Barriers to healthcare professionals recognizing and managing delirium in older adults during a hospital stay: A mixed-methods systematic review.

AIM: To investigate barriers to healthcare professionals recognizing and managing delirium in hospitalized older people. DESIGN: A mixed-methods systematic review. PROSPERO ID: CRD42020187932. DATA SOURCES: MEDLINE, EMBASE, PsycINFO and CINAHL were searched (2007 to February 2023). REVIEW METHODS: Included studies focused on healthcare professionals' recognition and management of delirium for patients aged 65 years and over in a hospital ward or emergency department. Enhancing rigour, screening of results was conducted independently by two researchers. Qualitative and quantitative data were tabulated separately and grouped. Data were compared to identify similarities and differences. All studies were quality appraised. RESULTS: 43 studies were included; 24 quantitative, 16 qualitative and three mixed-methods. Data synthesis highlighted synergy between qualitative and quantitative findings. Barriers were reflected in six themes: (1) healthcare professionals' knowledge and understanding; (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints. CONCLUSIONS: Of significance, for older adults in hospital experiencing delirium, there is variability in whether and how well it is recognized and managed. To prevent adverse outcomes best practice guidance for screening, recognizing, diagnosing and managing delirium in older people needs to be agreed and disseminated widely. Supporting healthcare professionals to care for this patient population using an integrated approach is essential, how to involve and communicate with patients and their family and friends, how to recognize and manage delirium for patients with additional needs, e.g., those living with dementia and/or a learning disability. Hospitals need to have policy and guidance in place for the recognition and management of delirium in older adults presenting to a ward or to an emergency department. An IT infrastructure is needed that integrates assessments and care management plans in patient electronic records and makes them accessible within and across teams in hospital, primary and community care settings. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution to this systematic review. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Healthcare professionals can be better supported to be able to recognize and manage delirium during an acute hospital stay for older adults. This includes maximizing best care for those patients living with dementia, involving families and friends to help understand patients' baseline status and changes and supporting families and friends during this process. Of significance, attention to hospital IT infrastructures is warranted, integrating screening, assessment and care management plans in patients' electronic records and making these accessible to healthcare professionals caring for this patient population across care settings. IMPACT: What problem did the study address? Delirium is a common condition experienced by older hospitalized patients, but it is consistently under-recognized which has implications for patient and organization outcomes. To help address this, understanding barriers to healthcare professionals recognizing and managing delirium for this patient population is paramount. What were the main findings? Barriers to healthcare professionals recognizing and managing delirium for this patient population were synthesized in six themes: (1) healthcare professionals' knowledge and understanding, (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints. Where and on whom will the research have an impact? The findings of this original systematic review can contribute to hospital policy and protocol for the recognition and management of delirium in older patients. The findings can meaningfully contribute to workforce professional development for practitioners caring for older people during an acute hospital stay and for practitioners in primary and community settings involved in the follow-up of patients post hospital discharge. For researchers, the findings indicate several research recommendations including investigating the impact of an education programme for nurses and other healthcare professionals on the recognition and management of the condition and understanding and investigating how best to support delirium-related distress experienced by patients and their families and practitioners. REPORTING METHOD: This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

Evaluation of the feasibility of an Education-Career pathway in Healthcare for Older People (ECHO) for early career nurses.

BACKGROUND: Rapid population ageing is driving demand for qualified gerontological nurses. Yet, early career nurse attrition and limited focus on retention in the speciality limits supply. OBJECTIVES: To test the feasibility and acceptability of an Education-Career pathway in Healthcare for Older People (ECHO) intervention for early career nurses to improve retention and capability in gerontological nursing. ECHO is a multicomponent intervention with integrated education, career planning and coaching components, tested over two 6-month cycles. METHODS: A feasibility study with a pre-post design using a multi-methods evaluation. Twenty-nine early career nurse participants were recruited from eight NHS acute and community care Trusts in England. ECHO participants completed online questionnaires at baseline (Time 1), 6-month (T2, end of intervention) and follow-up at 18 months from baseline (T3). Outcome measures were career intention, self-reported knowledge, career planning confidence, and burnout using the Maslach Burnout Inventory. Qualitative interviews were undertaken with participants (n = 23) and organizational stakeholders (n = 16) who facilitated ECHO. Data analysis used descriptive statistics and non-parametric tests for paired data and thematic analysis for qualitative data. RESULTS: Overall, 19 of 29 participants (65%) completed all aspects of the intervention. The evaluation was completed by 23 participants. ECHO was well received by participants and stakeholders. At T3, the 23 participants were working in the speciality, though two had changed organizations. There was a significant improvement in self-reported gerontological knowledge, pre 87 (IQR 81-102), post 107 (IQR 98-112) p = 0.006, but no significant changes in other outcomes. In qualitative data, participants and organizational stakeholders held similar views, presented under four main themes: intended outcomes (personal and professional development, raise gerontological profile, expand horizons); nurse retention-a double-edged sword, ECHO logistics, and sustainability. CONCLUSION: Education-Career pathway in Healthcare for Older People was feasible and may positively impact early career nurse retention, capability and socialization into gerontological nursing. ECHO requires further refinement and piloting, but learning can contribute to retention strategies. IMPLICATIONS FOR PRACTICE: Attracting and retaining early-career nurses to the gerontological speciality requires greater innovation, organizational and senior nurse leadership.

