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.

Assisting Cognitively Impaired Nursing Home Residents With Bathing: Effects of Two Bathing Interventions on Caregiving

PURPOSE

When cognitively impaired nursing home residents exhibit agitated and aggressive behaviors during bathing, nursing home caregivers are in a unique position to improve residents' experience. This report addresses whether certified nursing assistants (CNAs) who received training in a person-centered approach with showering and with the towel bath showed improved caregiving behaviors (gentleness and verbal support) and experienced greater preparedness (confidence and ease) and less distress (hassles) when assisting residents with bathing.

DESIGN AND METHODS

We used a crossover design and randomized 15 nursing homes into two treatment groups and a control group of 5 facilities each. In one treatment group, CNAs received person-centered training, first with showering for 6 weeks (Time 1) and then with the towel bath for 6 weeks (Time 2). We reversed the treatment order in the other treatment group. Control group CNAs used usual showering procedures without person-centered training. We collected observational and self-report data at baseline and at the end of Time 1 and Time 2 on five caregiving outcomes. We analyzed data from 37 CNAs assisting 69 residents by using 3x2 repeated measures analyses of variance to compare the three groups on change from baseline.

RESULTS

Compared with the control group, treatment groups significantly improved in the use of gentleness and verbal support and in the perception of ease.

IMPLICATIONS

A person-centered approach with showering and with the towel bath improved not only how care is given to residents who become agitated and aggressive during bathing but also how CNAs perceive their experience when bathing these residents.

The Bathing Of Older Adults with Dementia

Older adults who need assistance with bathing often find the activity to be both physically and emotionally demanding, as do their caregivers. Research has identified several contributing factors, including pain; fatigue and weakness; confusion; anxiety resulting from being naked in front of strangers, being afraid of falling, and being in a noisy or unfamiliar place; and discomfort from cold or drafty bathing areas or harsh water sprays. The authors of this article make the case for the elimination of forced bathing. Research supports this change in philosophy and practice, whereby bathing is not a task to be performed but rather a human interaction. Inexpensive, practical, and evidence-based alternatives are discussed.

Effect of Person-Centered Showering and the Towel Bath on Bathing-Associated Aggression, Agitation, and Discomfort in Nursing Home Residents with Dementia: A Randomized, Controlled Trial

OBJECTIVES

To evaluate the efficacy of two nonpharmacological techniques in reducing agitation, aggression, and discomfort in nursing home residents with dementia. The techniques evaluated were person-centered showering and the towel bath (a person-centered, in-bed bag-bath with no-rinse soap).

DESIGN

A randomized, controlled trial, with a usual-care control group and two experimental groups, with crossover.

SETTING

Nine skilled nursing facilities in Oregon and six in North Carolina.

PARTICIPANTS

Seventy-three residents with agitation during bathing (69 completed the trial) and 37 nursing assistants who bathed them.

MEASUREMENTS

Agitation and aggression were measured using the Care Recipient Behavior Assessment; discomfort was measured using a modification of the Discomfort Scale for Dementia of the Alzheimer Type. Raters who were blinded to subject status coded both from videotaped baths. Secondary measures of effect included bath duration, bath completeness, skin condition, and skin microbial flora.

RESULTS

All measures of agitation and aggression declined significantly in both treatment groups but not in the control group, with aggressive incidents declining 53% in the person-centered shower group (P<.001) and 60% in the towel-bath group (P<.001). Discomfort scores also declined significantly in both intervention groups (P<.001) but not in the control group. The two interventions did not differ in agitation/aggression reduction, but discomfort was less with the towel bath (P=.003). Average bath duration increased significantly (by a mean of 3.3 minutes) with person-centered showering but not with the towel bath. Neither intervention resulted in fewer body parts being bathed; both improved skin condition; and neither increased colonization with potentially pathogenic bacteria, corynebacteria, or Candida albicans.

CONCLUSION

Person-centered showering and the towel bath constitute safe, effective methods of reducing agitation, aggression, and discomfort during bathing of persons with dementia.

Pain in older adults

This chapter reviews 80 published research reports of pain and pain problems in older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) using the search terms pain, older adult, aged and pain, and dementia. Reports were included if published between 1985 to 2001, if conducted on samples age 60 or older, if conducted by nurses or relevant to nursing research, and if published in English. Descriptive, qualitative, correlational, longitudinal, and intervention studies were included. Key findings include the following: pain is widely prevalent in older adult populations; few studies have included minority groups; under-identification and undertreatment of pain in older adults is a consistent interpretation of research findings; pain intensity rating scales are as valid and reliable in older populations as in younger populations; current observational methods of assessing pain in cognitively impaired older adults must be used with caution; nursing intervention studies demonstrate the beneficial effects of education and interventions aimed at improved pain assessment. The main recommendations are: careful attention should be given to the conceptualization and definition of pain; examination of pain should include physiological, motivational, cognitive, and affective factors; studies evaluating undertreatment of pain should include measures of pain self-report; standardized pain measures should be used; studies of persons over the age of 85 and studies of ethnic minorities are needed; more attention should be given to nursing intervention studies and should include both pharmacological and nonpharmacological, psychosocial interventions.

