Development and validation of the Moral Distress in Dementia Care Survey instrument.

AIMS: To report on the development and validation of the Moral Distress in Dementia Care Survey instrument. BACKGROUND: Despite growing awareness of moral distress among nurses, little is known about the moral distress experiences of nursing staff in dementia care settings. To address this gap, our research team developed a tool for measuring the frequency, severity and effects of moral distress in nursing staff working in dementia care. DESIGN: The research team employed an exploratory sequential mixed method design to generate items for the moral distress questionnaire. Data were collected between January 2013 - June 2014. In this paper, we report on the development and validation of the Moral Distress in Dementia Care Survey instrument. METHODS: The Moral Distress in Dementia Care Survey instrument was piloted with a portion of the target population prior to a broader implementation. Appropriate statistical analyses and psychometric testing were completed. RESULTS: The team collected 389 completed surveys from registered nurses, licensed practical nurses and healthcare aides, representing a 43.6% response rate across 23 sites. The Moral Distress in Dementia Care Survey emerged as a reliable and valid instrument to measure the frequency, severity and effects of moral distress for nursing staff in dementia care settings. The relative value of the Moral Distress in Dementia Care Survey as a measurement instrument was superseded by its clinical relevance for dementia care staff. CONCLUSION: The Moral Distress in Dementia Care Survey is a potentially useful tool for estimating the frequency, severity and effects of moral distress in nursing staff working in dementia care settings and for the evaluation of measures taken to mitigate moral distress.

I was told it restarts your brain: knowledge, power, and women's experiences of ECT.

BACKGROUND: A discrepancy exists between clinician-led studies of people's experience of electroconvulsive therapy (ECT) and consumer-led studies, with the former typically being much more positive about the efficacy and side effects of ECT compared with the latter. Qualitative in-depth explorations of people's experiences of ECT are relatively rare, particularly those looking specifically at women's experience of ECT. AIMS: The aim of this qualitative study was to explore women's experiences of ECT, particularly their experience of knowledge and power related to ECT. RESULTS: Qualitative analysis of the interviews with nine women resulted in four main themes emerging from the interviews with the women: (i) "he really didn't say much," (ii) "I'm going to be very upset with you," (iii) "I was just desperate," and (iv) "it was like we were cattle." CONCLUSIONS: Overall, participants found their experiences with ECT to be quite negative, and characterized by a lack of knowledge during the procedure, and a lack of power throughout the entire process.

A guest in the house: nursing instructors' experiences of the moral distress felt by students during inpatient psychiatric clinical rotations.

Significant research has been done on the impact of moral distress among nurses, particularly in acute and intensive care settings. However, little research to date has investigated the experiences that nursing students have with moral distress. Additionally, there is a dearth of research on the role of nursing instructors' perceptions of their responsibilities to their students when encountering morally distressing situations. This manuscript describes a qualitative study conducted with eight mental health nursing instructors who acknowledged a responsibility for helping students deal with moral distress and ethical issues, but who also struggled with ways to do so. Additionally, instructors expressed frustration with their "guest" status on inpatient psychiatric units and their powerlessness to effect moral change in a medical model of psychiatric care.

Fear and loathing: undergraduate nursing students' experiences of a mandatory course in applied statistics.

This article describes the results of a qualitative research study evaluating nursing students' experiences of a mandatory course in applied statistics, and the perceived effectiveness of teaching methods implemented during the course. Fifteen nursing students in the third year of a four-year baccalaureate program in nursing participated in focus groups before and after taking the mandatory course in statistics. The interviews were transcribed and analyzed using content analysis to reveal four major themes: (i) "one of those courses you throw out?," (ii) "numbers and terrifying equations," (iii) "first aid for statistics casualties," and (iv) "re-thinking curriculum." Overall, the data revealed that although nursing students initially enter statistics courses with considerable skepticism, fear, and anxiety, there are a number of concrete actions statistics instructors can take to reduce student fear and increase the perceived relevance of courses in statistics.

Lets Do Lunch? The ethics of accepting gifts from the pharmaceutical industry.

When nurses think of ethical issues, debates on assisted suicide or maternal versus fetal rights often come to mind. A less obvious but undoubtedly more common ethical issue is whether or not sponsored lunches, educational events and other forms of gift giving should be accepted from pharmaceutical companies. The authors review the nature of pharmaceutical marketing and gift giving and examine some of the potential ethical issues that arise when nurses accept these gifts.