Professional development and career planning for nurses working in care homes for older people: A scoping review.

BACKGROUND: A skilled, knowledgeable, and compassionate nurse workforce is pivotal to caring well for older people living in care homes. This requires the provision of continuing professional development and career planning for nurses, which are key also for nurse recruitment and retention. Continuing professional development and career planning strategies and interventions should be evidence-driven. OBJECTIVE: To identify the extent, range and nature of contemporary evidence regarding professional development and career planning for nurses caring for older people living in care homes. METHODS: The methodological framework used was the Joanna Briggs Institute guidance for scoping reviews. The PRISMA extension for scoping reviews was used as the reporting framework. Four databases were searched from January 2010 to July 2021. Results were screened independently by two reviewers using eligibility criteria. Full texts and the reference lists of eligible articles were reviewed. Data were extracted for key elements from the 25 articles included. RESULTS: Of the 25 articles, the majority were authored in the United States (n = 10) and UK (n = 8) with the remaining from Australia (n = 3), Canada (n = 3) and the Netherlands (n = 1). Four articles reported on professional development programmes. Three literature reviews addressed challenges for nurse participation in professional development, experiences of care home nurses as clinical leaders and managers, and leadership. Two expert commentaries reported on the challenges related to professional development and career planning for care home nurses. Sixteen empirical studies investigated a range of topics including: competencies, roles, intention to stay and leave, continuing professional development, and leadership. Key emergent factors that support professional development and career planning were as follows: access to structured learning opportunities addressing knowledge and skills specific to nursing frail older adults, a supportive working environment including adequate staffing, study time and flexible working, and integration of leadership development. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This scoping review has highlighted factors that support and challenge professional development and career planning for nurses working in the care home sector. There remain important gaps in the opportunities for professional development and career planning for care home nurses that warrant attention.

Front-line staff perspectives on a caring culture in Chinese hospitals: Validation of a Chinese version of the Culture of Care Barometer.

AIMS: The aim of this study is to examine the psychometric properties of the Chinese version of the Culture of Care Barometer in health care organizations. BACKGROUND: There is a lack of tools to gauge the caring culture in Chinese hospitals. The Culture of Care Barometer is a psychometrically sound measure for caring culture developed in Western settings. METHODS: This study was guided by Sousa and Rojjanasrira's methodological approach. A total of 2365 staff were recruited from two tertiary hospitals. The Barometer was administered with the Hospital Culture Evaluation Index and Minnesota Satisfaction Questionnaire. RESULTS: The content validity index was calculated as 0.99. The goodness-of-fit indices, apart from the model chi-square, which was statistically significant, all exceeded established thresholds for adequate fit. The internal consistency was very satisfactory. Pearson's correlation indicated that the tool has good concurrent and convergent validity. CONCLUSIONS: The Barometer is a reliable and valid instrument to assess front-line staff perspectives on a caring culture in Chinese hospitals. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers can use the Barometer to gauge the caring culture in China. Tailored interventions can be designed to address specific domains, and additional support can be provided to more vulnerable departments or staff groups.

Social Distancing and Isolation Strategies to Prevent and Control the Transmission of COVID-19 and Other Infectious Diseases in Care Homes for Older People: An International Review.

