Stephanie A. Chamberlain

Dying in a nursing home: treatable symptom burden and its link to modifiable features of work context.

IMPORTANCE High-quality care at the end of life supports freedom from pain and other potentially burdensome symptoms. Lowering symptom burden at the end of life is an urgent and achievable goal in delivering services in nursing home settings. Few published reports describe symptom burden among older adults in nursing homes; none examine links between symptom burden and modifiable features of nursing home organizational context (work environment). OBJECTIVES To examine the influence of organizational context on symptom burden and to compare symptom burden in the last year of life between nursing home residents with and without dementia. DESIGN Retrospective analysis of longitudinal survey data. SETTING A stratified random sample of 36 nursing homes in the Canadian provinces of Alberta, Manitoba, and Saskatchewan. PARTICIPANTS A total of 2635 residents with dementia and 1012 without dementia; 1381 front-line care staff. MEASUREMENTS (1) Trajectories of 6 symptoms (dyspnea, pain, pressure ulcers, urinary tract infections, challenging behavior, delirium), assessed with the Resident Assessment Instrument-Minimum Data Set, version 2.0, between 2008 and 2012. All residents received assessments in each quarter of the year before death. (2) Modifiable organizational context, assessed with the Alberta Context Tool. Hierarchical mixed model, repeated measures regression, to simultaneously evaluate effects of time, dementia, and context on symptom trajectories. RESULTS For all residents, prevalence of symptoms increased over time. In the last quarter before death, challenging behavior was the most frequent symptom in the dementia group (40.2%), delirium the most frequent symptom in the nondementia group (31.0%), and urinary tract infections least frequent (9.0% to 10.0%). Facilities with more favorable context had significantly higher prevalence of challenging behavior and delirium and significantly lower use of antipsychotics without diagnosis of psychosis. CONCLUSION Symptom burden increases as the end of life approaches but differs between high- and low-context facilities and between residents with and without dementia. Trajectories of treatable, burdensome symptoms at the end of life in nursing homes should be a priority focus for quality improvement. Modifiable features of organizational context that are linked to symptom burden offer new potential strategies and interventions for quality improvement.

Influence of organizational context on nursing home staff burnout: A cross-sectional survey of care aides in Western Canada

PURPOSE Our study examined care aide characteristics, organizational context, and frequency of dementia-related resident responsive behaviours associated with burnout. Burnout is the experience of emotional exhaustion, cynicism, and professional inefficacy. Care aide burnout has implications for turnover, staff health, and quality of care. DESIGN AND METHODS We used surveys collected from 1194 care aides from 30 urban nursing homes in three Western Canadian provinces. We used a mixed-effects regression analysis to assess care aide characteristics, dementia-related responsive behaviours, unit and facility characteristics, and organizational context predictors of care aide burnout. We measured burnout using the Maslach Burnout Inventory, Short Form. RESULTS We found that care aides were at high risk for emotional exhaustion and cynicism, but report high professional efficacy. Statistically significant predictors of emotional exhaustion included English as a second language, medium facility size, organizational slack-staff, organizational slack-space, health (mental and physical) and dementia-related responsive behaviours. Statistically significant predictors of cynicism were care aide age, English as a second language, unit culture, evaluation (feedback of data), formal interactions, health (mental and physical) and dementia-related responsive behaviours. Statistically significant predictors of professional efficacy were unit culture and structural resources. Greater care aide job satisfaction was significantly associated with increased professional efficacy. IMPLICATIONS This study suggests that individual care aide and organization features are both predictive of care aide burnout. Unlike care aide or structural characteristics of the facility elements of the organizational context are potentially modifiable, and therefore amenable to intervention.

Individual and organizational predictors of health care aide job satisfaction in long term care.

BackgroundUnregulated health care aides provide the majority of direct health care to residents in long term care homes. Lower job satisfaction as reported by care aides is associated with increased turnover of staff. Turnover leads to inferior job performance and negatively impacts quality of care for residents. This study aimed to determine the individual and organizational variables associated with job satisfaction in care aides.MethodsWe surveyed a sample of 1224 care aides from 30 long term care homes in three Western Canadian provinces. The care aides reported their job satisfaction and their perception of the work environment. We used a hierarchical, mixed-effects ordered logistic regression to model the relative odds of care aide job satisfaction for individual, care unit, and facility factors.ResultsCare aide exhaustion, professional efficacy, and cynicism were associated with job satisfaction. Factors in the organizational context that are associated with increased care aide job satisfaction include: leadership, culture, social capital, organizational slack—staff, organizational slack—space, and organizational slack—time.ConclusionsOur findings suggest that organizational factors account for a greater increase in care aide job satisfaction than do individual factors. These features of the work environment are modifiable and predict care aide job satisfaction. Efforts to improve care aide work environment and quality of care should focus on organizational context.

