Maintaining cleanliness: an individualized approach

Finding the fundamental needs behind resistance to care: Using the Fundamentals of Care Practice Process

A person living with Alzheimer's disease (PA) can experience difficulty during bodily care and therefore may show resistance to care behaviours (RTCBs). Nurses must take a clinical approach to planning care that meets the person's needs. Therefore, it is necessary to identify training strategies for bedside nurses and nursing students.

AIMS AND OBJECTIVES

To describe and discuss how the FOC practice process (FOC-PP) can help nurses understand PAs who show RTCBs during bodily care.

BACKGROUND

Resistance to care behaviour phenomenon and the importance of bodily care as fundamental care are described. The FOC-PP enables nurses to apply the FOC framework in their practice.

DESIGN

This discursive paper is based on the literature of the FOC framework and PP.

METHOD

A clinical scenario that develops through the five stages of the FOC-PP.

RESULTS

The scenario centres on Mrs. Emily Morgan, 81, who lives in a nursing home and is not receiving the bodily care that she needs. Camille, a nursing student, and her supervisor Florence collaborate with Mrs. Morgan's family to improve the quality of her care. Three particular aspects of nursing practice based on the FOC-PP are described: the critical thinking process, relational process and pedagogical process.

CONCLUSION

The FOC-PP promotes holistic care centred on the person and his or her needs and encourages the nurse to use his or her skills and knowledge. All these dimensions are fundamental for high-quality nursing care.

RELEVANCE TO CLINICAL PRACTICE

Mrs. Morgan's scenario enables us to perceive that the FOC-PP is very useful for nursing students and bedside nurses. However, given the amount of specific and diverse knowledge required by the FOC-PP, it is necessary to identify avenues for teaching them. Using clinical scenarios could facilitate the integration of the FOC-PP, with taking into account the specific characteristics of individual clients.

Effect of the bathing without a battle training intervention on bathing-associated physical and verbal outcomes in nursing home residents with dementia: a randomized crossover diffusion study

OBJECTIVES

To evaluate the effectiveness of the Bathing Without a Battle intervention in reducing physical and verbal aggressive behaviors for nursing home residents with dementia.

DESIGN

A randomized crossover diffusion study, with one group receiving the intervention after one round of baseline observations and a delayed intervention group receiving the intervention after two rounds of baseline observations.

SETTING

Six nursing home facilities in the state of New York.

PARTICIPANTS

Nursing home residents with dementia (N = 240).

INTERVENTION

The Bathing Without a Battle educational program, designed for direct-care staff members responsible for bathing residents diagnosed with dementia and implemented through a train-the-trainer model.

MEASUREMENTS

Rates of verbal and physical aggressive and agitated behaviors were measured using the Care Recipient Behavior Assessment; secondary measures of effect included bath duration, bath modality, and antipsychotic medication use.

RESULTS

In spite of implementation obstacles (consent delays and change in leadership at one facility), a significant change was observed in how residents were bathed that translated into a significant reduction in the rate of aggressive and agitated behaviors, particularly verbal, during residents' baths. The use of in-bed baths increased 17%, and average bath duration decreased significantly (average 1.5 minutes less) in the postintervention period, particularly for in-bed baths. Verbal behaviors declined 17.8% (P = .008), combined verbal and physical behaviors declined 18.6% (P = .004), and antipsychotic use declined 30% (P = .002) after the intervention.

CONCLUSION

The Bathing Without a Battle educational program, delivered through a train-the-trainer format, is an effective means of improving the bathing experience of residents with dementia in nursing homes. This research supports broadly adopting this intervention, especially for nursing homes serving many residents with dementia.

Assessment of nursing students and nurses' orientation towards patient-centeredness

BACKGROUND

Being patient centered is a core value for nursing. Patient centered-care has been related to patient and health provider satisfaction, better health outcomes, higher quality of care and more efficient health care delivery.

OBJECTIVES

The purpose was to assess the orientation adopted by nurses and students in patient care, using The Patient-Practitioner Orientation Scale, as well as to compare the results between resident nurses and students from different academic years.

SETTINGS

Public School of Nursing and a Central Hospital, in Lisbon (Portugal).

PARTICIPANTS

Students in the first, second and fourth year of nursing school and nurses participated in the study.

METHODS

For data collection, we used The Patient-Practitioner Orientation Scale (European Portuguese version), an instrument designed to measure individual preferences toward the dimension of caring a sharing in health professional-patient relationship. Students and nurses also filled out two additional questions about their perception of competence in technical and communication skills. Additional demographic information was also collected, including gender, age, academic year and length of professional experience.

