Limited-treatment policies in long-term care facilities.

Two-thirds of the long-term care facilities in Minnesota accept do-not-resuscitate (DNR) orders and 73% accept care plans to limit medical treatment. The major objectives for limited-treatment plans cited by the 16.3% of facilities with administrative protocols for such plans was to provide for the resident's physical and emotional comfort and dignity. Nearly half of the protocols said limited treatment plans were intended to limit emergency care or hospitalization or to allow death to occur. Protocols advocated the alleviation of physical discomfort, anxiety, and social isolation. Tube feedings were not recommended when oral feeding became impossible. Airway suctioning, oxygen, or antibiotic treatment was suggested only as needed to alleviate suffering. Only a fourth of the protocols described a primary role for the resident in these decisions. This study demonstrates that nursing homes are developing administrative protocols for the formulation of limited-treatment plans and suggests that model policy statements describing key decision-making principles, issues, and procedural safeguards could play a constructive role in this process.

Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture.

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture. DESIGN: Prospective comparative survey design. PARTICIPANTS: A convenience sample of 88 hip fracture patients (53 cognitively impaired, 35 cognitively intact) from three Midwestern urban hospital orthopedic units was interviewed between days 2 and 5 postoperatively. Subjects whose Folstein Mini-Mental State Exam (MMSE) score was less than or equal to 23 were categorized as impaired. RESULTS: Pain report and intensity did not differ significantly between the two groups. One-third of the subjects in both groups rated pain as severe or worse. Cognitively impaired subjects scored significantly higher on the Checklist of Nonverbal Pain Indicators observed with movement (CNPI-m) than did cognitively intact subjects. Cognitively impaired subjects received significantly less opioid analgesics than cognitively intact subjects in the first and second 48 hours postoperatively. Both groups received less than 25% of the mean prescribed amount of opioid analgesics. Age, MMSE, and CNPI-m score accounted for 27% of the variance in the amount of opioid analgesic administered in the first 48 hours postoperatively. CONCLUSIONS: Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.

Value-added outcomes: the use of advanced practice nurses in long-term care facilities.

The purpose of this study was to determine the effect on clinical outcomes for newly admitted nursing home residents when advanced practice gerontological nurses (APNs) worked with staff to implement scientifically based protocols for incontinence, pressure ulcers, depression, and aggressive behavior. Use of APNs in this manner differs from the usual way APNs have been used in nursing homes, in which their primary focus has been to augment the physician's role. The APN treatment was randomly assigned to two nursing homes and usual care was assigned to a third. Trajectories from admission to 6 months revealed that residents with APN input into their care (n = 86) experienced significantly greater improvement or less decline in incontinence, pressure ulcers, and aggressive behavior, and they had higher mean composite trajectory scores compared with residents receiving usual care (n = 111). Significantly less deterioration in affect was noted in cognitively impaired residents in the treatment group. Findings suggest that APNs can be effective links between current scientific knowledge about clinical problems and nursing home staff.

We need to know more: nurse educators' interest and expertise in gerontology.

An assessment was made of 129 faculty who teach nursing students about the care of aged clients to determine their level of interest and expertise in 21 content areas related to gerontology. Faculty rated their expertise consistently lower than the relevance of, and their interest in, each of the content areas. Areas identified as most important for their professional growth tended to be areas where faculty ranked their expertise as already being high. The mean self-rated expertise of faculty who taught a course in gerontological nursing was significantly higher than those who did not. Most respondents lacked formal education in gerontology: 9% of respondents had gerontology in their undergraduate program; 27% in their graduate program. Only 4% were certified as gerontological nurses or gerontological nurse practitioners.

The clinical evaluation tool: a measure of the quality of clinical performance of baccalaureate nursing students.

This article describes an approach to the evaluation of students' clinical performance. Specifically, the paper describes: (a) the history of the evaluation of clinical performance in nursing education; (b) the development of the Clinical Evaluation Tool (CET), an instrument designed to measure the clinical performance of nursing students across settings; and (c) the relationships between basic baccalaureate nursing students' scores on the CET and the following variables: age, college credits earned prior to entry to the program, grade point average at entry, college aptitude, and moral reasoning.

Multi-course sequential learning as a model for content integration: ethics as a prototype.

Multi-course sequential learning (MCSL), a model for integrating content throughout the curriculum, is described using ethics education as a prototype. In this model, content is presented via a vertical course, with units embedded in existing courses across various levels of the nursing program, which is designed to provide coherent organization of content, visibility, and accountability, and to prevent gaps and unnecessary duplication. This article describes the process of developing an Ethics MCSL, which is being implemented and evaluated with support from a three-year grant from the Fund for the Improvement of Postsecondary Education (FIPSE).

Wrestling with the larger picture: placing ethical behavior in clinical situations in context.

This article provides an account of the use of a model-building process as an educational strategy for the teaching of ethics. Designed to integrate students' growing knowledge and skill in nursing with their intellectual and professional development, this model-building process has its theoretical foundations in cognitive moral development theory, and in an integrative approach to nursing education called Multi-Course Sequential Learning (MCSL).

Aggressive behavior. Educating nursing assistants.

Caring for cognitively impaired aggressive residents presents a challenge to nursing assistants in long-term care facilities. Nursing assistants participated in an educational program that included content about cognitive losses, precipitants of aggression, communication techniques, strategies for preventing aggressive behavior, and managing personal feelings. Following the educational intervention in this study, nursing assistants reported that caring for cognitively impaired residents was significantly more rewarding and less frustrating. The use of the clinical nurse specialist to teach and assist in role modeling direct care of residents was effective in improving nursing assistant skill in working with aggressive cognitively impaired residents.

