Supporting the "hallway residents": a qualitative descriptive study of staff perspectives on implementing the Namaste Care intervention in long-term care.

BACKGROUND: Long-term care (LTC) settings are becoming home to an increasing number of people living with advanced or late-stage dementia. Residents living with advanced dementia represent some of society's most vulnerable and socially excluded populations and are thus at an increased risk of social isolation. A multisensory intervention tailored to this population, Namaste Care, has been developed to improve quality of life for residents living with advanced dementia in LTC homes. To date, limited research has explored the perspectives of staff in implementing the Namaste Care program with an emphasis on social inclusion of residents in Canadian LTC homes. This study aimed to describe the perspectives of LTC staff on the implementation facilitators and barriers of Namaste Care as a program to support the social inclusion of residents living with advanced dementia. METHODS: Using a qualitative descriptive design, semi-structured interviews (n = 12) and focus groups (n = 6) were conducted in two LTC homes in Southern Ontario, Canada, over a 6-month period. Convenience sampling was used to recruit LTC home staff from the two participating sites. Thematic analysis was used to analyze data. RESULTS: LTC staff (n = 46) emphasized the program's ability to recognize the unique needs of residents with advanced dementia, and also stated its potential to facilitate meaningful connections between families and residents, as well as foster care partnerships between staff and families. Findings indicated staff also perceived numerous facilitators and barriers to Namaste Care. In particular, providing staff with dedicated time for Namaste Care and implementing volunteer and family participation in the program were seen as facilitators, whereas the initial perception of the need for extra staff to deliver Namaste Care and identifying times in the day where Namaste Care was feasible for residents, families, and staff, were seen as barriers. CONCLUSIONS: LTC staff recognized the need for formalized programs like Namaste Care to address the biopsychosocial needs of residents with advanced dementia and offer positive care partnership opportunities between staff and family members. Although staffing constraints remain the largest barrier to effective implementation, staff valued the program and made suggestions to build LTC home capacity for Namaste Care.

Experiences of Families, Staff, Volunteers, and Administrators With Namaste Care for Persons With Advanced Dementia in Canadian Long-Term Care Homes.

OBJECTIVE: To explore the experiences of the Namaste Care intervention for persons with advanced dementia (ie, moderate and late-stage) in long-term care (LTC). DESIGN: A qualitative descriptive design was used. Staff Carers (eg, personal support worker, nurse, or activity aide) delivered Namaste Care with the support of volunteers in a small group. Activities provided during the Namaste Care sessions to enhance quality of life included massages, aromatherapy, music, and snacks/beverages. SETTING AND PARTICIPANTS: Family carers of residents with advanced dementia, LTC staff, administrators, and volunteers from 2 Canadian LTC homes, located in a midsize metropolitan area, were included. METHODS: Experiences and acceptability of Namaste Care was assessed through semistructured interviews ranging from 30 to 60 minutes following the 6-month study duration period with family carers, LTC staff, administrators, and volunteers. Thematic analysis was used for interview transcripts. RESULTS: A total of 16 family carers and 21 LTC staff, administrators, and volunteers participated in the study. Namaste Care was found to be acceptable and successful in enhancing the quality of life of residents due to collaborative efforts of all group of participants. Families, volunteers, and staff noted positive responses in residents, such as smiling and laughing. The program environment supported the development of relationships within the LTC community, which included families, residents, staff, and volunteers. CONCLUSIONS AND IMPLICATIONS: Namaste Care was perceived by the LTC community as an acceptable intervention for persons with advanced dementia. It was perceived as offering multiple benefits for residents with advanced dementia such as improved communication and mood.

Feasibility and Effects of Namaste Care for Persons with Advanced Dementia in Canadian Long-Term Care Homes.

OBJECTIVE: To evaluate the feasibility and effects of the Namaste Care intervention for persons with advanced dementia (ie, moderate and late-stage) in long-term care (LTC) and their family carers. DESIGN: A pre-posttest study design. Staff carers delivered Namaste Care for residents with the support of volunteers in a small group setting. Activities provided included aromatherapy, music, and snacks/beverages. SETTING AND PARTICIPANTS: Residents with advanced dementia and family carers from 2 Canadian LTC homes, located in a midsize metropolitan area, were included. METHODS: Feasibility was evaluated using a research activity log. Outcome data for residents (ie, quality of life, neuropsychiatric symptoms, pain) and family carers (ie, role stress, quality of family visits) were collected at baseline and 3 and 6 months of the intervention. Descriptive analyses and generalized estimating equations were used for quantitative data. RESULTS: A total of 53 residents with advanced dementia and 42 family carers participated in the study. Mixed findings were found for feasibility as not all intervention targets were met. There was a significant improvement in resident neuropsychiatric symptoms at the 3-month time point only (95% CI -9.39, -0.39; P = .033) and family carer role stress at both time points (3-month 95% CI -37.40, -1.80; P = .031; 6-month 95% CI -48.90, -2.09; P = .033). CONCLUSIONS AND IMPLICATIONS: Namaste Care is an intervention with preliminary evidence of impact. Feasibility findings revealed that not all targets were met as the intended number of sessions were not delivered. Future research should explore how many sessions per week are required to lead to an impact. It is important to assess outcomes for both residents and family carers, and to consider enhancing family engagement in delivering the intervention. Given the promise of this intervention, a large-scale randomized controlled trial with a longer follow-up should be conducted to further evaluate its outcomes.