Impact of exercise on seniors' motor control response to external dynamics.

Research on postural stability, motor control, and fall occurrence in seniors is common, but few studies address the influence of exercise and external dynamics on elderly balance. Using pre- and post-training tests, the effects of a Fitball exercise program on performance in eight subjects was documented. The exercise program focused on improving dynamic balance and postural stability of seniors. To evaluate progress-related changes, pre- and post-tests in a dynamic environment were applied. Center of gravity (COG) excursion, catch success rate, and balance success rate were quantified, and synchronized data collection of 3D motion capture (VICON v8i) and ground reaction force (2 KISTLER platforms) was analyzed. During pre- and post-tests, participants stood in a walklike stance and were asked to catch a weighted ball, which dropped unexpectedly. Results showed no significant changes in balance success rate. Significant improvements were found, however, in both COG control and catch success rate following training (p<0.05).

Caring in the wake of the rising tide: Moral distress in residential nursing care of people living with dementia.

Objective Moral distress is increasingly being recognized as a concern for health care professionals. The purpose of this study was to explore the nature and prevalence of moral distress among nursing staff who care for people living with dementia. Methods This study was focused on nursing staff caring for people with dementia in long-term care and assisted living sites. The Moral Distress in Dementia Care Survey instrument was distributed to 23 sites and nursing staff rated the frequency and severity of situations that were identified as potentially causing moral distress. Results Moral distress is prevalent in the nursing staff who provide dementia care. Nursing staff reported experiencing moral distress at least daily or weekly. Both frequency and severity of moral distress increased with proximity to (amount of time spent at) the bedside. Moral distress had negative psychological and physiological effects on nursing staff, and affected intention to quit.

Measuring melancholy: a critique of the Beck Depression Inventory and its use in mental health nursing.

The Beck Depression Inventory (BDI) is one of the most commonly used depression measurement instruments. Mental health nurses often utilize the BDI to assess the level of depression in clients, and to monitor the effectiveness of treatments such as antidepressants and electroconvulsive therapy. Despite the widespread use of the BDI in both clinical practice and research, there is surprisingly little nursing literature critically examining the BDI or its use by mental health nurses. This paper reviews the origins, purpose, and format of the BDI, discusses some of the strengths and limitations of the BDI, and concludes with some implications for mental health nursing.

Sources of moral distress for nursing staff providing care to residents with dementia.

The World Health Organization estimates the number of people living with dementia at approximately 35.6 million; they project a doubling of this number by 2030 and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing care providers is a significant component of the dementia journey in most countries. Research has also shown that caring for persons with dementia can be emotionally, physically, and ethically challenging, and that turnover in nursing staff in residential care settings tends to be high. Moral distress has been explored in a variety of settings where nurses provide acute or intensive care. The concept, however, has not previously been explored in residential facility care settings, particularly as related to the care of persons with dementia. In this paper, we explore moral distress in these settings, using Nathaniel's definition of moral distress: the pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, makes a moral judgment about the correct action and yet, as a result of real or perceived constraints, cannot do what is thought to be right. We report findings from a qualitative study of moral distress in a single health region in a Canadian province. Our aim in this paper is to share findings that elucidate the sources of moral distress experienced by nursing care providers in the residential care of people living with dementia.

A new role for advanced practice nurses in Canada: bridging the gap in health services for rural older adults.

This article is a report on the evaluation of a new nursing initiative in rural western Canada-the gerontological advanced practice nurse (GAPN) project. Using a qualitative approach in the i initial evaluative phase, the authors determined how the GAPN evolved, functioning primarily in a clinical nurse specialist role, and identified the successes and challenges of the project. The initial findings indicated health benefits to rural older adults. The project's success was attributed to strong support from key players, and attempts to address perceived gaps in rural health service. Challenges in developing the GAPN role included limited planning time, and lack of a clear definition about the role and responsibilities of the GAPN. The introduction of a GAPN, especially in underserved rural communities, has the potential to provide essential health care services to older adults, and to make major contributions to changing gerontology practice.

Pain and agitation in long-term care residents with dementia: use of the Pittsburgh Agitation Scale.