Assess not assume--measuring the morale of cognitively impaired elderly.

The morale of cognitively impaired elderly has not been systematically studied as this group has been excluded in most studies of well-being. This study showed that most cognitively impaired persons who retain verbal skills were able to respond to a verbally administered assessment using the Philadelphia Geriatric Center Morale Scale. Support for the reliability and validity of measurement of morale in cognitively impaired elderly using the Philadelphia Geriatric Center Morale Scale was reported. Ratings of the morale of cognitively impaired persons by family members were significantly associated with self-report by elders, but tended to be lower.

Goal-directed care: caring for aggressive nursing home residents with dementia.

1. Aggressive behavior in elders with dementia occurs most often during personal care. It is often a response to invasion of private space and may be prevented or reduced by interpersonal approaches that reflect a set of individualized goals for the resident. 2. Five resident goals for preventing or reducing aggressive behavior are to feel safe, to feel physically comfortable, to experience a sense of control, to experience optimal stress, and to experience pleasure. 3. These goals provide a framework for humane care that respects the personhood of the individual and minimizes the need for psychotropic medications and physical restraints.

Examining pain in aggressive cognitively impaired older adults.

Few studies have explored the phenomenon of pain in people with severe cognitive impairment. Pain assessment, which depends primarily on people's ability to describe dimensions of pain, becomes problematic when clients' cognitive impairment is so severe they cannot respond to pain assessment tools. The purpose of this study was to describe the phenomenon of pain for a subgroup of aggressive cognitively impaired nursing home residents who were enrolled in a larger study of aggressive behavior. To determine if pain was a possible factor influencing aggression, information was sought from five sources: family members, nursing assistant (NA) caregivers, medical record listings of pain-related diagnoses, use of analgesics, and observations of aggressive behaviors. Families reported pain in 44% of subjects, while NAs reported pain in 66% of subjects. Seventy-six percent of subjects had one or more pain-causing diagnoses. Sixty-four percent of subjects whose family members thought they may have pain were being treated with analgesics, compared to 44% of subjects whose NA reported they may be experiencing pain. Aggression scores were significantly higher in subjects who had two or more pain-related diagnoses and in subjects with arthritis. Nurses who are aware of a history of pain, reports of pain by families and caregivers, presence of pain-related medical diagnoses, and who realize pain may be a trigger for aggressive behavior may be more likely to recognize pain in cognitively impaired older adults. Better pain assessment should lead to improved treatment of pain in this population.

Assessment of depression in a population at risk ... newly admitted nursing home residents.

Depression in newly admitted nursing home residents is a frequently overlooked area of nursing concern. Educating staff to systematically use a standardized depression assessment protocol with all newly admitted residents would facilitate efforts to enhance the quality of residents' lives by identifying depression so that prompt treatment is possible. Other previously admitted residents who appear to be particularly vulnerable to depression would also benefit from this assessment. The use of this protocol for the assessment of depression offers the possibility of providing more accurate and more comprehensive information regarding mood states than that currently being documented in the Minimum Data Set.

Aggressive behavior in persons with dementia who live in the community.

Aggressive behavior in persons with dementia who are living in the community was explored in a pilot study using a newly developed instrument, the Ryden Aggression Scale. Factors affecting this kind of research are addressed, including reliability and validity of the instrument, sample bias, diagnostic workup, and control groups. Results of a pilot survey of caregivers revealed aggressive behavior in 65% of a sample of 183 subjects, occurring weekly or more often in 31% and daily in 16%. Verbal and physical aggression were most prevalent (50% and 46%, respectively), while sexual aggression appeared less frequently (18%). Aggression was significantly related to degree of cognitive impairment and prior history of aggressive behavior, but not to diagnosis nor administration of psychotropic medications. Men showed significantly more sexual aggression. Further research to verify these findings is needed.

Morale and perceived control in institutionalized elderly.

This study explored patterns of causal relationships among perception of situational control, health, socioeconomic status, functional dependency, length of stay, and morale in institutionalized elderly. Causal patterns in residents at two levels of care were contrasted. A total of 113 residents on intermediate and skilled care units chosen randomly from 4 urban proprietary nursing homes were studied. Variables were measured by means of an interview. Instruments included the Philadelphia Geriatric Center Morale Scale, Chang's Situational Control of Daily Activities Scale, and the Resident's Questionnaire. Path analysis was used with a causal model to estimate direct and indirect effects of the independent variables on morale. Important differences in the way the independent variables affected morale for residents on the two levels of care were reported. Perception of situational control proved to be a key variable, significantly related to the morale of residents on both levels of care, although the strength of the association was stronger for residents on skilled care. Functional dependency, health, and socioeconomic status had significant direct effects on the morale of residents on intermediate care but not those on skilled care.

Environmental support for autonomy in the institutionalized elderly.

The climate for autonomy in four urban proprietary nursing homes was investigated as part of a larger study of the relationship between perceived control and morale. Data from 113 residents, 137 caregivers, and 10 administrative personnel revealed that caregivers see themselves as the predominant decision makers. Although they prefer a slightly higher level of self-determination for residents, only in one-to-one and solitary activities do they prefer giving residents the primary decision making role, possibly because they see most residents as not capable of making decisions. Residents saw themselves as having more control than did staff. Grooming and eating were identified by both groups as areas where residents had the least control. A substantial proportion of caregivers and administrative staff did not emphasize the availability of options to residents.