Mental health correlates of aggression in nursing home residents with dementia

PURPOSE

Aggression continues to challenge caregivers of persons with dementia, and identification of foci for effective interventions is needed. The purpose of this study was to examine the influence of (a) the resident characteristics of depression, communication, and cognition and (b) behavior management strategies on aggression in a group of older nursing home residents (N = 405) with evidence of dementia.

DESIGN AND METHODS

This cross-sectional correlational study examined the association of resident characteristics and behavior management strategies with bivariate aggression, physical aggression, and verbal aggression, using hierarchical regression.

RESULTS

Main findings are that impaired communication is associated with all forms of aggression, depression with physical aggression, and disorientation with verbal aggression. A 3-month prior pattern of antipsychotic drug use was consistently associated with all forms of aggression and physical restraint use with physical aggression. Most of the explained variance was attributable to antipsychotic drug use.

IMPLICATIONS

The separate explanatory models for physical and verbal aggression indicate that these may be unique entities with different foci for treatment. These results provide evidence that aggression persists despite antipsychotic drug use and that further mental health interventions might be targeted at compensating for impaired communication and the treatment of depression to improve the mental health of nursing home residents with dementia.

A critique of research measures used to assess inappropriate psychoactive drug use in older adults

An overview and critique of research measures of inappropriate psychoactive drug use in the treatment of frail older adults is presented. These measures are compared on the basis of six key criteria for the complex determination of inappropriate psychoactive drug use as a research variable. These six instruments/standards are examined also for their advantages and disadvantages as research tools. Based on this review and related literature, recommendations are made that future studies of inappropriate psychoactive drug use include expert clinician assessment, measures of target symptoms and functional status, physiological indicators wherever possible, and drug and dosage classifications according to interdisciplinary consensus-based criteria.

Responding to safety issues in frontotemporal dementias

As frontotemporal dementia progresses in individuals, safety issues related to behaviors and injury become a paramount concern. In addition to self-care deficits, frontotemporal dementias are often characterized by behavioral manifestations that include aggression and disinhibition. These behaviors may place the patient and caregivers at risk of injury, stress, and social embarrassment, and frequently lead to institutionalization. Additionally, motor disturbances associated with frontotemporal dementias may contribute to risk of injury from falls. The authors present an integrated biopsychosocial model to guide assessment of needs that may be expressed through behavior. Environmental, behavioral, and psychosocial strategies to assist caregivers in preventing and responding to behaviors and risks are discussed, with the goal of promoting maximum function and quality of life and minimizing caregiver strain. The authors discuss the dangers of physical restraints, which are commonly suggested as a response to fall risk and behavioral symptoms without an awareness of research-based data regarding their lack of efficacy. Benefits and risks of a variety of need-based interventions are presented in a practical, clinically relevant manner. The discussion of diverse safety-enhancing interventions is intended to enable clinicians and caregivers to identify individualized care strategies for patients with frontotemporal dementia.

Facilitating end-of-life decision-making: strategies for communicating and assessing

End-of-life decision-making is often a difficult process and one that many elderly patients and their families will undergo. The grounded theory study of nurses, physicians, and family members (n = 20) reported in this article examined provider behaviors that facilitated the process of decision-making near the end of patients' lives. According to participants, providers who are experienced and comfortable are more likely to engage in communication and assessment strategies that facilitate end-of-life decision-making. Communication strategies included: being clear, avoiding euphemisms, spelling out the goals and expectations of treatment, using words such as "death" and "dying," and being specific when using such words as "hope" and "better." Assessment strategies included: assessing patients' physical conditions and end-of-life wishes, patients' and family members' understandings of the disease and prognosis, and their expectations and goals. An important first step for improved care is making explicit the provider's communicating and assessing strategies that facilitate end-of-life decision-making.

Individualized interventions to prevent bed-related falls and reduce siderail use

Five categories of problems that often result in siderail use: memory disorder, impaired mobility, injury risk, nocturia/incontinence, and sleep disturbance. As nursing homes work toward meeting the Health Care Financing Administration's mandate to examine siderail use, administrators and staff need to implement interventions that support safety and individualize care for residents. While no one intervention represents a singular solution to siderail use, a range of interventions, tailored to individual needs, exist. This article describes the process of selecting individualized interventions to reduce bed-related falls.

Individualized assessment and intervention in bilateral siderail use

The use of bilateral siderails, similar to physical restraints, can be safely reduced by a comprehensive assessment process. This article presents an individualized assessment for evaluating siderail use to guide nurses in managing resident characteristics for falling out of bed and intervening for high-risk residents. The individualized assessment is consistent with federal resident assessment instrument requirements and includes risk factors specific to falls from bed.