RESULTS

A total of 525 students (84.7% female) and 108 nurses (77.8% female) participated in this study. In general, caring sub-scores, measuring the preference of about attending to patient emotional aspects, were higher than sharing sub-scores, measuring beliefs about giving information and perceiving patient as a member of the health team. Students were significantly more patient-centered throughout their nursing education (p<0.001). Comparing to students in the second and fourth academic years (p<0.001) nurses' scores were significantly lower both in total PPOS and in caring and sharing subscales.

CONCLUSIONS

These results reinforce the idea that patient centeredness may be developed in academic context. The scores obtained highlight the importance of studies that aim to identify factors that may explain the decrease of patient centeredness in professional practice.

The driving and restraining forces that promote and impede the implementation of individualised nursing care: a literature review

BACKGROUND

Despite substantial attention devoted to the development of individualised care in recent years, there is a lack of coherent information and empirical research assessing the driving and restraining forces that promote and impede its implementation.

OBJECTIVES

The aim of this integrative literature review is to describe the driving and restraining forces for the implementation of individualised nursing care from the nurse's point of view. This information is useful for the development of clinical nursing care and in identifying areas for future research.

DESIGN

An integrative literature review.

DATA SOURCES

An integrative analysis of empirical studies and reviews derived from the MEDLINE, CINAHL databases and EMB Reviews - The Cochrane Database of Systematic Reviews (individual* care & nurse, from earliest through April 2008) was conducted focusing on studies which used nurses as informants. The final sample of 43 articles published in English focusing on the individualised care of adult patients from the nurse's point of view was retrieved after a two-stage process.

REVIEW METHODS

The integrative analysis of the studies included three steps. Firstly, the full texts of the final eligible studies were read. Secondly, the driving and restraining forces, that respectively promote or impede the delivery of individualised care were identified and listed in a working sheet. A total of nine categories were identified. Thirdly, a working sheet was completed summarising the information found in the studies reviewed and listing the authors.

RESULTS

Nine categories describing both driving and restraining forces for individualised nursing care were identified: (1) nurse's personal characteristics, (2) skills enhancement, (3) ethical issues, (4) nursing care delivery and interventions, (5) patient characteristics, (6) organisation of work, (7) staffing, (8) team work and group dynamics, and (9) leadership and management.

CONCLUSIONS

A body of knowledge was identified for future research. The results inform both clinical practice and education and promote better use of the nursing work force in order to provide individualised care for patients and maximise good patient outcomes.

Initiating person-centered care practices in long-term care facilities

Person-centered care is a key concept guiding efforts to improve long-term care. Elements of person-centered care include personhood, knowing the person, maximizing choice and autonomy, comfort, nurturing relationships, and a supportive physical and organizational environment. The Oregon Health & Science University Hartford Center of Geriatric Nursing Excellence and the state agency that oversees health care for older adults worked in partnership with 9 long-term care facilities. Each developed and implemented person-centered care practices, including those focused on bathing, dining, or gardening. This article describes the processes used to develop and support these practices. Three exemplary facilities made significant practice changes, 4 made important but more moderate changes, and 2 made minimal progress. These facilities differed in terms of existing culture, management practices, staff involvement, and attention to sustainability.

Translating person-centred care: a case study of preceptor nurses and their teaching practices in acute care areas

AIMS AND OBJECTIVES

The research aims to explore how preceptors interpret, operationalize, document and teach person-centred care as they guide students within an acute surgical environment.

BACKGROUND

Person-centred care is a term that is widely used in the nursing literature; however, its interpretation in nursing practice remains virtually unexplored. This is of great significance to nurses in general but to Irish nurses in particular on whom this study is focused. As preceptor nurses have been identified as key people in the education of clinical students, it was considered important to explore how clinical preceptors promote person-centred care to current undergraduate nursing students.

DESIGN AND METHOD

Using a case study design and a qualitative approach, six preceptors were chosen to participate in this study. Data were collected by means of participant observation, review of nursing care records and semi-structured interviews. Data were analysed in two stages. The first stage involved the identification of themes. In the second stage data were analysed using a number of propositions to examine and explain what was gleaned from the data in the context of what was originally identified in the literature.

RESULTS

Findings highlighted that preceptors had a limited conception of person-centred care. Measures of care reflected the medical model of nursing. Beyond that, preceptors expressed care in terms of good manners or respectful etiquette. Preceptors also had limited appreciation of what learning entails and were sceptical about classroom theory other than what they considered essential for safe practice.

