Muriel B. Ryden

Treatment of Pain in Cognitively Impaired Compared with Cognitively Intact Older Patients with Hip-Fracture

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture.

AGGRESSIVE BEHAVIOR: Educating Nursing Assistants

Caring for cognitively impaired aggressive residents presents a challenge to nursing assistants in long-term care facilities. Nursing assistants participated in an educational program that included content about cognitive losses, precipitants of aggression, communication techniques, strategies for preventing aggressive behavior, and managing personal feelings. Following the educational intervention in this study, nursing assistants reported that caring for cognitively impaired residents was significantly more rewarding and less frustrating. The use of the clinical nurse specialist to teach and assist in role modeling direct care of residents was effective in improving nursing assistant skill in working with aggressive cognitively impaired residents.

Progress in the Moral Reasoning of Baccalaureate Nursing Students between Program Entry and Exit

Changes in moral reasoning between entry into and exit from a baccalaureate nursing program and the relationship between student characteristics and moral reasoning at entry and exit were explored in this descriptive study. The moral reasoning of four cohorts of students was measured using the Defining Issues Test (DIT). Admission grade point average, prior college credits, and gender accounted for 10% of the variance in DIT P% scores at entry and 14% of the variance at exit from the program. Female students had significantly higher moral reasoning scores than men. Age did not contribute significantly to explaining DIT score variance. DIT P% scores at entry for all four cohorts were within the range of reported norms for college students. Exit scores for all four cohorts were between the normative means for undergraduate students and graduate students. DIT P% score gains between entry and exit were significant for all four cohorts. Students whose entry scores were in the lowest categories had the greatest mean gains.

Morale and perceived control in institutionalized elderly.

This study explored patterns of causal relationships among perception of situational control, health, socioeconomic status, functional dependency, length of stay, and morale in institutionalized elderly. Causal patterns in residents at two levels of care were contrasted.A total of 113 residents on intermediate and skilled care units chosen randomly from 4 urban proprietary nursing homes were studied. Variables were measured by means of an interview. Instruments included the Philadelphia Geriatric Center Morale Scale, Changs Situational Control of Daily Activities Scale, and the Residents Questionnaire.Path analysis was used with a causal model to estimate direct and indirect effects of the independent variables on morale. Important differences in the way the independent variables affected morale for residents on the two levels of care were reported. Perception of situational control proved to be a key variable, significantly related to the morale of residents on both levels of care, although the strength of the association was stronger for residents on skilled care. Functional dependency, health, and socioeconomic status had significant direct effects on the morale of residents on intermediate care but not those on skilled care.

GOAL-DIRECTED CARE: Caring for Aggressive Nursing Home Residents With Dementia

1. Aggressive behavior in elders with dementia occurs most often during personal care. It is often a response to invasion of private space and may be prevented or reduced by interpersonal approaches that reflect a set of individualized goals for the resident. 2. Five resident goals for preventing or reducing aggressive behavior are to feel safe, to feel physically comfortable, to experience a sense of control, to experience optimal stress, and to experience pleasure. 3. These goals provide a framework for humane care that respects the personhood of the individual and minimizes the need for psychotropic medications and physical restraints.

Staff training and turnover in Alzheimer special care units: comparisons with non-special care units.

Nursing facility staff may not be properly trained to deal with behavioral symptoms of Alzheimers disease. We collected data about specialized dementia training and turnover among licensed nurses and nursing assistants in 400 nursing units in 124 Minnesota nursing facilities. Staff training may affect the retention of paraprofessional and professional nursing staff. A diversity of training methods, including workshops or seminars, films or videos, outside consultants, reading materials, training manuals, in-house experts, role playing techniques, or an orientation program for new staff, might be used to develop more effective training programs and reduce rates of nursing assistant turnover.

Limited-treatment policies in long-term care facilities

Two‐thirds of the long‐term care facilities in Minnesota accept do‐not‐resuscitate (DNR) orders and 73% accept care plans to limit medical treatment. The major objectives for limited‐treatment plans cited by the 16.3% of facilities with administrative protocols for such plans was to provide for the residents physical and emotional comfort and dignity. Nearly half of the protocols said limited treatment plans were intended to limit emergency care or hospitalization or to allow death to occur. Protocols advocated the alleviation of physical discomfort, anxiety, and social isolation. Tube feedings were not recommended when oral feeding became impossible. Airway suctioning, oxygen, or antibiotic treatment was suggested only as needed to alleviate suffering. Only a fourth of the protocols described a primary role for the resident in these decisions. This study demonstrates that nursing homes are developing administrative protocols for the formulation of limited‐treatment plans and suggests that model policy statements describing key decision‐making principles, issues, and procedural safeguards could play a constructive role in this process.

Development of a measure of resident satisfaction with the nursing home.

A satisfaction instrument specifically designed for use with nursing home residents, the Satisfaction with the Nursing Home Instrument (SNHI), was developed and tested with a sample of 110 nursing home residents from three proprietary facilities in Minnesota. As hypothesized, significant relationships were found between SNHI scores and measures of affect (negatively associated with depression and positively associated with morale), providing support for the construct validity of the scale. The lack of a significant relationship between SNHI scores and both age and mental status confirmed the predicted divergent validity of the instrument. The alpha coefficient for the 29-item scale was 0.81.

Relationships between aggressive behavior in cognitively impaired nursing home residents and use of restraints, psychoactive drugs, and secured units

This study examined relationships between aggressive behavior in cognitively impaired nursing home residents and physical restraints, psychoactive drugs, and placement on a secured unit. Data were obtained from 116 residents who were consistently aggressive as measured by the Ryden Aggression Scale 2. Subjects averaged 9.5 aggressive behaviors per day. Forty-seven percent of subjects were restrained, and 62% were regularly receiving psychoactive drugs. Use of restraints, antipsychotics, and placement on a secured unit were all significantly related to increased physical aggression scores. Four variables accounted for 23% of the variance in physical aggression scores: location on a secured unit, not receiving an antidepressant, being restrained, and number of psychotropic and/or anxiolytic medications administered. Significantly lower physical aggression scores were noted for subjects receiving antidepressants.

The relationship between social interaction and characteristics of aggressive, cognitively impaired nursing home residents

The extent of social interaction of aggressive, cognitively impaired nursing home residents and the relationship between social interaction and selected resident characteristics were explored in this study, which was part of a larger experimental study of the effect of dementia education for staff on the aggressive behavior of cognitively impaired residents. Staff rated residents using the Social Interaction Scale (SIS),which has two subscales: Institutional Interaction and Family/Community Interaction. Mean SIS scores were low; institutional interaction scores were higher than family/community scores. Marital status, morale, degree of cognitive impairment, dependency, and sexual aggression were significantly associated with social interaction, but gender and age were not.