indistinct.

DISCUSSION

The positive effects may be attributable to the inherent characteristics, including small group sizes, a stimulating design, and altered staff roles and responsibilities. Arguably, some of these characteristics might also be the reason for increased BPSD. Studies had variable methodological quality and results have to be considered with caution. Future research should examine these effects more closely and should investigate populations' preferences with regards to housing in the event of dementia.

Teaming up for long-term care: Recognizing all long-term care staff contribute to quality care

When looking to promising international approaches to improve quality care in long-term care, it is necessary to avoid cherry-picking specific dimensions ignoring the integrated nature of what makes these approaches promising in the first place. In looking at promising Scandinavian or Green House models, attention is often paid to the size of facility. This often overlooks the importance of higher level of staffing, mix, and compensation of direct care staff and the integration of dietary, laundry, and housekeeping staff to care teams. Other overlooked considerations include recognition of family and friends and policies supporting care continuity.

The implementation and outcomes of self-managing teams in elderly care: A scoping review

AIM

We aim to map the existing evidence and gaps in research on the implementation and outcomes of self-managing elderly care teams.

BACKGROUND

Due to increasing demand for elderly nursing care and an ageing workforce, recruiting and retaining community nurses have become challenging. Implementing self-managing teams may be a solution to address this problem.

EVALUATION

This scoping review included 27 studies, varying from narrative reviews to a quantitative cross-sectional study. The studies' primary focus on self-managing teams was essential for eligibility.

KEY ISSUES

Nurses' job satisfaction was high in self-managing teams due to improved relationships with patients and increased autonomy. Continuity of care and patient acceptability were high. Transformation of managers to coaches in a team with a flat hierarchy is needed to empower nurses with responsibility for their own work. Trust and teamwork should be assisted by suitable ICT support systems.

CONCLUSIONS

International interest in self-managing teams is large, but quantitative research is limited and guidelines for implementation are needed. Recommendations for potential successful implementation were made.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse autonomy and job satisfaction can increase by implementing self-managing teams. This requires a change in management styles, from managing to coaching nurses.

"From living in a hotel to living in a home": Stakeholders' views about living and working in a nursing home which is undergoing culture change

Culture change models are intended to improve the quality of life and care of nursing home residents. Using longitudinal qualitative methodology, this study evaluated the effectiveness of implementing culture change on the main stakeholders living and working in an Israeli nursing home. Eight focus groups with nursing home residents, family members and staff members (N = 57) were conducted at two-time points: one year after and two years after implementing a culture change model. Using thematic content analysis and comparing the experiences of each group and across time, the results revealed that implementing culture change in a nursing home is a complex process, which requires am adaptation in the values, expectations, and perceptions of care of all those involved. Particular attention should be paid to the unique needs of each stakeholder group, while ensuring their engagement and cooperation in the change process.

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care

OBJECTIVES

People with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff-resident interactions.

DESIGN

An exploratory, cross-sectional study.

SETTING AND PARTICIPANTS

In total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.

METHODS

Structured observations were carried out to assess the support of resident autonomy within staff-resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents' responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.

RESULTS

In total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents' needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.

CONCLUSIONS AND IMPLICATIONS

The findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents' individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.

Strategies to Improve Radiographic Practices for Patients With Alzheimer's Disease: A Systematic Review

BACKGROUND

Alzheimer's disease (AD) patients are one of the highest health care service users globally. In the context of radiography, there are many AD patients who undergo imaging procedures for common age-related conditions. However, there is currently no literature on how radiographers can effectively manage such patients in imaging situations.

METHODOLOGY

This review examined the literature regarding the interaction between Alzheimer's patients and other health care professionals (eg, nurses) and the strategies that have been used to improve patient compliance and accommodate functional decline.

FINDINGS

Many strategies relating to care of patients with AD are long term, and cannot be applied in a radiographic setting, where patients may only present once. Transferrable strategies for a radiographic setting include the support of carers during the examination process, a reduction in noise and use of calming music, and allowing the patient to personalize the examination room by bringing a photograph or an item of comfort.

CONCLUSION

These simple strategies can reduce the level of anxiety experienced by AD patients, reduce typical behavioral symptoms of agitation, aggression and discomfort, and increase patient cooperation and responsiveness.

