Examining dual roles in long-term-care homes in rural Alberta: a qualitative study.

INTRODUCTION: In rural settings, many healthcare professionals experience intersections of professional and personal relationships, often known as dual roles. Dual roles are traditionally studied in terms of their potential for ethical conflicts or negative effects on care. In the existing scholarship, there is little discussion of dual roles in long-term care (LTC) settings, which present distinct conditions for care. Unlike other forms of health care, LTC work is provided daily, over longer periods, in care recipients' home environments. This article outlines results from a case study of LTC in rural Alberta, Canada and provides evidence of some of the challenges and, more notably, the considerable benefits of dual roles in these settings. METHODS: The qualitative data discussed in this article come from a multi-site comparative case study of rural LTC that, among other questions, asked, 'How do personal and professional lives intersect in rural LTC settings across the province?' These data were collected through the use of rapid ethnographies at three rural LTC homes across the province of Alberta. The research team conducted semi-structured, in-depth interviews (n=90) and field observations (~200 hours). Participants were asked about care team dynamics, the organization of care work, the role of the LTC home in the community, and the intersections of public and private lives. The results were coded and critically analyzed using thematic analysis. RESULTS: Dual roles were primarily described as beneficial for care provision. In many cases, dual roles provided participants with opportunities for reciprocity, enhanced person-centered care, and increased perceptions of trust and community accountability. Similar to what has been documented in the extant literature, dual roles also presented some challenges regarding personal and professional boundaries for those in leadership. However, the negative examples were outweighed by positive accounts of how dual roles can serve as a potential asset of rural LTC. CONCLUSION: There is a need for more nuanced conversations around the implications of dual roles. Policies and care approaches need to emphasize and support the use of good judgment and the responsible navigation of dual roles, rather than taking either a permissive or prohibitive approach. Leaders in rural LTC can promote conversations among care providers, with an emphasis on the cultural context of care provision and how dual roles play out in their specific professional practice. Blanket policies or educational approaches that frame dual roles as necessarily problematic are not only insensitive to the unique nature of rural LTC, but prohibitive of relational elements that these results suggest are highly supportive of person-centered care.

Consistent assignment in long-term care homes: Avoiding the pitfalls to capitalise on the promises.

BACKGROUND: Consistent assignment (CA) is the practice within long-term care (LTC) by which care staff work with the same residents almost every shift for an indefinite period of time. CA is considered by many to be essential to person-centred care. OBJECTIVES: This paper explores how staff assignment practices impact the caregiving experience from the perspectives of resident care aides (RCAs), residents and family members and, by doing so, describe the nuanced conditions under which CA may or may not be beneficial to all, and why. METHODS: Data are drawn from 40 in-depth interviews conducted as part of a larger institutional ethnography exploring the social organisation of care in three purposively selected LTC homes in Western Canada. Data analysis was based on the principles of constant comparison. RESULTS: RCAs, residents and family members described the primary benefit of CA as being able to 'get to know' each other well and form meaningful relationships. However, the RCAs also indicated that CA can contribute to feelings of isolation, which has negative effects on worker comfort and satisfaction, care team dynamics and communication, and resident care. CONCLUSIONS: Management initiatives are needed to ensure that the implementation of CA does not result in the unintended consequences of decreasing RCAs' experience of teamwork, decreasing RCAs' exchange of individualised resident care information, or negatively impacting RCAs' ability and desire to care for each other as well as the residents. IMPLICATIONS FOR PRACTICE: The staffing practice of consistent assignment in long-term care homes provides increased opportunities for the development of stronger staff-resident and staff-family member relationships. Findings from this study enable us to offer several, evidenced-based recommendations for ensuring the successful implementation of consistent assignment, such that it may be beneficial to all.

Stakeholder Engagement in Practice Change: Enabling Person-Centred Mealtime Experiences in Residential Care Homes.

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

Strategies to facilitate shared decision-making in long-term care.

