Working group recommendations: methods for geriatric evaluation and management research.

Methodological issues relating to multi-site studies of inpatient geriatric evaluation and management units were the focus of this working group's deliberations. The group favored a randomized clinical trial in which the inpatient geriatric evaluation and management unit was coupled with outpatient geriatric care. Inclusion of a broad spectrum of patients stratified according to risk for poor hospital outcomes was proposed in order to obtain information on the types of patients that would be most likely to benefit. The need for a detailed definition and description of care in the unit and of "usual care" was emphasized. Serious concerns were raised about including both VA medical centers and private hospitals in the same trial due to differences in the implementation of such a program. Furthermore, fears of contamination of the control group suggested that hospitals could be randomized either to provide usual care or have a GEM unit. However, this strategy would necessitate that hospitals that have already developed inpatient GEM units would be excluded from the trial and could be costly because of the number of hospitals that would be required.

Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision.

OBJECTIVE: To investigate the factors that influenced fluid intake among nursing home residents who were not eating well. DESIGN: A prospective, descriptive, anthropological study. SETTING: Two proprietary nursing homes with 105 and 138 beds, respectively. PARTICIPANTS: Forty nursing home residents. MEASUREMENTS: Participant observation, event analysis, bedside dysphagia screening, mental and functional status evaluation, assessment of level of family/advocate involvement, and chart review were used to collect data. Data were gathered on the amount of liquid served and consumed over a 3- day period. Daily fluid intake was compared with three established standards: Standard 1 (30 mL/kg body weight), Standard 2 (1 mL/kcal/energy consumed), and Standard 3 (100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 15 mL/kg for the remaining kg). RESULTS: The residents' mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. The amount of fluid consumed with and between meals was low. Some residents took no fluids for extended periods of time, which resulted in their fluid intake being erratic and inadequate even when it was resumed. Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration. CONCLUSIONS: When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.

A prospective study of the use of liquid oral dietary supplements in nursing homes.

OBJECTIVE: To investigate the use of liquid oral dietary supplements among nursing home residents who were eating poorly and losing weight. DESIGN: A prospective, descriptive, anthropological study. SETTING: Two proprietary nursing homes with 105 and 138 beds. PARTICIPANTS: Purposive sampling was used to select 40 residents from among the 100 residents who were not eating well. Dietary data were collected on this sub-sample of 40 residents. MEASUREMENTS: Participant observation, in-depth interviews, event analysis, bedside dysphagia screenings, oral health examinations, body weight, body mass index (BMI), and chart review were used to collect data. Dietary data were collected over a 3-day period, and data were gathered on how supplements were ordered, served, and consumed. RESULTS: Supplements had been ordered for 29 of the subsample of 40 residents. Only nine of 29 residents were served the correct number and type of supplements as ordered by their physicians, and only two residents consumed the full amount of supplement as ordered. The overall mean percentage of supplement consumed compared with that ordered was 55.1%. Although supplements were ordered primarily to prevent weight loss and to facilitate weight gain, nearly half (n = 14) of the residents continued to lose weight. Supplements were ordered without investigating the underlying factors contributing to weight loss, such as inadequate staffing and lack of supervision at mealtime, undiagnosed dysphagia, and poor oral health. Without evaluation of these factors, it is unknown which residents might benefit from oral supplements. CONCLUSION: Findings indicate that supplements were used nonspecifically as an intervention for weight loss in nursing home residents without regard to dose, diagnosis and management of underlying problem(s), amount of supplement consumed, and outcome. Further research is needed to establish when supplements should be ordered, how to ensure that they will be taken, and whether they are effective.

Distributive justice and the treatment of acute illness in nursing homes.

Using participant observation and interviews, this research investigated the social-cultural factors that influence decision making in the evaluation and treatment of acute illness in nursing homes. Mental status and cost of care emerged as the predominant factors that influence physicians in the decision-making process. Drawing on some of the principles of distributive justice, it is argued that it is unjust to deny health care to the elderly because of their impaired mental status or a lack of financial resources. Quality of life from the patient's perspective, the patient's and their family's wishes and cultural and individual values must be considered in the decision-making process.