New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research

OBJECTIVE

To synthesize new findings from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare) related to the Green House (GH) model of nursing home care and broadly consider their implications.

DATA SOURCES

Interviews and observations conducted in GH and comparison homes, Minimum Data Set (MDS) assessments, Medicare data, and Online Survey, Certification and Reporting data.

STUDY DESIGN

Critical integration and interpretation of findings based on primary data collected 2011-2014 in 28 GH homes (from 16 organizations), and 15 comparison nursing home units (from 8 organizations); and secondary data derived from 2005 to 2010 for 72 GH homes (from 15 organizations) and 223 comparison homes.

PRINCIPAL FINDINGS

Implementation of the GH model is inconsistent, sometimes differing from design. Among residents of GH homes, adoption lowers hospital readmissions, three MDS measures of poor quality, and Part A/hospice Medicare expenditures. Some evidence suggests the model is associated with lower direct care staff turnover.

CONCLUSIONS

Recommendations relate to assessing fidelity, monitoring quality, capitalizing opportunities to improve care, incorporating evidence-based practices, including primary care providers, supporting high-performance workforce practices, aligning Medicare financial incentives, promoting equity, informing broad culture change, and conducting future research.

Workforce Characteristics, Perceptions, Stress, and Satisfaction among Staff in Green House and Other Nursing Homes

OBJECTIVE

To compare workforce characteristics and staff perceptions of safety, satisfaction, and stress between Green House (GH) and comparison nursing homes (CNHs).

DATA SOURCES/STUDY SETTING

Primary data on staff perceptions of safety, stress, and satisfaction from 13 GHs and 8 comparison NHs in 11 states; secondary data from human resources records on workforce characteristics, turnover, and staffing from 01/01/2011-06/30/2012.

STUDY DESIGN

Observational study.

DATA COLLECTION METHODS

Workforce data were from human resources offices; staff perceptions were from surveys.

PRINCIPAL FINDINGS

Few significant differences were found between GH and CNHs. Exceptions were GH direct caregivers were older, provided twice the normalized hours per week budgeted per resident than CNAs in CNHs or Legacy NHs, and trended toward lower turnover.

CONCLUSIONS

GH environment may promote staff longevity and does not negatively affect worker's stress, safety perceptions, or satisfaction. Larger studies are needed to confirm findings.

The Green House Model of Nursing Home Care in Design and Implementation

OBJECTIVE

To describe the Green House (GH) model of nursing home (NH) care, and examine how GH homes vary from the model, one another, and their founding (or legacy) NH.

DATA SOURCES/STUDY SETTING

Data include primary quantitative and qualitative data and secondary quantitative data, derived from 12 GH/legacy NH organizations February 2012-September 2014.

STUDY DESIGN

This mixed methods, cross-sectional study used structured interviews to obtain information about presence of, and variation in, GH-relevant structures and processes of care. Qualitative questions explored reasons for variation in model implementation.

DATA COLLECTION/EXTRACTION METHODS

Interview data were analyzed using related-sample tests, and qualitative data were iteratively analyzed using a directed content approach.

PRINCIPAL FINDINGS

GH homes showed substantial variation in practices to support resident choice and decision making; neither GH nor legacy homes provided complete choice, and all GH homes excluded residents from some key decisions. GH homes were most consistent with the model and one another in elements to create a real home, such as private rooms and baths and open kitchens, and in staff-related elements, such as self-managed work teams and consistent, universal workers.

CONCLUSIONS

Although variation in model implementation complicates evaluation, if expansion is to continue, it is essential to examine GH elements and their outcomes.

Longitudinal psychological outcomes of the small-scale nursing home model: a latent growth curve zero-inflated Poisson model

BACKGROUND

This study aims to examine the longitudinal effects of a small-scale nursing home model on the change rates of psychological outcomes by comparing green house (GH) and traditional nursing home residents.

METHODS

A total of 242 residents (93 GH and 149 traditional home residents) who resided at the home least 6 months from admission. Four minimum dataset assessments every six months from admission were included. The main psychological outcomes were depressive mood, and social engagement. The main independent variable was the facility type that the resident resided in: a GH or traditional unit. Age, gender, ADL function, and cognitive function at admission were controlled in the model. A zero-inflated Poisson (ZIP) growth curve model was utilized to compare change rates of two psychological outcomes between the two groups taking into account many zero counts of two outcome measures.