Pathways for best practice diffusion: the structure of informal relationships in Canada’s long-term care sector

BackgroundInitiatives to accelerate the adoption and implementation of evidence-based practices benefit from an association with influential individuals and organizations. When opinion leaders advocate or adopt a best practice, others adopt too, resulting in diffusion. We sought to identify existing influence throughout Canada’s long-term care sector and the extent to which informal advice-seeking relationships tie the sector together as a network.MethodsWe conducted a sociometric survey of senior leaders in 958 long-term care facilities operating in 11 of Canada’s 13 provinces and territories. We used an integrated knowledge translation approach to involve knowledge users in planning and administering the survey and in analyzing and interpreting the results. Responses from 482 senior leaders generated the names of 794 individuals and 587 organizations as sources of advice for improving resident care in long-term care facilities.ResultsA single advice-seeking network appears to span the nation. Proximity exhibits a strong effect on network structure, with provincial inter-organizational networks having more connections and thus a denser structure than interpersonal networks. We found credible individuals and organizations within groups (opinion leaders and opinion-leading organizations) and individuals and organizations that function as weak ties across groups (boundary spanners and bridges) for all studied provinces and territories. A good deal of influence in the Canadian long-term care sector rests with professionals such as provincial health administrators not employed in long-term care facilities.ConclusionsThe Canadian long-term care sector is tied together through informal advice-seeking relationships that have given rise to an emergent network structure. Knowledge of this structure and engagement with its opinion leaders and boundary spanners may provide a route for stimulating the adoption and effective implementation of best practices, improving resident care and strengthening the long-term care advice network. We conclude that informal relational pathways hold promise for helping to transform the Canadian long-term care sector.

Nursing-Home Resident Quality of Life: A Longitudinal Case Study Approach

ABSTRACT Longitudinal quality-of-life (QOL) research incorporating multiple perspectives can add to knowledge about how nursing home residents experience QOL, but these methods are seldom used. This study employed interviews and participant observation to conduct multiple-perspective, longitudinal case studies of six residents. Close, reciprocal relationships with staff members, staff knowledge of residents, and autonomy were fundamental to QOL. Autonomy was experienced through choice and self-advocacy. Changes in QOL over time related to changes in resident health status, acclimation to the setting and family member availability. Study results may have implications for staffing and staff training.

Health of health care workers in Canadian nursing homes and pediatric hospitals: a cross-sectional study

BACKGROUND Poor health of health care workers affects quality of care, but research and health data for health care workers are scarce. Our aim was to compare physical/mental health among health care worker groups 1) within nursing homes and pediatric hospitals, 2) between the 2 settings and 3) with the physical/mental health of the Canadian population. METHODS Using cross-sectional data collected as part of the Translating Research in Elder Care program and the Translating Research on Pain in Children program, we examined the health of health care workers. In nursing homes, 169 registered nurses, 139 licensed practical nurses, 1506 care aides, 145 allied health care providers and 69 managers were surveyed. In pediatric hospitals, 63 physicians, 747 registered nurses, 155 allied health care providers, 49 nurse educators and 22 managers were surveyed. After standardization of the data for age and sex, we applied analyses of variance and general linear models, adjusted for multiple testing. RESULTS Nursing home workers and registered nurses in pediatric hospitals had poorer mental health than the Canadian population. Scores were lowest for registered nurses in nursing homes (mean difference -4.4 [95% confidence interval -6.6 to -2.6]). Physicians in pediatric hospitals and allied health care providers in nursing homes had better physical health than the general population. We also found important differences in physical/mental health for care provider groups within and between care settings. INTERPRETATION Mental health is especially poor among nursing home workers, who care for a highly vulnerable and medically complex population of older adults. Strategies including optimized work environments are needed to improve the physical and mental health of health care workers to ameliorate quality of patient care.

Factors Influencing Family-Member Perception of “Homelikeness” in Long-Term Care Homes

ABSTRACT Background: A number of long-term care homes in Nova Scotia, Canada, have been built or redesigned with new models of care with expanded care aide scope of practice and neighborhood-style layouts. Our objective was to examine what physical characteristics (bed size, owner-operator), model of care, and relational (family–staff relationship, perceived staff–resident relationship) factors were associated with increased family-member perception of homelikeness in long-term care homes. Methods: We analyzed surveys collected from 273 family members from 23 long-term care homes in Nova Scotia, Canada. We conducted a multivariate linear regression to assess variables associated with increased family-member perception of homelikeness. Results: We found that relationships between family and staff, perceived resident-to-resident relationships, and family involvement in decision making were positively associated with increased family perception of homelikeness. We found no significant associations between model of care or physical characteristics and increased family perception of homelikeness. Conclusion: Relationships among family members, residents, and staff are integral to family members feeling at home in their loved ones long-term care home. Feeling at home in long-term care is largely related to family-member perception of meaningful social interactions between family and staff, and between residents.

What makes a nursing home a home? Insights from family members and friends

Purpose The purpose of this paper is to explore the concept of homelikeness from the perspective of family members and friends of nursing home residents across different models of nursing homes. Design/methodology/approach This mixed-methods study examined survey data collected from 397 family members and friends of residents living in 23 nursing homes representing three models of care (traditional, new augmented, and full scope). Participants completed a homelikeness scale and a measure of the importance of nursing home spaces to family members and friends. This study also involved conducting three focus groups with 20 family members and friends to provide further insights into the findings. Findings Analysis of survey data indicated quite high levels of homelikeness overall. Significant differences did emerge between traditional model nursing homes compared to new full-scope and new augmented models for all items in the homelikeness scale and for many items about nursing home spaces. Qualitative results provided insights into how homelikeness can be fostered through public and private spaces and through care and relationships. Research limitations/implications As this study was conducted in one Canadian province, the results may not be applicable to other geographic areas. In addition, there are limitations in survey response rate. Practical implications Homelikeness can be supported across models of care by fostering relationships between residents and staff, ensuring that that family and friends feel welcome, and creating public and private physical spaces that are conducive to new and ongoing relationships. Originality/value The results provide evidence to nursing home decision makers about how to foster a homelike environment in various models of nursing homes.