AIM: The aim of this study was to explore shared decision-making among residents, their families and staff to determine relevant strategies to support shared decision-making in long-term care (LTC). BACKGROUND: Meaningful engagement of long-term care home (LTCH) residents and their families in care decisions is key in the provision of quality of care. Shared decision-making is an interprofessional approach to increasing resident and family engagement in care decisions which can lead to higher quality decisions, more relevant care interventions and greater resident, family, and staff satisfaction. Despite these advantages, shared decision-making has not been widely implemented in practice in LTC. METHODS: The study took place in one LTCH in Toronto, Ontario, Canada. A qualitative descriptive design was used to explore how residents, family members and staff described how they collaborate when making decisions concerning resident care, and their perceptions of facilitators and challenges to a collaborative approach to decision-making. Individual interviews were conducted with nine participants: residents, families and staff. Data were analysed using content and thematic analysis. FINDINGS: Four main themes that described resident, family and staff perspectives of shared decision-making were as follows: (a) oral communication pathways for information sharing; (b) supporting resident decision-making autonomy; (c) relational aspects of care facilitate shared decision-making; and (d) lack of effective communication creates barriers to shared decision-making. CONCLUSION: As the demand for LTC continues to increase, it is crucial that healthcare providers engage in collaborative, relational practices that foster high-quality resident care. While a relational approach to care can facilitate shared decision-making, there are opportunities to further cultivate shared decision-making in LTCHs through more effective communication and collaboration. IMPLICATIONS FOR PRACTICE: Understanding how information is shared and decisions are made can facilitate shared decision-making in LTCHs. The strategies identified from this study could be further co-developed and implemented in LTCHs.

The Influence of Supportive Supervisory Practices and Health Care Aides' Self-Determination on the Provision of Person-Centered Care in Long-Term Care Facilities.

Person-centred care (PCC) is recognized as best practice in long-term care (LTC). Using a cross-sectional design, we examined the relationship between supportive supervisory practices and health care aides' (HCAs) self-determination on HCAs' perceived ability to provide PCC. A total of 131 HCAs from four LTC facilities participated in the study. There were strong, positive associations between HCAs' self-determination and their perceived ability to provide PCC, r = .59, p < .0001, and how supportive their supervisors were, r = .50, p < .0001. Mediation analysis using structural equation modeling found the direct effect of self-determination on PCC was 73% of its total effect on PCC; its indirect effect mediated through supervisory support was 27% of its total effect on PCC. Improving supportive supervisory relationships that encourage and enable HCAs' self-determination in LTC settings may be an important and effective means by which to increase the provision of PCC.

Mitigating Moral Distress in Dementia Care: Implications for Leaders in the Residential Care Sector.

In 2012, the World Health Organization estimated that the number of people living with dementia worldwide was approximately 35.6 million; they projected a doubling of this number by 2030, and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing providers is a common part of the dementia journey in most countries. Previously published research confirms that caring for people living with dementia in such facilities often creates moral distress for nursing care providers. In this paper, the authors share additional findings from a two-year, two-phase, mixed methods study of moral distress as experienced by nursing caregivers of residents with dementia in residential care settings in a Western Canadian province. The findings relate to strategies to reduce moral distress in this caregiving group, with a particular focus on the role of supportive and responsive leadership. Important implications for practice and for leadership in the residential care sector are presented.

Nonpharmacological Management of Behavioral and Psychological Symptoms of Dementia: What Works, in What Circumstances, and Why?

OBJECTIVE: Behavioral and psychological symptoms of dementia (BPSD) refer to the often distressing, noncognitive symptoms of dementia. BPSD appear in up to 90% of persons with dementia and can cause serious complications. Reducing the use of antipsychotic medications to treat BPSD is an international priority. This review addresses the following questions: What nonpharmacological interventions work to manage BPSD? And, in what circumstances do they work and why? METHOD: A realist review was conducted to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases for empirical studies that reported a formal evaluation of nonpharmacological interventions to decrease BPSD. RESULTS: Seventy-four articles met the inclusion criteria. Three mechanisms emerged as necessary for sustained effective outcomes: the caring environment, care skill development and maintenance, and individualization of care. We offer hypotheses about how different contexts account for the success, failure, or partial success of these mechanisms within the interventions. DISCUSSION: Nonpharmacological interventions for BPSD should include consideration of both the physical and the social environment, ongoing education/training and support for care providers, and individualized approaches that promote self-determination and continued opportunities for meaning and purpose for persons with dementia.