CONCLUSIONS

This study highlights that preceptors need both internal and external support to implement the changes advocated by the Commission in Nursing in 1998, the Nursing Education Forum in 2000, the Department of Health and Children in 2001 and An Bord Altranais in 2003.

RELEVANCE TO CLINICAL PRACTICE

Person-centred care is a relatively new concept in nursing and recommended for practice. Preceptors need facilitation with its implementation. In an effort to promote changes in the delivery of health care, it is suggested that university-based lecturers empower students to practice evidence-based nursing as students and subsequently as qualified nurses.

Challenges to Intervention Implementation

BACKGROUND

The pressing need for interventions to improve outcomes for vulnerable caregivers of individuals with Alzheimer's disease (AD) is hindered by inadequate knowledge of variables affecting intervention delivery, receipt, and enactment.

OBJECTIVE

To analyze intervention implementation issues encountered within the Bathing Persons with Alzheimer's Disease at Home (BATH) study.

METHODS

The BATH study, a home-based, randomized, controlled trial of interventions to improve behavioral symptoms and caregiver self-efficacy, consisted of 130 intervention visits to 42 care recipients-caregiver dyads. Data include direct observation, nurse interventionist field notes, case analyses, and caregiver journals, reflecting various perspectives. Content analysis was used to identify key treatment process themes.

RESULTS

Issues that affected the delivery, receipt, and enactment of interventions reflect the intersection of in vivo caregiving and research design.

DISCUSSION

The primary lessons learned were: (a) early identification of caring dyads prior to crisis must be improved; (b) in vivo observation is essential to individualized interventions targeting behavioral etiologies and developing caregiver skills; (c) intervention delivery depends on the nurse interventionist's skills and a flexible, trusting researcher-dyad relationship; (d) complex caregiver situations affect treatment receipt and enactment; and (e) intervention enactment requires coaching, practice, and support over time. These findings help to explain issues impacting intervention implementation to a vulnerable population. Recommendations for intervention research design to maximize internal and external validity in real-life care contexts can inform future outcome studies, aid in the search for improved care, and lead to supportive public policy for families living with AD.

Assessing and Comparing Physical Environments for Nursing Home Residents: Using New Tools for Greater Research Specificity

PURPOSE

We developed and tested theoretically derived procedures to observe physical environments experienced by nursing home residents at three nested levels: their rooms, the nursing unit, and the overall facility. Illustrating with selected descriptive results, in this article we discuss the development of the approach.

DESIGN AND METHODS

On the basis of published literature, existing instruments, and expert opinion about environmental elements that might affect quality of life, we developed separate observational checklists for the room and bath environment, unit environment, and facility environment. We trained 40 interviewers without specialized design experience to high interrater reliability with the room-level assessment. We used the three checklists to assess 1,988 resident room and bath environments, 131 nursing units, and 40 facilities in five states. From the data elements, we developed quantitative indices to describe the facilities according to environmentally relevant constructs such as function-enhancing features, life-enriching features, resident environmental controls, and personalization.

RESULTS

We reliably gathered data on a large number of environmental items at three environmental levels. Environments varied within and across facilities, and we noted many environmental deficits potentially relevant to resident quality of life.

IMPLICATIONS

This research permits resident-specific data collection on physical environments and resident-level research using hierarchical analysis to examine the effects of specific environmental constellations. We describe practice and research implications for this approach.

Individualized care, quality of life and satisfaction with nursing care

AIMS

This paper reports a study of the maintenance of individualized care from surgical patients' point of view and examines associations between individualized care, patient satisfaction with nursing care, and health-related quality of life. Rationale. There is preliminary evidence that individualized care is effective from patients' point of view, and is associated with improved patient outcomes, such as patient satisfaction and quality of life. However, individualized care has mainly been studied from the vantage-point of nurses' experiences.

METHODS

In this cross-sectional, descriptive, correlational study the data were collected with surgical adult patients (n = 279, response rate 93%) in surgical wards in Finland using self-administered questionnaires including the Individualized Care Scales, Patient-Satisfaction Scale, and Finnish versions of the Nottingham Health Profile and EuroQol 5D. Associations between individualized care, satisfaction with care and health-related quality of life were examined. Cronbach's alpha values and item analysis were used to evaluate the psychometric properties of the instruments, especially the Individualized Care Scales.