Older people living in care homes are at high risk of poor health outcomes and mortality if they contract COVID-19 or other infectious diseases. Measures used to protect residents include social distancing and isolation, although implementation is challenging. This review aimed to assess the social distancing and isolation strategies used by care homes to prevent and control the transmission of COVID-19 and other infectious diseases. Seven electronic databases were searched: Medline, CINAHL, Embase, PsycINFO, HMIC, Social Care Online, and Web of Science Core Collection. Grey literature was searched using MedRxiv, PDQ-Evidence, NICE Evidence Search, LTCCovid19.org and TRIP. Extracted data were synthesised using narrative synthesis and tabulation. 103 papers were included (10 empirical studies, seven literature reviews, and 86 policy documents). Strategies used to prevent and control the transmission of COVID-19 and other infectious diseases included social distancing and isolation of residents and staff, zoning and cohorting of residents, restriction of resident movement/activities, restriction of visitors and restriction of staff working patterns. This review demonstrates a lack of empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. Evaluative research on these interventions is needed urgently, focusing on the well-being of all residents, particularly those with hearing, vision or cognitive impairments.

'Five things about me' - enhancing person-centred care for older people.

Although person-centred care represents the gold standard of nursing practice, there are still instances of care that fail to recognise patients as individuals. Person-centred care depends on the nurse's knowledge of the whole person, including their values, beliefs and aspirations. This article describes a quality improvement project that sought to develop patient profiles based on the concept of 'five things about me', thereby contributing to person-centred care for older people on a medical ward. The effect on staff, older people and their families was assessed through questionnaires, and group and individual discussions. During the project period, 37 person-centred profiles were completed from 52 eligible patients. Ward staff reported increased confidence when delivering person-centred care and older people and their family members confirmed improvements in care delivery and strengthened relationships with staff.

Protecting older people living in care homes from COVID-19: a protocol for a mixed-methods study to understand the challenges and solutions to implementing social distancing and isolation.

INTRODUCTION: Older people living in residential and nursing care homes often have complex needs and are at high risk of poor health outcomes and mortality, especially if they contract COVID-19. Care homes use infection prevention and control measures such as social distancing and isolating residents to protect them from COVID-19. The care home sector has stated that implementing social distancing and isolation when caring for residents is a significant challenge. This paper presents the protocol of a mixed-methods study to explore and understand the real-life experiences of implementing social distancing and isolation of residents in care homes for older people from the perspective of residents, families/friends and staff working in and with care homes. The study aims to develop a toolkit of resources for health and care delivery now and for future outbreaks of infectious diseases. METHODS AND ANALYSIS: The study will be conducted in three phases. Phase 1 is a rapid review of evidence to collate knowledge on the mechanisms and measures used by care homes and long-term facilities to socially distance and isolate older people or control the spread of other infectious and contagious diseases. The review results will contribute to participant interviews in phase 2 and toolkit development in phase 3. Phase 2 will involve case studies with six care homes in England, involving the conduct of individual interviews with residents, families and friends, and staff, collection of care home policies and protocols related to social distancing and isolation for residents, and routinely collected care home data. A focus group with a purposive sample of external key informants will also be conducted. Phase 3, synthesising findings from phases 1 and 2, will inform the codesign of a toolkit of resources for residents, families/friends and care homes. ETHICS AND DISSEMINATION: The study has been approved by Coventry and Warwick Research Ethics Committee (20/WM/0318). To maximise impact, we will work closely with the Study Committees and the Patient and Public Involvement group to ensure the findings reach key stakeholders, including residents, families/friends, care homes, commissioners and organisations representing care home providers. We will disseminate the study outputs in peer-reviewed and professional journals, at professional conferences and via other knowledge transfer activities with the care home sector, and resident and carer organisations. The toolkit comprising evidence-informed guidance and resources and a mosaic film will be hosted on a project webpage. REGISTRATION DETAILS: This project is funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (Project reference NIHR132541). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. PROSPERO REGISTRATION NUMBER: CRD42021226734.

Evaluating a specialist education programme for nurses and allied health professionals working in older people care: A qualitative analysis of motivations and impact.

BACKGROUND: Developing clinical leaders is essential for high-quality, safe care for older people. Fundamental to achieving this is specialist continuing professional development for nurses and allied health professionals. OBJECTIVES: To investigate the motivations of nurses and allied health professionals to undertake a national specialist gerontological programme, the Older Persons Fellowship, and its impacts on their development and on older people care. DESIGN: A qualitative descriptive design. METHODS: Participants were nurses and allied health professionals undertaking a national specialist gerontological programme in England. A purposive sample of 63 participants was recruited. Twelve focus groups and four individual interviews were conducted between February 2015 and February 2019. Data were analysed using thematic analysis. RESULTS: Three themes were identified: credible gerontological experts; challenging ageism and suboptimal services; and legitimising gerontological practice as a speciality. CONCLUSIONS: Understanding the motivations to undertake a specialist gerontological programme and the impacts on practitioners and older people care and services will help inform the continuing professional development agenda for nurses and allied health professionals working in this field of practice. Policy makers, commissioners, managers, and educators can use the findings to inform continuing professional development priorities and provision for the gerontological workforce.