KIE: As elderly patients become increasingly frail, decision making as to medical intervention for acute illness becomes a difficult issue for health professionals, as well as for patients and their families. Kayser-Jones describes a study that used interviews and participant observation to investigate the sociocultural and personal factors that influence the decision making process in nursing homes. She found that mental status and cost of care were the predominant factors influencing physician decisions. She argues that it is unjust to deny health care to the elderly because of their impaired mental status or lack of financial resources, but favors considering quality of life from the patient's perspective, and the wishes and values of patients and their families, in the decision making process.

Institutional structures: catalysts of or barriers to quality care for the institutionalized aged in Scotland and the U.S.

The care of the elderly in two long-term care institutions, one in Scotland and one in the United States, is described, compared, and analyzed. In Scotland three institutional structures, the National Health Service, the Geriatric Service, and the specialty of geriatrics are identified as catalysts of quality care. In the U.S. Medicare and Medicaid, the absence of geriatrics as a specialty, and the nursing home are identified as barriers to quality care for the institutionalized aged. The findings suggest that three components, an adequate government insurance program, professionals who specialize in the care of the aged, and a structure to provide continuing comprehensive care, are essential for a successful program of care for the institutionalized elderly.

Defensive work in nursing homes: accountability gone amok.

This paper contrasts conditions in intensive care nurseries and skilled nursing facilities in order to bring out certain features of organizational functioning in nursing homes. Data stem from a study of three American nursing homes which focused on the circumstances influencing decision-making in the evaluation and treatment of acute illness. DEFENSIVE WORK--work that is institution-protective and/or self-protective-emerged as a dominant process. It is demonstrated that the avoidance strategies which constitute defensive work lead to a progression of counterstrategies and foster skewed priorities. Consequences are: an acceptance of substandard care and a diversion of attention from therapeutic work. The relationship of defensive work to the larger question of how the nation handles its sick elderly is examined in the conclusion of the paper. Recommendations are offered for organizational steps that would re-channel the wasted energy that is spent on defensive work toward more productive therapeutic work.

The use of nasogastric feeding tubes in nursing homes: patient, family and health care provider perspectives.

This anthropological study investigated attitudes of patients, family members, nurses, and physicians toward the use of nasogastric tube feedings in 3 nursing homes. In-depth interviews and participant observation were used to obtain data. Fifty-three percent of the patients, 58% of families, and 70% of the nursing staff approved of the use of tube feedings. Diverse opinions characterized physicians' responses. Findings disclosed inadequate communication among health care providers, patients, and families, and that some families perceive the tubes as being inserted for the convenience of nursing home staff.

Factors contributing to the hospitalization of nursing home residents.

This anthropological study describes and analyzes the clinical and social-structural factors contributing to the hospitalization of nursing home residents. In 48.2% of the cases, hospitalization could have been avoided. Factors such as an insufficient number of adequately trained nursing staff, the inability of nursing staff to administer and monitor intravenous therapy, lack of diagnostic services, and pressure for transfer from the staff and family contributed to hospitalization. In the United States each year, an estimated 216,000 nursing home residents who are hospitalized might be treated in the nursing home, for a cost savings of $942,763,530.

An instrument to assess the oral health status of nursing home residents.

This article presents data from the development and testing of an instrument to evaluate the oral health of nursing home residents by nursing personnel (RNs, LVNs, and CNAs). After the instrument was developed, nursing staff were taught to do a brief oral health status examination (BOHSE). Using the instrument, a dentist examined 100 residents; the examination was repeated on the same residents by each category of nurse examiners. Correlation coefficients indicate that statistically significant interrater reliability between the three categories of nursing personnel and the dentist was established, suggesting that nursing staff can be taught to evaluate the oral health of residents. Replication of the study in multiple sites is recommended.

Experts recommend minimum nurse staffing standards for nursing facilities in the United States.

