Predictors of activity involvement in dementia care homes: a cross-sectional study.

BACKGROUND: Despite the finding that involvement in activities is one of the most important needs of residents with dementia living in care homes, care facilities struggle to fulfill this need. Over the years, various factors are suggested which may contribute to or disable activity provision in dementia care homes. These include limited financial resources, task oriented staff and disease-related characteristics of residents. This study aims to further clarify which of these factors predict higher activity involvement. METHODS: Data were derived from the second measurement (2011) of the Living Arrangements for people with Dementia study. One thousand two hundred eighteen people residing in 139 dementia care homes were involved. Forty predictors of higher involvement were studied. Multilevel backward regression analyses were performed. RESULTS: The most important predictors of higher involvement were: absence of agitation, less ADL dependency, and a higher cognitive status of the residents, higher staff educational level, lower experienced job demands by care staff and a smaller number of residents living in the dementia care wards of a facility. More social supervisor support as perceived by staff was found to predict less activity involvement. CONCLUSIONS: To increase the activity involvement of care home residents with dementia it seems vital to: 1) reduce staff's experienced job demands; 2) elevate their overall educational level; 3) train staff to provide suitable activities, taking account of the behavior and preserved capabilities of residents; and 4) foster transition towards small-scale care. In order to achieve these aims, care organizations might need to evaluate the use of their financial means.

Is an unhealthy work environment in nursing home care for people with dementia associated with the prescription of psychotropic drugs and physical restraints?

BACKGROUND: Research showed that long-term care facilities differ widely in the use of psychotropic drugs and physical restraints. The aim of this study is to investigate whether characteristics of an unhealthy work environment in facilities for people with dementia are associated with more prescription of psychotropic drugs and physical restraints. METHODS: Data were derived from the first wave (2008-2009) of a national monitoring study in the Netherlands. This paper used data on prescription of psychotropic drugs and physical restraints from 111 long-term care facilities, residing 4,796 residents. Survey data of a sample of 996 staff and 1,138 residents were considered. The number of residents with prescribed benzodiazepines and anti-psychotic drugs, and physical restraints were registered. Work environment was assessed using the Leiden Quality of Work Questionnaire (LQWQ). RESULTS: Logistic regression analyses showed that more supervisor support was associated with less prescription of benzodiazepines. Coworker support was found to be related to less prescription of deep chairs. Job demands and decision authority were not found to be predictors of psychotropic drugs and physical restraints. CONCLUSIONS: Staff's job characteristics were scarcely related to the prescription of psychotropic drugs and physical restraints. This finding indicates that in facilities with an unhealthy work environment for nursing staff, one is not more likely to prescribe drugs or restraints. Further longitudinal research is needed with special attention for multidisciplinary decision making - especially role of physician, staff's knowledge, philosophy of care and institutional policy to gain further insight into factors influencing the use of psychotropic drugs and restraints.

Activity involvement and quality of life of people at different stages of dementia in long term care facilities.

OBJECTIVES: Involvement in activities is assumed to positively influence the quality of life of people with dementia, yet activity provision in long-term care remains limited. This study aims to provide more insight into the value of activity involvement for domains of the quality of life of long-term dementia care residents, taking resident characteristics and cognitive status into account. METHOD: Data were derived from 144 long-term care facilities participating in the second measurement (2010/2011) of the living arrangements for dementia study. Amongst 1144 residents, the relationship between time involved in activities (activity pursuit patterns; RAI-MDS) and quality of life (Qualidem) was studied using multilevel linear regression analyses. Analyses were adjusted for residents' age, gender, neuropsychiatric symptoms, ADL dependency and cognition. To check for effect modification of cognition, interactions terms of the variables activity involvement and cognitive status were added to the analyses. RESULTS: Despite resident's cognitive status, their activity involvement was significantly related to better scores on care relationship, positive affect, restless tense behaviour, social relations, and having something to do. A negative relationship existed between the activity involvement and positive self-image. The explained variance in the quality of life between residents caused by the activity involvement was small. CONCLUSION: Activity involvement seems to be a small yet important contributor to higher well-being in long-term care resident at all stages of dementia. Adjusting activities to individual preferences and capabilities might enlarge this relationship. Further research is needed to confirm this hypothesis, using measurement instruments less sensitive to recall bias and differentiating between the active and passive activity involvement.