The Responsive Leadership Intervention: Improving leadership and individualized care in long-term care.

The Responsive Leadership Intervention (RLI) is a multi-faceted intervention. We evaluated the influence of the RLI on i) responsive leadership practices by team leaders; ii) health care aides' (HCAs) self-determination; iii) HCAs' perceived ability to provide individualized care. A quasi-experimental repeated measures non-equivalent control group design was used to assess participant outcomes in four long-term care facilities (two control, two intervention) across four time periods. Change from baseline to 1-month post-intervention was greater in the intervention group than control group for Individualized Care (IC) (p = 0.001), but not for Self Determination (p = 0.26). Perceived levels of responsive leadership was greater following the intervention among participants with baseline measures that were less than the median (p = 0.007), but not if greater. At 3-months post-intervention, the intervention group retained 32% of the difference from control in IC, and 49% of the difference from control in responsive leadership; at 6-months post-intervention, 35% and 28%, respectively. The RLI is a feasible method for improving responsive leadership practices and individualized care.

Mitigating Moral Distress in Dementia Care: Implications for Leaders in the Residential Care Sector.

In 2012, the World Health Organization estimated that the number of people living with dementia worldwide was approximately 35.6 million; they projected a doubling of this number by 2030, and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing providers is a common part of the dementia journey in most countries. Previously published research confirms that caring for people living with dementia in such facilities often creates moral distress for nursing care providers. In this paper, the authors share additional findings from a two-year, two-phase, mixed methods study of moral distress as experienced by nursing caregivers of residents with dementia in residential care settings in a Western Canadian province. The findings relate to strategies to reduce moral distress in this caregiving group, with a particular focus on the role of supportive and responsive leadership. Important implications for practice and for leadership in the residential care sector are presented.

Practice Change Interventions in Long-Term Care Facilities: What Works, and Why?

Over the past three decades, there has been a notable increase in studies of practice change interventions in long-term care (LTC) settings. This review, based on a modified realist approach, addresses the following questions: What practice change intervention characteristics work? And, in what circumstances do they work and why? A modified realist approach was applied to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases and published literature for empirical studies of practice change interventions that (a) were conducted in LTC settings, (b) involved formal care staff members, and (c) reported a formal evaluation. Ninety-four articles met the inclusion criteria. Interventions that included only predisposing factors were least likely to be effective. Interventions that included reinforcing factors were most likely to produce sustained outcomes. We concluded that interventions aimed at practice change in LTC settings should include feasible and effective enabling and reinforcing factors.

The Influence of Organizational Systems on Information Exchange in Long-Term Care Facilities: An Institutional Ethnography.

Person-centered care is heavily dependent on effective information exchange among health care team members. We explored the organizational systems that influence resident care attendants' (RCAs) access to care information in long-term care (LTC) settings. We conducted an institutional ethnography in three LTC facilities. Investigative methods included naturalistic observations, in-depth interviews, and textual analysis. Practical access to texts containing individualized care-related information (e.g., care plans) was dependent on job classification. Regulated health care professionals accessed these texts daily. RCAs lacked practical access to these texts and primarily received and shared information orally. Microsystems of care, based on information exchange formats, emerged. Organizational systems mandated written exchange of information and did not formally support an oral exchange. Thus, oral information exchanges were largely dependent on the quality of workplace relationships. Formal systems are needed to support structured oral information exchange within and between the microsystems of care found in LTC.

Influence of individual and contextual characteristics on the provision of individualized care in long-term care facilities.