The organisational context of nursing practice in hospitals in China and its relationship with quality of care, and patient and nurse outcomes: A mixed-methods review.

BACKGROUND: Achieving high-quality care and retention of nurses are major concerns for nurse leaders in hospitals. The organisational context is theorised to influence the quality of care and patient and nurse outcomes. This review focuses on China where the healthcare system is different from most Western countries in terms of government healthcare expenditure, public health insurance and healthcare delivery system. OBJECTIVES: To explore the organisational context of nursing practice in hospitals in China and its relationship with quality of care, patient outcomes (patient adverse events, safety and satisfaction) and nurse outcomes (burnout, job satisfaction and intention to leave). DESIGN: A mixed-methods review. DATA SOURCES: The electronic databases PubMed, EMBASE, CINAHL, PsycINFO and China Academic Journals Database were used. METHODS: This review was conducted using the SALSA (Search, Appraisal, Synthesis and Analysis) framework. Quality assessment was conducted using the Joanna Briggs Institute (JBI) critical appraisal checklists for cross-sectional studies and qualitative research. A narrative synthesis was conducted and was supported by tabulation of study data. The PRISMA guidelines were used for this review. RESULTS: Twenty-three articles met the inclusion criteria and were retrieved, analysed and synthesised. This review supports the link between organisational context, quality of care, and patient and nurse outcomes in the Chinese healthcare system. Aspects of organisational context warrant attention including nurse staffing levels, the shortage of nurses, a lack of nurse participation in hospital affairs and support for the professional development of nurses. CONCLUSIONS: The findings suggest that tailored interventions are needed to improve the organisational context of nursing practice in Chinese hospitals and, in particular, to address the nurse workforce issues and organisational leadership and support. The unique policy context of the Chinese healthcare system should be considered when developing these interventions. RELEVANCE TO CLINICAL PRACTICE: Recognising the importance of the organisational context, it is imperative that nurse leaders make every effort to legislate for safe nurse staffing and to establish a caring culture to improve quality of care and nurse and patient outcomes.

Managing deterioration in older adults in care homes: a quality improvement project to introduce an early warning tool.

Many older adults living in care homes have complex health needs requiring comprehensive care. Early warning tools can help identify deterioration, but currently they are less often used in care homes. The aim of this quality improvement project was to introduce an early warning tool, the Significant 7, to facilitate identification and management of deterioration in care home residents. The plan, do, study, act (PDSA) method was used, and process mapping informed a tailored intervention. Introducing the tool had positive outcomes for residents and care staff. There was a reduction in the incidence of pressure ulcers and falls, and care staff were more confident in recognising resident deterioration. Next steps include scaling up the project to further examine how this early warning tool can improve resident, staff and organisational outcomes, in order to explore the potential use of the tool by community nurses with older people living at home.

Facilitators and inhibitors of transition for older people who have relocated to a long-term care facility: A systematic review.

Moving into a long-term care facility to live permanently is a significant life event for older people. Care facilities need to support older people to make a healthy transition following relocation. To help achieve this, we need to understand what facilitates and inhibits the transition process from the perspective of older people, their families, and care facility staff. Our review generated new knowledge to inform this understanding. We addressed the question: what factors facilitate and inhibit transition for older people who have relocated to a long-term care facility? Five electronic databases, PsychINFO, British Nursing Index, CINAHL, MEDLINE and Web of Science were searched for the period January 1990 to October 2017. Grey literature searches were conducted using Google Scholar, and Social Science Research Network. Data were extracted for individual studies and a narrative synthesis was conducted informed by Meleis's Theory of Transition. Thirty-four studies (25 qualitative, 7 quantitative and 2 mixed methods) met the inclusion criteria. Data synthesis identified that transition following relocation was examined using a variety of terms, timelines and study designs. Potential personal and community focused facilitators and inhibitors mapped to four themes: resilience of the older person, interpersonal connections and relationships, this is my new home, and the care facility as an organisation. These findings can inform the development of interventions for these target areas. They highlight also that further research is warranted to understand the organisational culture of long-term care facilities, how this influences transition, and how it might be shaped to create and sustain a caring culture for older people.

