When is nighttime? A description of bedtime in persons with dementia in the nursing home.

The purpose of this secondary data analysis was to describe the bedtime patterns of persons with dementia in the nursing home and make recommendations for nursing practice. Nursing staff observed, researcher observed, and actigraph data on bedtimes were compared with nighttime facility routines. Seventy per cent (n = 14) of all participants (n = 20) were in bed before 8:30 pm and 30% (n = 6) of the participants went to bed after 8:30 pm. All participants who went to bed before 8:30 pm (n = 14) took evening medications and 64% (n = 9) were dependent upon nursing care for nighttime activities of daily living (ADLs). Results suggested that bedtimes may be influenced by nighttime tasks. An understanding of these unique sleep patterns may facilitate the development of nonpharmacological, person-centered interventions for building sleep cycles around individual preferences versus facility-driven routines.

Factors associated with sleep disturbance among older adults in inpatient rehabilitation facilities.

PURPOSE: The purpose of this article is to provide an overview of changing sleep patterns and common sleep disorders in older adults and to discuss treatment options of sleep disturbances within inpatient rehabilitation facilities (IRFs). METHODS: Through extensive review of the existing literature, common sleep disorders among older adults and several key factors that may impact sleep in older adults in inpatient rehabilitation facilities, such as behavioral and environmental factors, psychosocial and emotional factors, medical conditions, and medications were identified. FINDINGS: Current literature on the factors associated with sleep disturbance in older adults in IRFs is based on work with community-dwelling older adults and those in long-term care facilities. While interventions to address these disorders and research investigation key factors associated with sleep problems among older adults appear in the literature, there is very little work that applies these interventions within IRFs. CONCLUSIONS AND CLINICAL RELEVANCE: Research is needed to examine the impact of sleep problems on older adults in IRFs, including work that focuses on intervention trials to identify successful treatments for these problems and translate those approaches into practice.

The effects of slow-stroke back massage on minutes of nighttime sleep in persons with dementia and sleep disturbances in the nursing home: a pilot study.

PURPOSE: This pilot study tested the effects of a 3-minute slow-stroke back massage (SSBM) on total minutes of nighttime sleep on persons with dementia with sleep disturbances aged 65 years or older in the nursing home. DESIGN: Pilot randomized controlled trial. METHODS: Participants were randomized to an intervention group (n = 20) who received the 3-minute SSBM or a usual care control condition group (n = 20) who received usual bedtime care. Forty-eight hours of actigraphy data was recorded and analyzed on sleep variables at baseline and postintervention. FINDINGS: Descriptive statistics showed a 36-minute increase on minutes of nighttime sleep in the SSBM intervention group (46.1 minutes) compared with the control group (10.32 minutes). Analysis of covariance did not reveal significant differences between the intervention and control groups on minutes of nighttime sleep, F(1, 37) = 1.90, p = .18, partial η(2) = .05, or on other sleep variables. CONCLUSIONS: Dose-finding studies are needed to determine the duration of SSBM for sleep promotion. Findings from this pilot study suggest that SSBM may be an effective nursing intervention for sleep in persons with dementia in the nursing home, but further testing is needed to provide definitive results.

Using spirituality to cope with early-stage Alzheimer's disease.

Alzheimer's disease (AD) robs persons living with the disease of their independence and self-esteem, which can lead to depression, anxiety, and loneliness. Understanding how people with early-stage AD cope is a critical step in enhancing their adaptive abilities and ultimately improving their quality of life. This qualitative study describes how individuals with early-stage AD use spirituality to cope with the losses of self-esteem, independence, and social interaction that they face. The purposive sample for this focused ethnographic study consisted of 15 participants living at home in central Arkansas. Holding onto faith, seeking reassurance and hope, and staying connected were the global themes. Personal faith, prayer, connection to church, and family support enhanced the ability of people with early-stage AD to keep a positive attitude as they face living with AD.

Challenges in conducting qualitative research with individuals with dementia.

Qualitative research can capture the meaningful experiences and life values of individuals with dementia not reported in quantitative studies. This article shares a personal experience of the challenges faced and the lessons learned while conducting a qualitative study of 15 people with early-stage Alzheimer's disease. The purpose of this article is to discuss the issues concerning determination of capacity to consent to research, consent/assent, communication challenges, and trustworthiness of data when conducting a qualitative study of people with dementia. Understanding communication challenges related to dementia is important to develop effective communication strategies, such as simplifying the structure of questions, allowing ample time for the participant's response, using reminiscence, and redirecting the dialogue. This information will be valuable to researchers conducting qualitative studies and the resulting contributions to the body of knowledge about Alzheimer's disease.

A trial of a comprehensive nursing rehabilitation program for nursing home residents post-hospitalization.

This pilot study examined the feasibility of implementing a comprehensive nursing rehabilitation program (CNRP) designed to promote the physical functioning of moderately frail nursing home residents post-hospitalization. The 4-week to 8-week CNRP incorporated three interventions: the Capacity Intervention (improving strength and balance), Performance Intervention (fostering daily mobility and activity), and Facilitating Intervention (providing education, support, and stress management). A longitudinal design was used with a convenience sample of 24 moderately frail residents. The CNRP was found to be not practical as designed because the intervention occurred too close to hospital discharge, and many prospective participants did not "feel up" to participating in a voluntary nursing rehabilitation program in addition to other prescribed rehabilitation. Regardless, participants were found to be able to perform the exercises safely and the CNRP was easily implemented in nursing homes. Testing the efficacy of the CNRP with nursing home residents is recommended after the initial post-hospitalization period.

Nursing student descriptions that suggest changes for the classroom and reveal improvements needed in study skills and self-care.