AIM: to explore the relationship between total and sub-scores of the Pittsburgh Agitation Scale (PAS) and five proxy measures of pain in long-term care (LTC) residents. STUDY DESIGN: descriptive correlational design. SAMPLE AND SETTING: 58 residents in three LTC facilities in rural Western Canada with moderate to severe cognitive impairment took part in the study. Six full-time registered nurses working in the facilities and three palliative care nurse consultants provided pain and agitation assessments. MEASUREMENTS: registered nurses used PAS to assess agitation. The five proxy measures of pain were the Discomfort Scale for Dementia of the Alzheimer's Type (DS-DAT), number of pain diagnoses, use of analgesic medications, and pain ratings by both facility nurses and palliative care nurse consultants. RESULTS: there was a moderately strong relationship between total PAS agitation scores and total DS-DAT pain scores (r=0.51, P<0.01). The PAS sub-score "resisting care" was significantly correlated with total DS-DAT scores (r=0.46, P<0.01), and pain ratings by both facility nurses (r=0.48, P<0.01) and palliative care nurse consultants (r=0.51, P<0.01). CONCLUSIONS: for certain residents with dementia, PAS may allow assessment of both agitation and uncommunicated pain. It is possible that the PAS form of agitation "resistance to care" may indicate pain that individual cannot otherwise communicate. One possible response to such resistance would be to trial pain medication and reassess agitation. Nursing staff in LTC facilities may need additional training in pain assessment of residents with dementia.

A longitudinal study of home care clients and their informal carers.

The objective of the longitudinal study was to monitor physical and cognitive changes in a population of 330 older people being supported at home by health services. The participants were 75 years and older and classified as having moderate-to-high needs. A total of 210 primary informal carers were recruited to determine their specific needs and how they coped as dependency levels of their care-recipients changed. Data were collected using six different tools. Two questionnaires were mailed out to participating carers. Assessments of care recipients were carried out at three sampling points over the study period. The clients showed a significant increase in physical dependency and an overall increase in cognitive impairment over time. Only 32% of carers lived with care recipients, and changes in dependency, cognitive changes, lack of respite and performing activities of daily living were all major stressors for informal carers. The needs of informal carers are reported and discussed in the context of recommendations of the Commission on the Future of Health Care in Canada.

Adolescent health: a rural community's approach.

INTRODUCTION: Significant health problems encountered in adulthood often have their roots in health behaviours initiated during adolescence. In order to reverse this trend, school and health personnel, as well as parents and other community members working with high school students, need to be aware of the health-related beliefs and choices that guide the behaviours of teenagers. Although a wide variety of research has been conducted on this topic among urban adolescents, less is known about the health beliefs and behaviors of adolescents residing in rural areas, particularly in Canada. In general, rural Canadians are less healthy than their urban counterparts. Building on the knowledge and understanding of their own community, key stakeholders were invited to engage in the design and implementation of a participatory action research project aimed at understanding and improving the health of rural adolescents. METHODS: A group of parents, teachers, students, school administrators and public health nurses engaged in a participatory action research project to better understand determinants of the health of rural adolescents at a high school in Western Canada. Group members developed and administered a health survey to 288 students from a small rural high school, in an effort to identify areas of concern and interest regarding health practices and beliefs of rural adolescents, and to take action on these identified concerns. RESULTS: Results indicated some interesting but potentially worrying trends in this population. For example, while frequent involvement in a physical activity was noted by 75.9% of participants, close to half of the females (48%) described their body image as 'a little overweight' or 'definitely overweight', and approximately 25.8% of respondents noted that they skipped meals most of the time. Differences between the genders were apparent in several categories. For example, more girls smoked (16.2%) than boys (12.3%), and more males (55.0%) than females (41%) had tried illegal drugs. Participants indicated awareness of other health-compromising behaviours, including unsafe driving habits and high stress levels, and acknowledged several steps they wanted to take to improve their health, as well as the barriers to taking those steps. Students identified improved nutrition, stress reduction, and increased levels of physical activity as particular important health goals. Students also recommended ways in which information and support could be provided within the school environment to enable them to achieve their health-related goals. Several activities developed in collaboration with students have incorporated the recommendations, and have spawned other activities in response to the ongoing identification of new concerns. CONCLUSIONS: The process of including the rural community in the identification of health assets and needs from the perspective of students -- as well as the planning and implementation of appropriate strategies to address those needs -- demonstrates the strengths inherent within a small rural population. Community members' awareness of the need to create a healthy environment for youth is reflected in their willingness to participate in activities leading to improved health. Greater awareness of the health needs of rural adolescents, and of the influence of gender in some aspects of health behaviors, will help researchers to explore ways in which the unique culture of rural communities can be harnessed to help shape health-focused interventions.

Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada.

OBJECTIVES: Assisted living (AL) is an increasingly used residential option for older adults with dementia; however, lower staffing rates and service availability raise concerns that such residents may be at increased risk for adverse outcomes. Our objectives were to determine the incidence of hospitalization over 1 year for dementia residents of designated AL (DAL) facilities, compared with long-term care (LTC) facilities, and identify resident- and facility-level predictors of hospitalization among DAL residents. METHODS: Participants were 609 DAL (mean age 85.7 ± 6.6 years) and 691 LTC (86.4 ± 6.9 years) residents with dementia enrolled in the Alberta Continuing Care Epidemiological Studies. Research nurses completed a standardized comprehensive assessment of residents and interviewed family caregivers at baseline (2006-2008) and 1 year later. Standardized administrator interviews provided facility level data. Hospitalization was determined via linkage with the provincial Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to identify predictors of hospitalization. RESULTS: The cumulative annual incidence of hospitalization was 38.6% (34.5%-42.7%) for DAL and 10.3% (8.0%-12.6%) for LTC residents with dementia. A significantly increased risk for hospitalization was observed for DAL residents aged 90+ years, with poor social relationships, less severe cognitive impairment, greater health instability, fatigue, high medication use (11+ medications), and 2+ hospitalizations in the preceding year. Residents from DAL facilities with a smaller number of spaces, no chain affiliation, and from specific health regions showed a higher risk of hospitalization. CONCLUSIONS: DAL residents with dementia had a hospitalization rate almost 4-fold higher than LTC residents with dementia. Our findings raise questions about the ability of some AL facilities to adequately address the needs of cognitively impaired residents and highlight potential clinical, social, and policy areas for targeted interventions to reduce hospitalization risk.

On a happier note: validation of musical exercise for older persons in long-term care settings.

This paper describes a quasi-experimental study of a musical exercise intervention to improve the physical, cognitive, behavioral status and life satisfaction of older residents in a long-term care facility in the United Kingdom. Twenty long-term care residents from three different units (n=60) were recruited and assigned to one of three groups: a control (C) group (no intervention), an occupational therapy (OT) group (comparison group) and a music exercise group (intervention group). Assessments of physical and cognitive status were made pre-intervention and repeated at the end of the 10-week exercise program and again 10 weeks after the completion of the program. The results show that both OT and exercise participation is associated with improvement in physical and cognitive function. However, the exercise group showed significant improvement in more areas than the OT group. The functional benefits from OT and exercise were not sustainable after these activities ceased and showed significant decline 10 weeks after the end of the programs.

Positive outcomes in cardiac rehabilitation: the little program that could.

Cardiac rehabilitation programs (CRPs) are receiving increasing attention because they restore, maintain, or improve both physiologic and psychosocial client outcomes (Evenson, Rosamond & Luepker, 1998). However, less attention has been paid to the effect such programs may have on the health-related quality of life of participants. The objective of this study was to measure health-related quality of life outcomes before and after participation in a CRP. Participants were 64 clients entering one of five CRP groups at the Lethbridge Regional Hospital in southern Alberta. Participants completed the Short Form 36 Health Survey (SF-36) (Ware, 1997) both at the beginning and at the end of one 13-week CRP intervention. The SF-36 examines eight health concepts: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). Analysis showed a significant difference between the pre-test and post-test scores for six of the eight categories. Larger effect sizes were found for PF (d = .746), RP (d = .657), and VT (d = .593). Smaller effects were found for BP (d = .299), SF (d = .337), and RE (d = .271). The findings of this study highlight improved health-related quality of life outcomes for clients participating in comprehensive cardiac rehabilitation programs.

Assessing cognitive impairment in older people: the Watson clock drawing test.

A non-random sample of 331 community-based clients aged 75 years and over, who were being cared for at home, were involved in a longitudinal study to assess cognitive impairment (CI). The clock drawing test (CDT) using the Watson et al (1993) scoring protocol was used to determine its utility as a tool for community nurses to assess CI. In the first phase of the study, 294 CDTs were used in analysis and 58.8% (n = 172) of participants were cognitively impaired. Subsequent assessments at 9 months and 18 months using both the CDT and the Mini-Mental State Examination (MMSE) confirmed the high initial level of cognitive impairment among the sample. Over the course of the study 37 participants who had high CDT scores were admitted to institutional care and their cognitive status continued to decline. Among those who remained in the community, the percentage with some degree of cognitive impairment remained high, and over the course of the study there was a significant linear decline in the mean MMSE score. The CDT takes less time to administer than the MMSE and appears to be a more sensitive tool for detecting early changes in cognition. The CDT could therefore be useful as an initial assessment tool by community mental health nurses to help facilitate early intervention for older clients who are beginning to experience cognitive changes.