PURPOSE: Previous research examining improved provision of individualized care (I-Care) in long-term care (LTC) facilities has primarily considered contextual influences. Using Kanter's theory of structural empowerment, this study explored the relationship among contextual-level characteristics, individual-level characteristics, and access to empowerment structures on LTC staffs' perceived ability to provide I-Care. METHODS: Multilevel models were used to examine 567 staffs' (registered nurse [RN], licensed practical nurses [LPN], care aides) reported ability to provide I-Care, nested within 41 LTC facilities. I-Care was first modeled as a function of within-person (e.g., age, job classification, experience) and between-context (e.g., facility ownership status, culture change models) variables. Independent of these predictors, we then assessed the influence of staffs' access to empowerment structures (information, support, opportunities, resources, informal power, and formal power) on reported ability to provide I-Care. RESULTS: The intraclass correlation coefficient indicated that 91.7% of the total variance in perceived ability to provide I-Care reflected within- versus between-person differences, with the 6 empowerment variables accounting for 31% of this within-person variance independent of the other context- and person-level covariates. In the final model, only informal power (i.e., quality of interprofessional relationships) and resources (i.e., adequate time and supplies) uniquely predicted I-Care. Notably, access to resources also attenuated the significant effect of support, suggesting a possible mediating effect. IMPLICATIONS: These findings suggest that both contextual- and individual-level factors exert considerably less influence on I-Care than factors associated to staffs' perceptions of empowerment. Consequently, interventions aimed at increasing I-Care in LTC settings should carefully consider staffs' access to structural empowerment.

Clinical features and multidisciplinary approaches to dementia care.

Dementia is a clinical syndrome of widespread progressive deterioration of cognitive abilities and normal daily functioning. These cognitive and behavioral impairments pose considerable challenges to individuals with dementia, along with their family members and caregivers. Four primary dementia classifications have been defined according to clinical and research criteria: 1) Alzheimer's disease; 2) vascular dementias; 3) frontotemporal dementias; and 4) dementia with Lewy bodies/Parkinson's disease dementia. The cumulative efforts of multidisciplinary healthcare teams have advanced our understanding of dementia beyond basic descriptions, towards a more complete elucidation of risk factors, clinical symptoms, and neuropathological correlates. The characterization of disease subtypes has facilitated targeted management strategies, advanced treatments, and symptomatic care for individuals affected by dementia. This review briefly summarizes the current state of knowledge and directions of dementia research and clinical practice. We provide a description of the risk factors, clinical presentation, and differential diagnosis of dementia. A summary of multidisciplinary team approaches to dementia care is outlined, including management strategies for the treatment of cognitive impairments, functional deficits, and behavioral and psychological symptoms of dementia. The needs of individuals with dementia are extensive, often requiring care beyond traditional bounds of medical practice, including pharmacologic and non-pharmacologic management interventions. Finally, advanced research on the early prodromal phase of dementia is reviewed, with a focus on change-point models, trajectories of cognitive change, and threshold models of pathological burden. Future research goals are outlined, with a call to action for social policy initiatives that promote preventive lifestyle behaviors, and healthcare programs that will support the growing number of individuals affected by dementia.

Measurement of workplace empowerment across caregivers.

Culture change models (CCM) developed to improve the provision of individualized care in long-term care (LTC) facilities often include initiatives that are thought to empower care staff. Therefore, the ability to measure empowerment accurately across all levels of care staff is necessary. The objective of this study was to examine the structure of responses by registered nurses (RNs), licensed practical nurses (LPNs), and care aides to 3 instruments measuring workplace empowerment: the Conditions of Work Effectiveness Questionnaire, Job Activities Scale, and Organizational Relationships Scale. Despite considerable differences in education and job function, both caregiver groups appear to interpret and respond to 38 of 40 empowerment items in a similar manner. Therefore, our findings support the inclusion of all care staff when using these instruments to measure work place empowerment in LTC settings.

The differential influence of culture change models on long-term care staff empowerment and provision of individualized care.