RESULTS

The more often patients felt they received support for individuality through specific nursing interventions, the higher the individuality of care received. Secondly, the more individualized patients regarded their care, the higher the level of reported patient satisfaction with nursing care. However, the correlation between individualized care and health-related quality of life was fairly low, albeit statistically significant.

CONCLUSION

Individualized care may produce positive outcomes, such as patient satisfaction. Further research is needed to explore individualized care in relation to health-related quality of life.

Decreasing Assault Occurrence on a Psychogeriatric Ward

An agitation management model providing staff education, quantitative assessment of agitation, and emphasized psychosocial interventions was introduced on a geriatric psychiatry ward for male patients. A within-subjects comparison was made of Cohen-Mansfield Agitation Inventory (CMAI) scores and frequency of committing assault under pre- and post-intervention conditions. Among participants (N = 8) who finished the 72-week study, CMAI scores did not differ significantly under either of the study conditions (p > .05, two-tailed t test). Twenty-nine assaults occurred during the pre-intervention time period and six assaults occurred during the post-intervention time period. According to analysis with the Wilcoxon signed ranks test, the distribution of assaults differed significantly between the two time periods (p < .05, two-tailed). Among individuals who were excluded from the intervention because of lack of consent, assaults increased over the same two time periods. Psychosocial interventions intended to reduce agitation among elderly men with dementia may not necessarily serve to decrease agitation, but may serve to decrease assault occurrence.

Nursing home staffing and quality under the nursing home reform act

PURPOSE

We examine whether the Nursing Home Reform Act (NHRA) improved nursing home staffing and quality.

DESIGN AND METHODS

Data from 5,092 nursing homes were linked across the 1987 Medicare/Medicaid Automated Certification System and the 1993 Online Survey, Certification and Reporting system. A dummy-year model was used to examine the effects of the NHRA on pressure ulcers, physical restraints, and urinary catheters, and a first-difference approach to fixed-effects regression analyses was used to estimate the effects of time-varying staffing on the quality of care.

RESULTS

Overall, we found a significant increase in nursing home staffing levels from 1987 to 1993. Moreover, after controlling for other facility, resident, market, and state factors, there was a significant decrease in the proportion of residents with pressure ulcers, physical restraints, and urinary catheters following the implementation of the NHRA. Across all facilities, the increase in staffing was not directly related to the improvement in quality over the period of our study, but there was a positive relationship between registered nurse staffing and quality for facilities that were particularly deficient prior to the NHRA.

IMPLICATIONS

Following the NHRA, quality improvements were found in nursing homes nationwide, and these results suggest that part of this improvement was due to the quality and staffing regulations within the NHRA.

Testing the individualized care model

BACKGROUND

Although there has been some research to identify the dimensions on which individualized care should be measured, the indicators that constitute individualized care remain unclear.

OBJECTIVES

To describe briefly the maintenance of individualized care and to test a hypothetical model of individualized care in a sample of surgical patients.

DESIGN AND METHODS

A correlational survey design was used. Data were collected with questionnaires from adult patients (n = 454) discharged from surgical wards in one Finnish hospital district (response rate 91%). Structural equation modelling LISREL SIMPLIS using maximum likelihood estimation was used to estimate and test the parameters of the hypothesized model derived deductively from the previous literature.

RESULTS

The goodness-of-fit statistics supported the basic solution of the Individualized Care Model, although two additional paths indicating error covariances between the sub-concepts were identified in the revised model. In this model individualized care is defined in terms of patients' views of nursing activities aimed at supporting individuality in care and in terms of perceptions of individuality in their own care.

CONCLUSIONS

The model has been found to capture attributes that characterize individualized care. It can be used as a basis for evaluation in clinical nursing practice from patients' point of view. The study highlights the importance of patients' clinical situation, personal life situation and decisional control as predictors of individualized care. The results also confirm the construct validity of the previously developed Individualized Care Scale.

Do nurses exercise power in basic care situations?

Power is a matter of authority and control. It can be wielded either consciously or unconsciously, and it can be either overt or latent. Using a structured questionnaire, this study set out to describe nurses' opinions about the exercise of power in basic care situations in both acute and long-term care. The questionnaire was organized into four categories in which items concerned: power in obligatory daily activities; power in activities necessitated by obligatory activities; power in voluntary activities; and power in activities that take into account the patient's characteristics. The samples consisted of 228 nurses from five medical and surgical wards of district hospitals, and 233 nurses from five geriatric units of a community health centre and from one nursing home in Finland. The final response rate was 65% (acute care 76%; long-term care 55%). Data analysis was based on statistical methods. The results showed that, in the nurses' own opinion, negative power is exercised only in certain situations and in the patient's best interest, when for instance there are concerns that something may happen to the patient.