RESULTS

A rate of increase in depressive symptoms for GH home residents was higher than that of traditional home residents (β = 0.135, p-value = 0.025). GH home residents had a lower rate of increase of the probability of "not being socially engaged" over time compared to traditional home residents (β = -0.274, p-value = 0.010).

CONCLUSION

The GH nursing home model had a longitudinal effect on increasing the probability of residents' social engagement over time, but also increasing the recognition of depressive symptoms compared to traditional nursing homes.

A measure of person-centered practices in assisted living: the PC-PAL

OBJECTIVES

Develop self-administered questionnaires of person-centeredness for completion by residents and staff in assisted living (AL), in response to concerns that AL is not person-centered; also, demonstrated person-centeredness is necessary for Medicaid support as a home- and community-based services provider.

DESIGN

Community-based participatory research partnership among a research team, a consortium of 11 stakeholder organizations, and others. Methods included literature review, item generation and reduction, cognitive testing, field testing, exploratory factor analysis, and convergent and discriminant validity testing.

SETTING

Cognitive testing conducted in 2 AL residences and field testing conducted in 19 diverse, stratified AL residences in 6 states.

PARTICIPANTS

Eight residents and staff participated in cognitive testing, and 228 residents and 123 staff participated in field testing.

MEASUREMENTS

Feasibility and psychometric testing of draft questionnaires that included 75 items (resident version) and 102 items (staff version), with parallel items on both versions as appropriate.

RESULTS

The final resident questionnaire included 49 items and 4 factors: well-being and belonging, individualized care and services, social connectedness, and atmosphere. The staff questionnaire included 62 items and 5 factors: workforce practices, social connectedness, individualized care and services, atmosphere, and caregiver-resident relationships. Staff scored person-centeredness higher than did residents, reflecting their different perspectives.

CONCLUSION

The Person-Centered Practices in Assisted Living (PC-PAL) questionnaires measure person-centeredness from the perspectives of residents and staff, meaning that they reflect the concepts and items considered to be important to these key stakeholders. Use of these instruments to describe, assess, quantify, ensure, and ultimately improve person-centeredness in AL is feasible and appropriate for all AL settings, and supported by numerous national organizations.

Long-Term Care of the Elderly in Uruguay

Objective: To explore the perception of care of the elderly in long-term centers. Design: Qualitative study through participant observation and 23 in-depth interviews with administrators, caregivers, and residents between January 2011 and January 2012 in nine long-term care centers in Uruguay. From analysis, three care-perception factors emerged: (a) meaning of care, (b) experience of care, and (c) care continuity. Conclusion: Care of the elderly in nursing homes is perceived as a duty. There is an exchange of feelings and recognition of the caregiver is needed. However, the need for technical or specialized training is not mentioned. Recognition of the task of care provision, duty as a moral determinant, the exchange of affection and solidarity between staff and the elderly allows care continuity despite the centers’ lack of resources. Clinical Relevance: This study contributes information that may help improve the care conditions of elderly institutionalized people.

Developing the green house nursing care team: variations on development and implementation

PURPOSE OF THE STUDY

A core component of the Green House nursing home model is an altered supervisory relationship between the nurse and direct care workers. Some have expressed concern that the Green House model might weaken professional nursing oversight, threatening the quality of clinical care. This qualitative research study explores the role of the nurse as implemented in the Green House model, focusing on how variations in the nursing team influence clinical care practices.

DESIGN AND METHODS

Dimensional analysis, a "second generation" grounded theory methodology, was used to conduct this study. Data were collected through observations and interviews with 37 nurses, 68 CNAs, and 11 Guides working at 11 Green House sites.

RESULTS

Implementation of the nursing role within the Green House model varied both within and across sites. Four nursing model types were identified: Traditional, Visitor, Parallel, and Integrated. Care processes, CNA/Shahbaz skill development, and worker stress varied with each nursing model.

IMPLICATIONS

Government policies have been enacted to support culture change. However, there is currently little guidance for regulators, providers, or consumers regarding variability in how culture change practices are implemented and consequences of these variations. This article outlines the importance of understanding these practices at a level of detail that distinguishes and supports those that are most promising.