Staff-resident interactions in long-term care for people with dementia: the role of meeting psychological needs in achieving residents' well-being.

OBJECTIVES: The aim of this study is to explore the extent to which staff-resident interactions address or undermine residents' psychological needs and how such interactions are associated with residents' well-being. METHOD: Data on staff-resident interactions and residents' well-being were collected for 51 residents from nine long-term care settings using dementia care mapping (DCM). DCM yields a count and detailed description of staff-resident interactions that either address (personal enhancers - PEs) or undermine (personal detractions - PDs) residents' psychological needs, and every 5-minute scores for each resident's mood and engagement (ME-value). The relationship between PEs and PDs and well-being was analysed by studying residents' ME-values before and three time frames after a PE or PD occurred. RESULTS: A total of 76 PEs and 33 PDs were observed. The most common PEs were those addressing psychological needs for comfort and occupation. However residents' well-being increased most often after PEs that addressed residents' need for identity, attachment and inclusion. The most common PDs were those which undermined the need for comfort, inclusion and occupation. Residents' well-being decreased most often after PDs that undermined the need for comfort. CONCLUSION: Increasing interactions which address residents' need for attachment, identity and inclusion and eliminating interactions which undermine residents' need for comfort may be particularly important in achieving residents' well-being. In the long run, residents' well-being could be achieved by staff availing of the opportunities to empower and facilitate residents, thus meeting their needs for occupation. These findings provide directions for training in person-centred care.

Staff's person-centredness in dementia care in relation to job characteristics and job-related well-being: a cross-sectional survey in nursing homes.

AIM: To explore the role of nursing staff's person-centredness caring for people with dementia in relation to their work environment and job-related well-being. BACKGROUND: Given the development towards person-centred care and labour force issues, research has recently focused on the effect of person-centredness on nursing staff's well-being. Findings from occupational stress research suggest that employees' personal characteristics, such as person-centredness, can moderate the impact particular job characteristics have on their job-related well-being. DESIGN: Cross-sectional survey. METHODS: A national survey was conducted among healthcare staff (n = 1147) in 136 living arrangements for people with dementia in the Netherlands (2008-2009). Hierarchical regression analyses were used. RESULTS: Person-centredness moderates the relationship between coworker support and three outcomes of job-related well-being and between supervisor support and two of these outcomes. For highly person-centred nursing staff, coworker support was found to have a weaker impact and supervisor support to have a stronger impact on their job-related well-being. In addition, direct effects showed that person-centredness was weakly associated with more job satisfaction, more emotional exhaustion and more strongly with more personal accomplishment. CONCLUSION: Nursing staff's person-centredness does play a modest role in relation to job characteristics and job-related well-being. Findings indicate that person-centredness is not only beneficial to residents with dementia as found earlier, but also for nursing staff themselves; specifically, in case nursing staff members feel supported by their supervisor. Since a more person-centred workforce feels more competent, further implementation of person-centred care might have a positive impact on the attractiveness of the profession.

Wellbeing-enhancing occupation and organizational and environmental contributors in long-term dementia care facilities: an explorative study.