Exploring the factors influencing meaningful engagement of persons living with advanced dementia through the Namaste Care Program: a qualitative descriptive study.

Background: Meaningful engagement has been described as active participation based on a person's interests, preferences, personhood, or perceived value. It has many benefits for persons living with dementia in long-term care (LTC) homes, including improvement in physical and cognitive function, and mental health. People with advanced dementia continue to need and benefit from inclusion and social contact in LTC, yet there is not a well-developed understanding of how to support this. A tailored intervention called Namaste Care has been shown to be an effective approach to meaningfully engage residents in LTC, decrease behavioral symptoms, and improve their comfort and quality of life. There is a need to consider how best to deliver this intervention. Objective: The aim of this study was to describe environmental, social, and sensory factors influencing meaningful engagement of persons with advanced dementia during Namaste Care implementation in LTC. Methods: In this qualitative descriptive study, focus groups and interviews were conducted with families, volunteers, staff, and managers at two LTC homes. Directed content analysis was conducted. The Comprehensive Process Model of Engagement was used as a coding framework. Results: With respect to environmental attributes, participants emphasized that a designated quiet space and a small group format were helpful for engagement. In terms of social attributes, participants emphasized Namaste Care staff capacity to deliver individualized care. Regarding sensorial factors, familiarity with the activities delivered in the program was emphasized. Conclusion: Findings reveal the need to offer small group programs that include adapted recreational and stimulating activities, such as Namaste Care, for residents at the end of life in LTC. Such programs facilitate meaningful engagement for persons with dementia as they focus on individual preferences, comfort, and inclusion while recognizing changing needs and abilities of residents.

Relying on nursing staff for oral hygiene care: A qualitative interpretive description study.

Nurses may not prompt or offer assistance with oral hygiene care activities to patients who do not ask for help because they appear independent in their ability to perform their oral hygiene care. That is, nurses may be inclined to preserve patient autonomy over ensuring adequate oral hygiene outcomes. The purpose of this qualitative Interpretive Description study was to explore, with older patients in post-acute settings, their perspectives and experiences with being autonomous or relying on nursing staff for oral hygiene care. Bedside interviews with 21 patients revealed that: (a) their oral hygiene had deteriorated since hospitalization; (b) nurses may not be aware of patients' oral health values or offer help unless asked; and (c) patients are generally open to being asked if they need help with oral care, being prompted to complete oral care, being asked if they have completed oral care, and having nurses ensure adequate oral care.

Nurses' oral hygiene care practices with hospitalised older adults in postacute settings.

AIM AND OBJECTIVE: The purpose of this study was to explore how nurses provide bedtime oral hygiene care, how they decide on interventions provided, and what factors influence their ability to provide oral care. BACKGROUND: Current evidence links poor oral hygiene to systemic and infectious diseases such as pneumonia. Hospitalised patients, who now retain their teeth into older adulthood, often rely on nurses to provide oral hygiene care. Nurses have the potential to impact oral health outcomes and quality of life by controlling plaque. However, oral hygiene care practices of nurses in postacute hospital settings are relatively unknown. DESIGN: A qualitative, exploratory multiple-case study was conducted with 25 nurses working on five inpatient units at different hospitals. METHODS: Nurses were accompanied on their evening rounds to observe oral care practices, the physical environment and workflow. Thematic analysis was used to analyse the case study data including transcripts of guided conversations, field notes and documents. Within-case analysis was followed by cross-case analysis. RESULTS: Findings indicate that (i) nurses often convey oral hygiene care to their patients as being optional; (ii) nurses are inclined to preserve patient autonomy in oral hygiene care; (iii) oral hygiene care is often spontaneous and variable, and may not be informed by evidence; and (iv) oral hygiene care is not embedded into bedtime care routines. CONCLUSIONS: Oral hygiene care is discretionary and often missed care. IMPLICATIONS FOR PRACTICE: Nurses need knowledge of the health benefits of oral care, and skills related to assessment and approaches to oral care. Availability of effective products and supplies facilitates provision of oral care. The evidence for oral hygiene care practices, outcomes of nurse-administered oral care and nursing's role in influencing the oral health literacy of patients require further study.

Observations of oral hygiene care interventions provided by nurses to hospitalized older people.

Dependent older hospitalized patients rely on nurses to assist them with the removal of plaque from their teeth, dentures, and oral cavities. Oral care interventions by 25 nurses on post-acute units, where patients have longer hospital stays, were observed during evening care. In addition to efforts to engage patients in oral care, nurses provided the following interventions: (a) supporting the care of persons with dentures; (b) supporting the care of natural teeth; (c) cleansing the tongue and oral cavity; and (d) moisturizing lips and oral tissues. Patients' oral hygiene care was supported in just over one-third of encounters. Denture care was inconsistently performed, and was infrequently followed by care of the oral cavity. Nurses did not encourage adequate self-care of natural teeth by patients, and infrequently moisturized tissues. Evidence-based oral hygiene care standards are required to assist nurses to support patients in achieving optimal oral hygiene outcomes.