Transforming nursing home culture: evidence for practice and policy

The nursing home culture change movement aims to improve resident quality of life and quality of care by emphasizing the deinstitutionalization of nursing home culture and focusing on person-centered care. This article briefly reviews the history of culture change, discusses some of the challenges related to culture change in nursing homes, and overviews the conceptualization and select models of culture change. Building from this background, it critiques current understanding, identifies critical research questions, and notes key issues arising during a workshop that addressed existing and emerging evidence in the field. This review and analysis provide a context for how 9 accompanying papers in this supplemental issue of The Gerontologist fill identified evidence gaps and provide evidence for future practice and policies that aim to transform nursing home culture.

Person-Centeredness in Home- and Community-Based Services and Supports: Domains, Attributes, and Assisted Living Indicators

As a result of the Centers for Medicare & Medicaid Services (CMS) interest in creating a unifying definition of "community living" for its Medicaid Home and Community Based Services and Support (HCBS) programs, it needed clarifying descriptors of person-centered (PC) practices in assisted living to distinguish them from institutional ones. Additionally, CMS's proposed language defining "community living" had the unintended potential to exclude many assisted living communities and disadvantage residents who receive Medicaid. This manuscript describes the consensus process through which clarifying language for "community living" and a framework for HCBS PC domains, attributes, and indicators specific to assisted living were developed. It examines the validity of those domains based on literature review, surveys, and stakeholder focus groups, and identifies nine domains and 43 indicators that provide a foundation for defining and measuring PC practice in assisted living. Ongoing efforts using community-based participatory research methods are further refining and testing PC indicators for assisted living to advance knowledge, operational policies, practices, and quality outcomes.

An assessment of cultural values and resident-centered culture change in U.S. nursing facilities

BACKGROUND

Culture change initiatives propose to improve care by addressing the lack of managerial supports and prevalent stressful work environments in the industry; however, little is known about how culture change facilities differ from facilities in the industry that have not chosen to affiliate with the resident-centered care movements.

PURPOSE

The aim of this study was to evaluate representation of organizational culture values within a random sample of U.S. nursing home facilities using the competing values framework and to determine whether organizational values are related to membership in resident-centered culture change initiatives.

DESIGN AND METHODS

We collected reports of cultural values using a well-established competing values framework instrument in a random survey of facility administrators and directors of nursing within all states. We received responses from 57% of the facilities that were mailed the survey. Directors of nursing and administrators did not differ significantly in their reports of culture and facility measures combined their responses.

FINDINGS

Nursing facilities favored market-focused cultural values on average, and developmental values, key to innovation, were the least common across all nursing homes. Approximately 17% of the facilities reported that all cultural values were strong within their facilities. Only high developmental cultural values were linked to participation in culture change initiatives. Culture change facilities were not different from non-culture change facilities in the promotion of employee focus as organizational culture, as emphasized in group culture values. Likewise, culture change facilities were also not more likely to have hierarchical or market foci than non-culture change facilities.

PRACTICE IMPLICATIONS

Our results counter the argument that culture change facilities have a stronger internal employee focus than facilities more generally but do show that culture change facilities report stronger developmental cultures than non-culture change facilities, which indicates a potential to be innovative in their strategies. Facilities are culturally ready to become resident centered and may face other barriers to adopting these practices.

Real teams and their effect on the quality of care in nursing homes

BACKGROUND

Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes.

METHODS

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships.

RESULTS

The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave.

CONCLUSIONS

The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

Creating and supporting a mixed methods health services research team

OBJECTIVE

To use the experience from a health services research evaluation to provide guidance in team development for mixed methods research.

METHODS

The Research Initiative Valuing Eldercare (THRIVE) team was organized by the Robert Wood Johnson Foundation to evaluate The Green House nursing home culture change program. This article describes the development of the research team and provides insights into how funders might engage with mixed methods research teams to maximize the value of the team.

RESULTS

Like many mixed methods collaborations, the THRIVE team consisted of researchers from diverse disciplines, embracing diverse methodologies, and operating under a framework of nonhierarchical, shared leadership that required new collaborations, engagement, and commitment in the context of finite resources. Strategies to overcome these potential obstacles and achieve success included implementation of a Coordinating Center, dedicated time for planning and collaborating across researchers and methodologies, funded support for in-person meetings, and creative optimization of resources.

CONCLUSIONS

Challenges are inevitably present in the formation and operation of effective mixed methods research teams. However, funders and research teams can implement strategies to promote success.