Bathing. Pleasure or pain?

Bathing creates some of the highest levels of discomfort in the lives of individuals diagnosed with dementia. The present study measured the frequency of 14 agitated behaviors during bathing in 15 elderly residents with dementia residing in a continuing care center. Each resident was observed for four sessions of two different bathing methods, the conventional tub bath and a modification of the bed bath, known as the Thermal bath. The summed frequencies of all agitated behaviors was significantly less for the Thermal bath than the tub bath. This overall effect was greater in men than women and in one particular behavior, shivering. The results suggest that for individuals with dementia the Thermal bath offers a viable alternative to the conventional tub method. Further research may clarify other parameters, such as cost effectiveness and long-term effects of the use of non-rinse cleansers for elderly individuals.

"Individualised care" from patients', nurses' and relatives' perspective--a review of the literature

This paper provides an overview of the empirical research literature on individualised care. It offers a description of the methods that have been used in studies of individualised care over the years, and then discusses the meaning and realisation of individualised care from patients', nurses' and relatives' points of view in order to highlight needs for further research. The review focuses on empirical articles retrieved from the MEDLINE database published between 1973 and June 1999. It draws attention to the complexity of individualised care, which at first sight may look like a relatively straightforward nursing activity. It is shown that a wide range of methods have been used to study individualised care in the current literature. There is a lack of research where patients' experiences of the individuality of care in hospital settings are concerned.

Individualized care: perceptions of certified nurse's aides

Despite substantial attention devoted to the development of individualized care in nursing homes during recent years, empirical research assessing progress is limited. Further, few studies have explored the experiences of certified nurse's aides (CNAs) in this regard. This survey examines the perceptions and experiences of CNAs in providing individualized care. CNAs (n = 254) were asked to describe a number of current practices and obstacles to implementing individualized care in nursing homes. The majority of respondents reported experiencing: flexibility to change daily schedules; supervisor assistance with challenging residents; active participation in care planning; freedom to test new approaches to care; and supervisors who are open to CNA suggestions. Several barriers to individualized care were also described, including: inadequate staffing; poor team communication; staff attitudes; and a lack of knowledge and training in alternative approaches. These findings provide important insights into the supports and obstacles to implementing individualized care in nursing homes from the perspective of CNAs.

Individualized care in a Finnish healthcare organization

This paper reports the findings of a study exploring the provision of individualized care in a regional hospital in Finland. Individualized care was defined in terms of how patient individuality was taken into account and how patient participation in decision-making was facilitated. The data were collected from hospitalized patients (n = 203) using a questionnaire specially developed for this study. The response rate was 89%. A strong support to facilitate patient participation in decision-making was reported. Most shortcomings concerning the provision of individualized care related to consideration of the patient's cultural background and the involvement of the patient's family in the planning of care. Patients' age and the type of ward were associated with the provision of individualized care: patients aged 65 or over were more satisfied than younger age groups with the way in which their personal life situation had been taken into account. Patients from the gynaecological ward thought, more than patients from the surgical ward, that their situation had been taken into account during hospitalization.

Developing individualized care in nursing homes: integrating the views of nurses and certified nurse aides

Despite recent attention devoted to the development of individualized care in nursing homes, empirical research assessing changes in practice is quite limited, and very few studies have explored specifically the experiences and perceptions of certified nurse aides (CNAs). This study reports findings from a comparative analysis conducted on a data set including quantitative and qualitative data from CNAs (N = 289) and nurses in Connecticut (N = 245). Measures of obstacles to individualized care and needs for future supports were explored. A number of significant differences in perceptions of obstacles to providing individualized care were found. The nurses were significantly more likely to identify the following impediments to change: cost (p < .0001), concepts not integrated into work (p < .0001), lack of administrative support (p < .10), and staff attitudes (p < .10). The CNAs were significantly more likely to report inadequate staffing (p < .001), lack of interdisciplinary teams (p < .001), and resident and family attitudes (p < .01) as problematic. These findings suggest substantial discordance among nurses and CNAs on a number of important issues surrounding individualized care. Such disparate perceptions pose challenges to nursing homes committed to the implementation of individualized care alternatives. Successful approaches must consider the various vantage points of caregivers and administrators.