BACKGROUND: Occupation remains an unmet need in long-term dementia care. To increase residents' occupation, knowledge of types of occupation related to wellbeing, and organizational and environmental characteristics encouraging involvement in these types of occupation, is indispensable. METHODS: In this explorative study, Dementia Care Mapping was used to study involvement in different types of occupation and wellbeing among 57 residents of 10 dementia care facilities. For each type of occupation, mean experienced wellbeing was studied. Occupation types with high mean wellbeing scores were classified as "wellbeing-enhancing occupation." Care facilities were ranked according to the mean time residents spent in types of wellbeing-enhancing occupation. Using information on staff-to-resident ratio, individual space, and items of the Physical Environment Evaluation Component of Dementia Care Mapping, organizational and environmental characteristics of the facilities were compared to study their relationship with wellbeing-enhancing occupation. RESULTS: Reminiscence, leisure, expression, and vocational occupation had greatest potential to enhance wellbeing, but these types were seldom offered. Much variation existed in the extent to which wellbeing-enhancing occupation was provided. Long-term care facilities that did so more frequently generally had a more homelike atmosphere, supported social interaction through the environment, and had no central activity program. CONCLUSIONS: This study suggests that it is possible to engage residents in wellbeing-enhancing occupation, within current means of budget and staff. The physical environment and care organization might play a role, but the key factor seems to equip staff with skills to integrate wellbeing-enhancing occupation into care practice.

The relationship between small-scale care and activity involvement of residents with dementia.

BACKGROUND: Nursing home care for people with dementia is increasingly organized in small-scale care settings. This study focuses on the question of how small-scale care is related to the overall activity involvement of residents with dementia, and their involvement in different types of activities. As several studies have indicated, activity involvement is important for the quality of life of residents. METHODS: Data were derived from the first measurement cycle (2008/2009) of the Living Arrangements for people with Dementia study, in which 136 care facilities and 1,327 residents participated. The relationship between two indicators of small-scale dementia care (group living home care characteristics, and the total number of residents with dementia in the facility) and activity involvement (Activity Pursuit Patterns of the Resident Assessment Instrument Minimum Data Set) were studied with multilevel multiple regression analyses. All analyses were adjusted for the residents' age, sex, neuropsychiatric symptoms, and dependency on the activities of daily living. RESULTS: Residents of care facilities with more group living home care characteristics were more involved in overall and preferred activities. Furthermore, they were involved in more diverse activities. Overall, no relationship was found between the number of residents at the facility and activity involvement. CONCLUSIONS: These results indicate that small-scale dementia care has a positive effect on activity involvement of residents. The current study also sheds light on the lack of activity involvement of many residents with dementia, especially those who are older, male, and with higher dependency.

Nursing home care for people with dementia and residents' quality of life, quality of care and staff well-being: design of the Living Arrangements for people with Dementia (LAD)-study.

BACKGROUND: There is limited information available on how characteristics of the organization of nursing home care and especially group living home care and staff ratio contribute to care staff well being, quality of care and residents' quality of life. Furthermore, it is unknown what the consequences of the increasingly small scale organization of care are for the amount of care staff required in 2030 when there will be much more older people with dementia. METHODS/DESIGN: This manuscript describes the design of the 'Living Arrangements for people with Dementia study' (LAD-study). The aim of this study is to include living arrangements from every part of this spectrum, ranging from large scale nursing homes to small group living homes. The LAD-study exists of quantitative and qualitative research. Primary outcomes of the quantitative study are wellbeing of care staff, quality of care and quality of life of residents. Furthermore, data concerning staff ratio and characteristics of the living arrangements such as group living home care characteristics are assessed. To get more in-depth insight into the barriers and facilitators in living arrangements for people with dementia to provide good care, focus groups and Dementia Care Mapping are carried out. DISCUSSION: Results of this study are important for policymakers, directors and staff of living arrangements providing nursing home care to people with dementia and essential for the development of methods to improve quality of care, residents' and staff well-being. Data collection will be repeated every two years, to generate knowledge on the results of changing policies in this field.

The long-term effect of group living homes versus regular nursing homes for people with dementia on psychological distress of informal caregivers.