The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs) in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes. These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA could introduce minimum staffing standards through the regulatory process. In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed selected states and found that 21 states had either proposed new legislation or were considering proposals for new legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to meet the needs of their residents, especially because government is paying for 61% of the expenditures. Adopting these minimum standards will have an important impact on improving the quality of the nation's nursing home care. Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to residents. These studies could test the proposed staffing standards against existing staffing levels to examine the impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made if necessary to ensure that high standards are maintained.

Decision making in the treatment of acute illness in nursing homes: framing the decision problem, treatment plan, and outcome.

This article investigates the social-cultural factors and other circumstances that influence decision making in the treatment of acute illness in three West Coast nursing homes. Participant observation, in-depth interviews with physicians, nursing staff, nursing home residents, and family members, and event analysis were used to gather data. Using decision-making theory as the theoretical framework, analysis focuses on how internal and external factors influence the decision-making process. Two case studies are used to illustrate how in real-life acute clinical situations, physicians frame decision problems, treatment plans, and expected outcomes in order to persuade residents and their families to comply with their preferred treatment plans.

Middle Eastern nursing students in the United States.

The United States, then, surprises, upsets, delights, challenges, and to some extent, changes Middle Eastern students. For those who have studied in the United States and participated in our study, their experience has been rewarding in many respects and not only in academic terms. "The academic degree is only part of the experience of studying in America," says one Lebanese student, "One gains perspective, a global look and broadens horizons as one interacts and is being exposed to the society." Middle Eastern nursing students in the United States can perhaps look at their experiences more positively and the challenges of the academic setting more constructively if they have the support of faculty and classmates and if they are allowed the flexibility in structuring their own programs to meet their own and their countries' health needs.

Asian nursing students in the United States.

It is obvious that there is a great need to familiarize faculty and students with the Asian culture and heritage and to sensitize them to the difficulties and problems that Asian nursing students encounter in their adjustment to the university nursing program in the United States. Recommendations and strategies to achieve the above goals are: (1) Organizing cross-cultural courses for Asians and non-Asians to familiarize them with different cultures, (2) sensitizing faculty and counselors to the detrimental effects of existing nursing programs on international students, and (3) helping Asian nursing students better adjust to the American culture by providing English tutorial classes, support groups and host families that will act as socializing agents during the student's adjustment process. Through such educational and support programs, it is hoped that Asian nursing students will experience fewer difficulties which in turn will make their studies more meaningful and applicable.

Latin American nursing students in the United States.

The Latino students confront a unique set of difficulties and patterns of adjustment in the majority culture and the educational experiences in the United States. Careful consideration must be given not only to the general characteristics of this group, but also to the individual's history of immigration, socioeconomic status, educational experiences and background. Multicultural education for the international nursing students can benefit all students, but it should not gloss over conflicts of values and beliefs. It must honestly deal with differences and similarities. It must be based on experience, not on stereotypes of root cultures or ethnic characteristics. In addition to addressing the cognitive affect and skill needs of all students, the multicultural education must address the special needs of minorities. Anglo students or majority-group students need realistic opportunities for experience and interaction with minority students and minority-faculty. Every group has something to teach the other. Faculty advisors and majority students should be encouraged to acquaint themselves with the need to establish rapport with the Latino student. There is also a need to develop in the classroom an atmosphere that enhances the learning experiences. The learning experiences should be so designed that all students and school personnel can intellectually, emotionally and socially participate on equal terms in a culturally diverse society.

Nigeria: the land, its people, and health care.