Development and testing of the 'Culture of Care Barometer' (CoCB) in healthcare organisations: a mixed methods study.

OBJECTIVE: Concerns about care quality have prompted calls to create workplace cultures conducive to high-quality, safe and compassionate care and to provide a supportive environment in which staff can operate effectively. How healthcare organisations assess their culture of care is an important first step in creating such cultures. This article reports on the development and validation of a tool, the Culture of Care Barometer, designed to assess perceptions of a caring culture among healthcare workers preliminary to culture change. DESIGN/SETTING/PARTICIPANTS: An exploratory mixed methods study designed to develop and test the validity of a tool to measure 'culture of care' through focus groups and questionnaires. Questionnaire development was facilitated through: a literature review, experts generating items of interest and focus group discussions with healthcare staff across specialities, roles and seniority within three types of public healthcare organisations in the UK. The tool was designed to be multiprofessional and pilot tested with a sample of 467 nurses and healthcare support workers in acute care and then validated with a sample of 1698 staff working across acute, mental health and community services in England. Exploratory factor analysis was used to identify dimensions underlying the Barometer. RESULTS: Psychometric testing resulted in the development of a 30-item questionnaire linked to four domains with retained items loading to four factors: organisational values (α=0.93, valid n=1568, M=3.7), team support (α=0.93, valid n=1557, M=3.2), relationships with colleagues (α=0.84, valid n=1617, M=4.0) and job constraints (α=0.70, valid n=1616, M=3.3). CONCLUSIONS: The study developed a valid and reliable instrument with which to gauge the different attributes of care culture perceived by healthcare staff with potential for organisational benchmarking.

Improving service user self-management: development and implementation of a strategy for the Richmond Response and Rehabilitation Team.

Community rapid response and rehabilitation teams are used to prevent avoidable hospital admissions for adults living with multiple long-term conditions and to support early hospital discharge by providing short-term intensive multidisciplinary support. Supporting self-management is an important service intervention if desired outcomes are to be achieved. A Care Quality Commission inspection of the Richmond Response and Rehabilitation Team in 2014 identified that self-management plans were not routinely developed with service users and reported this as requiring improvement. This quality improvement project aimed to develop and implement a self-management strategy for service users and for 90% of service users to have a personalised self-management plan within 3 months. The quality improvement intervention used the Plan-Do-Study-Act model comprising: (1) the development of a self-management plan, (2) staff education to support service users to self-manage using motivational interviewing techniques, (3) piloting the self-management plan with service users, (4) implementation of the self-management plan and (5) monthly audit and feedback. Evaluation involved an audit of the number and quality of self-management plans developed with service users and a survey of staff knowledge and confidence to support service users to self-manage. Following implementation of the intervention, the number of self-management plans developed in collaboration with service users increased from 0 to 187 over a 4-week period. Monthly audit data confirmed that this improvement has been sustained. Results indicated that staff knowledge and confidence improved after an education intervention. Quality improvement methods facilitated development and operationalisation of a self-management strategy by a community rapid response and rehabilitation team. The next phase of the project is to evaluate the impact of the self-management strategy on key service outcomes including self-efficacy, unplanned and emergency hospital admissions and early discharges.

The development of the Older Person's Nurse Fellowship: Education concept to delivery.

BACKGROUND: Preparing the nursing workforce to meet the challenges of an ageing population is a priority for many countries. The development of an Older Person's Nurse Fellowship (OPNF) programme for senior clinical nurses is an important innovation. OBJECTIVES: This article describes the philosophical development, delivery and early evaluation of the OPNF. DESIGN: In 2014, Health Education England funded 24 senior clinical nurses to participate in the OPNF. The Fellowship was designed to build clinical leadership and innovation capability and develop a network of nurses to influence local and national strategy for older people's care. The Fellows selected were drawn from mental health (n=4), community/primary care (n=9) and acute care (n=11). The twelve month programme consisted of two Masters-level modules, delivered through study days and e-learning. The first cohort (n=12) commenced the course in November 2014 with a module designed to enhance clinical knowledge and skills. METHODS: Evaluation data were collected from the first cohort using anonymous surveys (n=11) and focus group interviews (n=9). Descriptive statistics are presented for the quantitative data and common themes are described in the qualitative data. RESULTS: The overall satisfaction with the clinical module was high with a median score of 18/20 (range 17-20). Topics such as comprehensive geriatric assessment, frailty, pharmacology and cognitive assessment were regarded as highly relevant and most likely to result in a change to clinical practice. In the focus group interviews students discussed their learning experience in terms of: module specificity, peer-to-peer learning and using the OPNF as leverage for change. CONCLUSIONS: The OPNF is a timely innovation and a positive commitment to developing an academic pathway for senior nurses. It marks an important step in the future development of the older person's nursing workforce.