With this study we set out to determine if differences exist across culture change models (CCM) in relation to formal caregivers' perceived access to empowerment structures and reported provision of individualized care. We recruited staff working in facilities that had implemented the Eden Alternative, GentleCare, Facility Specific Social Models of Care (FSSMOC), or no CCM. Multivariate analyses of variance (MANOVA) compared these constructs by CCM for each of three caregiver groups (Registered Nurses, Licensed Practical Nurses, and care aides). Results suggest that considerable differences exist between formal caregivers and by CCM. The greater caregivers' day-to-day contact with residents, the more CCMs appear to affect perceived empowerment and reported provision of individualized care. Findings suggest the greatest benefits existed for staff working in facilities with a FSSMOC. Conversely, in only one instance did responses from staff in Eden Alternative facilities differ from those in facilities with no CCM.

Measurement and analysis of individualized care inventory responses comparing long-term care nurses and care aides.

PURPOSE: Motivating and enabling formal caregivers to provide individualized resident care has become an increasingly important objective in long-term care (LTC) facilities. The current study set out to examine the structure of responses to the individualized care inventory (ICI). DESIGN AND METHODS: Samples of 242 registered nurses (RNs)/licensed practical nurses (LPNs) and 326 care aides were recruited from 54 LTC facilities in 3 of 5 British Columbia health authorities. Baseline confirmatory factor analytic (CFA) models were computed separately for RNs/LPNs and care aides; invariance analyses were next undertaken to compare these CFA models. RESULTS: For both RNs/LPNs and care aides, support was found for a 4-factor model of ICI responses mapping onto a higher order individualized care (IC) construct. This model was largely equivalent between formal caregiver groups, although the relative contribution of certain first-order factors differed between the two. Of further note, both groups appear to interpret and respond to 31 of 35 ICI items in a similar manner. IMPLICATIONS: The results of this study provide further support for the psychometric properties of ICI responses. Although further research is required, the ICI appears to be an appropriate self-report measure. This instrument may be used by researchers, policymakers, administrators, and practitioners alike to assess strengths as well as areas for improving the delivery of IC to LTC residents by formal caregivers.

Cognitive status and the psychological well-being of long-term care residents over time.

The majority of research within long-term care (LTC) has emphasized the physical health of residents, has been cross-sectional in design and has focused almost exclusively on residents with dementia. Few longitudinal studies have followed participants over intervals longer than 1 year. In contrast, the current study set out to examine the experience of LTC residents with and without significant cognitive loss over a 2-year period comparing the psychological well-being of groups over time. Significant Group x Time interaction effects were observed between residents with and without significant cognitive loss in life satisfaction and depressive symptomatology. Results of this study underscore the need for longitudinal measurement in LTC research, the use of multivariate statistical procedures and the need to identify and meet the distinct needs of residents with and without significant cognitive loss.

The influence of care provider access to structural empowerment on individualized care in long-term-care facilities.

OBJECTIVES: Implementing management initiatives that enable formal caregivers to provide quality, individualized care to older adults in long-term-care (LTC) facilities is increasingly important given that the number of LTC residents is projected to triple by 2031. The objective of this study was to explore the relationship between care provider access to structural empowerment and the provision of individualized care in LTC. METHODS: We computed structural equation models separately for registered nurses and licensed practical nurses (n = 242) and care aides (n = 326) to examine the relationship between access to empowerment structures (i.e., informal power, formal power, information, support, resources, opportunity) and the provision of individualized care. We subsequently undertook invariance analyses to determine if the association between empowerment structures and reported provision of individualized care differed between caregiver groups. RESULTS: Access to structural empowerment had a statistically significant, positive association with provision of individualized care for both groups. For registered nurses/licensed practical nurses and care aides, empowerment explained 50% and 45% of observed variance in individualized care, respectively. These notable percentages did not differ significantly between caregiver groups. DISCUSSION: Of the empowerment structures, support, especially in the form of access to educational opportunities and recognition for a job well done, seems to be particularly significant to care providers. Findings from this study suggest that provision of individualized care in LTC may be enhanced when formal caregivers have appreciable access to empowerment structures.