OBJECTIVE: In this follow-up study, the long-term influence of group living homes (GLHs) on informal caregiver distress was compared with modern yet regular nursing homes (NHs). METHOD: Informal caregivers of GLH (N = 37) and NH residents (N = 49) were studied at the time of admission, 6 months thereafter, and approximately 24 months after admission. Repeated measures of ANOVA were performed to study group-by-time effects on psychopathology, role overload, and feelings of competence. RESULT: All outcomes of psychological distress in GLH caregivers showed significantly greater decline compared with NH caregivers during the first six months after admission. The course of psychological distress stabilized in both caregiver groups after six months. CONCLUSION: GLHs may have played a role in reducing caregiver burden during the first six months after the nursing home admission of the care recipient. The stabilization of caregivers' psychological distress between T1 and T2 may indicate that there is no further room for improvement in the GLH and NH groups after six months. The implication would be that both GLHs and NHs succeeded in keeping caregivers' distress relatively low over the long term. More knowledge is needed on whether and how caregivers' psychological distress after institutionalization of the care recipient can be reduced to a greater extent.

Group living homes for older people with dementia: the effects on psychological distress of informal caregivers.

OBJECTIVES: The aim of this study was to investigate the effects of group living care for people with dementia on the psychological distress of informal caregivers, compared with regular nursing home care. METHOD: This study had a quasi-experimental design with two measurements. 67 primary informal caregivers in 19 group living homes and 99 primary informal caregivers in seven regular nursing homes filled in a questionnaire upon admission (baseline measurement) of their relative and six months later (effect measurement). Linear and logistic regression analyses were performed on three outcomes of psychological distress - psychopathology, caregiving competence and caregiver burden. RESULTS: There were no significant differences in caregiver competence and caregiver burden between informal caregivers of residents in group living homes and those in regular nursing homes, although there was a trend towards less psychopathology in group living homes after adjustment for confounding. CONCLUSION: Informal caregivers of residents in group living homes do not have less psychological distress than informal caregivers of residents in regular nursing homes. Although there was a trend towards less psychopathology in informal caregivers of group living homes, the amount of symptoms remained very high in both caregiver groups. This means that the psychological well-being of caregivers deserves the continuing attention of health care providers, also after admittance of their relative in a nursing home facility.

The moderating role of decision authority and coworker- and supervisor support on the impact of job demands in nursing homes: a cross-sectional study.

BACKGROUND: Healthcare workers in nursing homes are faced with high job demands that can have a detrimental impact on job-related outcomes, such as job satisfaction. Job resources may have a buffering role on this relationship. The Demand-Control-Support (DCS) Model offers a theoretical framework to study how specific job resources can buffer the adverse effects of high demands, and can even activate positive consequences of high demands. OBJECTIVES: The present study tests the moderating (i.e. buffering and activating) effects of decision authority and coworker- and supervisor support that are assumed by the hypotheses of the DCS Model. DESIGN: A national cross-sectional survey was conducted with an anonymous questionnaire. SETTING: One hundred and thirty six living arrangements that provide nursing home care for people with dementia in the Netherlands. PARTICIPANTS: Fifteen healthcare workers per living arrangement. In total, 1147 people filled out the questionnaires (59% response rate). METHODS: Hierarchical multilevel regression analyses were conducted to test the assumption that the effect of job demands on the dependent variables is buffered or activated the most when both decision authority and social support are high. This moderation is statistically represented by three-way interactions (i.e. demands×authority×support), while lower-order effects are taken into account (i.e. two-way interactions). The hypotheses are supported when three-way interaction effects are found in the expected direction. The dependent variables studied are job satisfaction, emotional exhaustion, and personal accomplishment. RESULTS: The proposed buffering and activation hypotheses of the DCS Model were not supported in our study. Three-way interaction effects were found for emotional exhaustion and personal accomplishment, though not in the expected direction. In addition, two-way interaction effects were found for job satisfaction and emotional exhaustion. Decision authority was found to buffer the adverse effect of job demands and to activate healthcare staff. Supervisor support was found to buffer the adverse effect of job demands on emotional exhaustion in situations with low decision authority. Finally, coworker support was found to have an adverse effect on personal accomplishment in high strain situations. CONCLUSIONS: Findings reveal that decision authority in particular makes healthcare workers in nursing homes less vulnerable to adverse effects of high job demands, and promotes positive consequences of work.