Try to see the bigger picture.

MANY OLDER people are healthy and live independently or with some support in their own homes. However, an increasing ageing population with a varied profile of health, functioning and wellbeing means that in later life more people may need some form of health and social care and live in various facilities.

Views and experiences of nurses and health-care assistants in nursing care homes about the Gold Standards Framework.

AIM: To explore the views and experiences of nurses and health-care support staff about the use of the Gold Standards Framework (GSF) for end-of-life care (EoLC) for older people in nursing care homes (NCHs) with GSF accreditation. METHODS: A qualitative descriptive study was conducted with three purposively selected NCHs in London. Individual interviews were conducted with NCH managers (n=3) and in each NCH, a focus group was conducted with registered nurses (RNs) and health-care assistants (HCAs): focus group 1, n=2 RN, n=2 HCA; focus group 2, n=2 RN, n=3 HCA; focus group 3, n=3 RN, n=3 HCA. Interviews were audio-recorded, transcribed and analysed using framework analysis. FINDINGS: Three core themes were identified: (i) a positive regard for the GSF for care homes (GSFCH); (ii) challenges around EoLC for older people; and (iii) difficulties in using the GSFCH. CONCLUSIONS: RNs, HCAs and managers regarded the training and support afforded by the GSFCH programme to inform EoLC for older residents positively. The framework has the potential to promote a coordinated approach to EoLC for older people. In the post accreditation period, there is a need for ongoing support and development to help embed the key tenets of the GSFCH in the culture of caring.

Caring for minority ethnic older people in nursing care homes.

This article aims to identify best practice guidance in relation to caring for minority ethnic older people in UK care homes that provide nursing care, highlighting key issues and identifying gaps that require redress. Current best practice guidance focuses on client issues, such as the recognition of cultural preferences, and organizational issues, such as workforce and the environment. However, while there is some best practice guidance regarding the care of minority ethnic older people in care homes, it is not sufficiently explicit. The article concludes by suggesting key strategies to help address the needs of minority ethnic older people in care homes.

Minority ethnic elders in care homes: a review of the literature.

BACKGROUND: Health and social care services are required to provide quality service provision to meet all older people's needs, including any needs specific to minority ethnic groups. The heterogeneity of the population, however, highlights the need to offer a range of services that reflect people's language, cultural and religious differences. OBJECTIVES: This paper reviews the literature concerned with minority ethnic elders in care homes. METHODS: Systematic searches were conducted using the following online databases: Web of Science, Pub Med, Sociological Abstracts, Social Sciences Index, AMED, British Nursing Index, Medline, PsycInfo and CINAHL. Independent reviewers undertook a structured assessment of each piece of literature. Data extraction and analysis were in accordance with established methods. FINDINGS: The literature has been classified into two key areas. First, issues arising from international literature, including factors relating to access, equality and workforce issues, care satisfaction and placement decision-making. The second area focuses on the issues emerging from the UK literature. Issues of particular concern include barriers to care provision for minority ethnic older people, loss of independence and the recognition of cultural needs. CONCLUSION: The review indicates how problems remain in ensuring the delivery of best-quality long-term care to ethnic elders in care homes. The review also highlights the absence of studies focusing on the perception of care from residents' perspectives and their involvement in making placement and care decisions.

Challenges for care homes: education and training of healthcare assistants.

The spotlight is increasingly on all care homes, including those catering specifically for older people, to deliver on quality targets in an attempt to drive up the standards of care provision. These targets include the education, training and supervision of care staff. Representing a major component of the care staff workforce in care homes are healthcare assistants and they play a key role in care provision and will continue so to do. However, pivotal to their effective role performance is preparation and support - the provision of which has been patchy to date. For care homes that provide nursing care the challenges of delivering on these targets by 2005 are significant, particularly as the majority of these homes are run as private enterprises and in the absence of any form of central funding. This article examines key issues to education and training provision. A strategic nationwide approach to education and training for healthcare assistants in care homes is recommended, coupled with robust evaluation of outcomes. Such initiatives will need to be supported by significant financial investment if the Government's targets are to be achieved.