This article describes a longitudinal study that took place in a college of nursing with baccalaureate students between 2002 and 2004 at a university medical center. Its purpose was to provide a climate of success for the students yet challenge them to make additional efforts to complete the program. The qualitative section of the study consisted of students answering the following open-ended questions: (1) Describe ways that faculty can help you be successful in the future and (2) What can you do for yourself to achieve the goal of finishing the program? Students identified what change could be made in the classroom, how increased study time and skills might help, and how self-care would facilitate success. Descriptions were shared with faculty and students in an effort to improve classroom delivery, provide study tips to students, and help students become aware of increased self-care. Students as future nurses, enter practice and care for patients who will need the best care and self-care instruction. Using techniques that students identified to be successful, making efforts through hard work (increased study skills), and realizing how to better care for themselves could assist RNs in providing comprehensive and best care to patients.

Nursing home staff's views on quality improvement interventions: a follow-up study.

Ongoing problems with nursing home care mandates understanding nursing home staff's perspectives on innovative quality improvement programs. This follow-up study used focus groups to examine the experiences of staff who participated in a clinical trial that involved Quality Indicator (QI) feedback reports, quality improvement training, and APN consultation. The authors found that QI reports provided staff with a benchmark to judge their care and a means to track problems; APN consultation was essential for staff to learn best practices; and staff questioned the validity of the QI reports, which hindered them from seeking new solutions to problems identified in the QI reports. Findings indicate that innovative QI programs and APN consultation can positively influence nursing home quality improvement efforts and improve care.

Prevalence and characteristics of nursing homes residents requiring light-care.

Rising nursing home (NH) costs and the poor quality of NH care make it important to recognize elders for whom NH care may be inappropriate. As a first step in developing a method to identify these elders, we examined the characteristics of NH residents requiring light-care and changes in their care level from NH admission to 12-months. Using data from the Missouri Minimal Data Set electronic database, we developed three care-level categories based on Resource Use Groups, Version III (RUG-III) and defined light-care NH residents as those requiring minimal assistance with late-loss ADLs (bed mobility, transfer, toilet use, or eating) and having no complex clinical problems. Approximately 16% of Missouri NH residents met the criteria for light-care. They had few functional problems with mobility, personal care, communication, or incontinence; approximately 33% had difficulty maintaining balance without assistance; and 50% of those admitted as light-care were still light-care at 12-months. Findings suggest that many NH residents classified as light-care by these criteria could be cared for in community settings offering fewer services than NHs.

Nursing home quality, cost, staffing, and staff mix.

PURPOSE: The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes. DESIGN AND METHODS: A three-group exploratory study design was used, with 92 nursing homes randomly selected from all nursing homes in Missouri and classified into resident outcome groups. Resident outcomes were measured by use of quality indicators derived from nursing home Minimum Data Set resident assessment data. Cost and staffing information were derived from Medicaid cost reports. Participant observation methods were used to describe the care delivery processes. RESULTS: In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. The analysis revealed necessary organizational attributes that must be in place in order for those basics of care to be accomplished: consistent nursing and administrative leadership, the use of team and group processes, and an active quality improvement program. The only facility characteristic across the outcome groups that was significantly different was the number of licensed beds, with smaller facilities having better outcomes. No significant differences in costs, staffing, or staff mix were detected across the groups. A trend in higher total costs of 13.58 dollars per resident per day was detected in the poor-outcome group compared with the good-outcome group. IMPLICATIONS: For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.

Getting the basics right. Care delivery in nursing homes.

In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.

Health belief model and reversal theory: a comparative analysis.

BACKGROUND: In recent years, an increasing number of nurses have demonstrated interest in health behaviour change interventions and research. Despite this heightened enthusiasm, there appears to have been less interest in exploring new and emerging health behaviour change theories. AIM: The goal of this work is to assist clinicians and researchers to make more informed choices about the use of the Health Belief Model and Reversal Theory in their practice settings and research projects. METHOD: Primary sources were analysed using qualitative data analysis methods in order to compare and contrast the two models. Four comparative categories provided the structure for analysis: origins of models, ways of knowing and behaving, role of health care providers in behaviour change, and desired outcomes. RESULTS: Based, in part, on their historical origins, the Health Belief Model and Reversal Theory offer differing tenets regarding how individuals perceive, understand, and behave. According to Reversal Theory, ways of knowing and behaving are dependent upon innate physiological factors and subjectively structured perceptions. In contrast, the Health Belief Model suggests that health-related behaviours are largely attributable to cognitive decision-making processes. As such, health care providers are directed to approach health behaviour change in different ways. CONCLUSIONS: Although the Health Belief Model has been widely implemented, Reversal Theory may offer a more comprehensive framework for health behaviour change interventions and research. Clinicians and researchers are urged to learn more about this theory and how it may apply to their areas of practice and research.

Why older adults with light care needs enter and remain in nursing homes.

Many patients in nursing homes receive limited services. In 1996, approximately 17% of the 1.6 million nursing home residents received assistance with two or less activities of daily living (ADL). This descriptive study addressed this issue by investigating why residents with light care needs enter and remain in nursing homes. Residents with light care needs (N = 20) identified by directors of nursing were interviewed to elicit why they entered and remain in nursing homes. Their care level was estimated using the Minimum Data Set (MDS) and Resource Utilization Groups, Version III (RUG-III). In this study, older adults with light care needs who decide to enter and remain in nursing homes were found to be influenced by a prior hospitalization or a health event; the perceived inability to manage instrumental ADLs (IADLs), ADLs, or health monitoring at home; and lack of knowledge about alternatives to nursing home care. This study demonstrates the vital role nurse case managers can play in both acute care settings and nursing homes. They can help older adults with light care needs to make informed decisions about long-term care, seek out community options, and set in place assistive care systems that can help them age in the community.