No place to turn: nursing students' experiences of moral distress in mental health settings.

While researchers have documented the significant issue of moral distress among nurses, few have explored moral distress among mental health nurses. In addition, no research to date has explored nursing students' experiences of moral distress during mental health clinical rotations, despite nursing students typically reporting negative attitudes towards mental health nursing. This manuscript reports on a qualitative study involving seven Canadian baccalaureate nursing students, who reported on their experiences of moral distress during a 13-week clinical rotation on inpatient psychiatric units. Overall, nursing students reported significant moral distress related to the perceived lack of nurses talking meaningfully to patients on the unit, a hierarchical power structure for physicians, a lack of information given to patients about their psychiatric medications, and an inability of their nursing instructors to advocate for ethical change on the units. Several students made a specific connection between their moral distress and not wanting to pursue a career in mental health nursing.

High rates of hospital admission among older residents in assisted living facilities: opportunities for intervention and impact on acute care.

BACKGROUND: Little is known about health or service use outcomes for residents of Canadian assisted living facilities. Our objectives were to estimate the incidence of admission to hospital over 1 year for residents of designated (i.e., publicly funded) assisted living (DAL) facilities in Alberta, to compare this rate with the rate among residents of long-term care facilities, and to identify individual and facility predictors of hospital admission for DAL residents. METHODS: Participants were 1066 DAL residents (mean age ± standard deviation 84.9 ± 7.3 years) and 976 longterm care residents (85.4 ± 7.6 years) from the Alberta Continuing Care Epidemiological Studies (ACCES). Research nurses completed a standardized comprehensive assessment for each resident and interviewed family caregivers at baseline (2006 to 2008) and 1 year later. We used standardized interviews with administrators to generate facility- level data. We determined hospital admissions through linkage with the Alberta Inpatient Discharge Abstract Database. We used multivariable Cox proportional hazards models to identify predictors of hospital admission. RESULTS: The cumulative annual incidence of hospital admission was 38.9% (95% confidence interval [CI] 35.9%- 41.9%) for DAL residents and 13.7% (95% CI 11.5%-15.8%) for long-term care residents. The risk of hospital admission was significantly greater for DAL residents with greater health instability, fatigue, medication use (11 or more medications), and 2 or more hospital admissions in the preceding year. The risk of hospital admission was also significantly higher for residents from DAL facilities with a smaller number of spaces, no licensed practical and/ or registered nurses on site (or on site less than 24 hours a day, 7 days a week), no chain affiliation, and from select health regions. INTERPRETATION: The incidence of hospital admission was about 3 times higher among DAL residents than among long-term care residents, and the risk of hospital admission was associated with a number of potentially modifiable factors. These findings raise questions about the complement of services and staffing required within assisted living facilities and the potential impact on acute care of the shift from long-term care to assisted living for the facility-based care of vulnerable older people.

All I have is a void: women's perceptions of the benefits and side effects of ECT.

BACKGROUND: Recent reviews of the benefits and risks associated with electroconvulsive therapy (ECT) have often reported mixed and conflicting results. Although there are very few qualitative studies on ECT, qualitative research offers the advantage of in-depth explorations into how people perceive and experience ECT. OBJECTIVE: The objective of this qualitative study was to explore women's experiences and perceptions of the benefits and side effects associated with having ECT. METHODS: The authors used narrative inquiry and in-depth interviews to obtain nine women's accounts and stories of ECT, focusing particularly on their accounts of perceived benefits and side effects associated with ECT. RESULTS: Qualitative thematic analysis of the interviews with nine women resulted in four main themes emerging from the interviews: "it's sort of like housecleaning," "I don't remember the wedding," made me stupider," and "putting them in a cage with a bear." CONCLUSIONS: Three of the women were able to articulate some perceived benefit arising from ECT, although these women also acknowledged the benefits did not last more than two weeks. The majority of women complained of significant and persistent autobiographical memory loss, cognitive deficits, and fear of the procedure.