The unique health care needs in developing countries and the responsibilities of the nursing profession in such countries place a heavy responsibility on schools of nursing involved in the education of foreign nursing students. The students in this study indicated that it was frustrating to repeat course content that was already familiar to them knowing that there are many courses that would better meet their needs. In developing countries, like Nigeria, it has been suggested that there is a need to prepare a "comprehensive nurse"--a combination bedside nurse, public health nurse, and midwife who can provide preventive and curative services in multiple settings. Such a task is awesome and illustrates the need for schools of nursing to provide an academic counselor who has some knowledge of the culture and health needs of the students' native land. When asked: "How could the school of nursing have helped you cope with your academic problems?" 43% of the students suggested a foreign student advisor or counselor. "To have a foreign student advisor who has been overseas and who will relate to the student at their level," replied one student. Only when education is relevant to the specific needs of a given country, will there be an improvement in the health of the people of that country. To educate registered nurses abroad is very costly for countries with low G.N.P. If we accept students from developing countries into our nursing programs, we have a responsibility to prepare them to be effective practitioners when they return to their homeland. The special needs of nursing students and the health care needs of the community for which they are trained must therefore be integrated into their training.

Culture, environment, and restraints: a conceptual model for research and practice.

1. Despite its importance to the care of the elderly, little research has focused on the effects of the environment on health and well-being. 2. It is hypothesized that environmental factors, including cultural attitudes and beliefs of nursing home staff, contribute to restraint of nursing home residents. 3. Nurses can be instrumental in creating a nursing home culture that values a restraint-free environment.

Mealtime in nursing homes: the importance of individualized care.

Malnutrition, a common problem among nursing home residents, contributes to: a) higher rates of infection, b) an impaired immune response, and c) the development of pressure sores. Eating habits are highly individualized and eating problems often occur due to a complex constellation of interacting factors such as poor oral health, medications, clinical conditions, and lack of attention to individual food likes and dislikes. By educating nursing assistants on how to provide individualized care at mealtime and ensuring that an adequate number of staff are available to assist those who need help, mealtime rather than being a task-oriented procedure will be an individualized, pleasant social event.

A case study of the death of an older woman in a nursing home: are nursing care practices in compliance with ethical guidelines?

This article presents a case study describing and analyzing ethical issues in the care during the last 11 weeks of life of a 101-year-old nursing home resident. The case presented here is part of a larger ongoing ethnographic study of death and dying in nursing homes. Two nursing care issues with ethical implications are discussed. First, the resident could not eat or drink independently, but she received no assistance with her meals. Second, she remained in a wheelchair for many hours and developed three pressure ulcers on her buttocks. Furthermore, she became tired when sitting in the wheelchair for long periods of time, fell out of the wheelchair, and subsequently was restrained "for her safety." Using selected principles from the International Council of Nurses and the American Nurses Association code for nurses, the resident's care is discussed and recommendations for improving the care of nursing home residents are presented.

Advocacy for the mentally impaired elderly: a case study analysis.

The authors present a case study to illustrate how a mentally impaired but socially intact nursing home resident, who had no one to act as an advocate for her, was denied appropriate treatment for an acute illness which ultimately resulted in her death. The case raises important questions about advocacy for the mentally-impaired, acutely-ill institutionalized patient. This Article explores the role of the advocate, how advocates are selected, what qualities and talents they should possess, and what responsibilities should be assigned to them. The authors suggest that nursing home residents should be encouraged to engage in self-advocacy to the greatest extent possible. The competent elderly should be urged to name their preferred advocates. Individuals who serve in advocacy roles should be advised to seek information regarding the patient's wishes from those who know the patient well. Furthermore, there is a need for quality education and training of those who serve in advocacy roles on behalf of nursing home residents, and state laws need to specify the responsibilities of persons who serve as advocates.

Strategies for conducting dental examinations among cognitively impaired nursing home residents.

Many nursing home residents have poor oral health and are in need of treatment. A major barrier to providing care is the difficulty of examining cognitively impaired elders. In two research studies, 625 exams were conducted on 181 nursing home residents, the majority of whom suffered severe cognitive impairment. Qualitative data collected during the course of these two studies revealed strategies that permitted examiners to conduct the examinations successfully, including developing rapport with the residents, providing a quiet environment, and enlisting the help of the primary caregiver. The importance of interdisciplinary collaboration among health professionals, especially dentists and nurses, is discussed.