An Education Intervention to Enhance Staff Self-Efficacy to Provide Dementia Care in an Acute Care Hospital in Canada: A Nonrandomized Controlled Study.

Education is needed for enhanced capacity of acute hospitals to provide dementia care. A nonrandomized controlled, repeated-measures design was used to evaluate a dementia education program delivered to an intervention group (IG, n = 468), compared to a wait-listed group (n = 277), representing separate sites of a multisite hospital. Participants completed self-efficacy for dementia and satisfaction measures and provided written descriptions of dementia care collected at baseline, postintervention (IG only), and at 8-week follow-up. Oral narratives were gathered from IG participants 8 weeks postintervention. The IG demonstrated significant improvement in self-efficacy scores from baseline to immediately postintervention (P < .001), sustained at 8 weeks. There were no changes from baseline to 8 weeks postintervention evident in the wait-listed group (P = .21). Intervention group participants described positive impacts including implementation of person-centered care approaches. Implementation of dementia care education programs throughout hospital settings is promising for the enhancement of dementia care.

Gentle persuasive approaches: introducing an educational program on an orthopaedic unit for staff caring for patients with dementia and delirium.

Gentle Persuasive Approaches in Dementia Care (GPA), a curriculum originally designed for long-term care, was introduced into an acute care setting. This person-centered approach to supporting and responding to persons with behaviors associated with dementia was shown to be applicable for staff on an orthopaedic surgery unit where they had reported significant challenges and care burdens when faced with behaviors such as shouting, explosiveness, and resistance to care. Staff confidence in their ability to care for persons with behaviors increased after attending the 1-day GPA workshop, and they reported being highly satisfied with the curriculum, found it to be applicable to their practice, indicated that it was also useful for patients with delirium, and would recommend it to others. Some of the staff on the orthopaedic unit became certified GPA coaches. The passion of those champions, along with demonstrated success of the program on their unit, contributed to its spread to other units, including rehabilitation and acute medicine.

Sustainability of an innovation to support and respond to persons with behaviors related to dementia and delirium.

Gentle Persuasive Approaches (GPA) in Dementia Care, a program designed for staff caring for patients in long-term care who exhibit challenging behaviors, was implemented and has been sustained in an acute care setting. Outcomes include fewer codes indicating violent situations, a reduction in physical restraint and sitter use, and fewer reports of safety incidents involving agitated patients. In this article, we describe the innovation (GPA) and the strategies used to sustain its successful implementation.

Positioning clinical nurse specialists and nurse practitioners as change champions to implement a pain protocol in long-term care.

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

The effect of programs to improve oral hygiene outcomes for older residents in long-term care: a systematic review.

Nurses have a critical role in promoting oral health in dependent older adults residing in long-term care or having extended hospital stays. Strategies aimed at improving the quality of oral hygiene care nurses provide may contribute to better oral hygiene outcomes. The purpose of this systematic review was to examine the effect of intervention programs designed to enhance the ability of nurses or those to whom they delegate care to improve oral hygiene outcomes in frail older adults. Studies reported an educational program, either alone or augmented in some way. The study interventions consisted of: (a) single in-service education sessions; (b) single in-service education sessions supplemented by a "train-the-trainer" approach; and (c) education sessions supplemented with ongoing active involvement of a dental hygienist. None of the approaches emerged as being desirable over the others, as methodologically strong studies with good intervention integrity were lacking, and a variety of oral health outcomes were used to measure effectiveness of the interventions, making comparisons across studies difficult.

A concept analysis of oral hygiene care in dependent older adults.

AIM: To report a concept analysis of oral hygiene care. BACKGROUND: Oral hygiene care, as it is provided to older patients in hospital and long-term care settings by nurses and their delegates, has the potential to contribute to the oral health of patients while preventing aspiration pneumonia as well as periodontitis, which itself has been associated with several systemic diseases. However, the state of oral cleanliness in such patients tends to be poor and despite the existence of guidelines, nursing care practices may be inadequate and not reflective of recent advances in knowledge. DESIGN: Concept analysis. DATA SOURCES: A search of electronic databases (2002-2012), use of internet search engines, and hand searching yielded an international data set of 66 research studies, reviews, and practice guidelines. REVIEW METHODS: The concept analysis method of Walker and Avant was used to explore the concept of oral hygiene care in the context of frail older patients. RESULTS: Oral hygiene care involves approaches informed by knowing the patient, inspecting the oral cavity, removing plaque, cleansing the oral tissues, decontaminating the oral cavity, using fluoride products and maintaining oral tissue moisture. Those attributes, along with their antecedents and consequences, form a conceptual framework from which a middle-range theory of nurse-administered oral hygiene care is derived that could be tested, evaluated, modified, and translated into practice. CONCLUSIONS: Clarity around the concept of oral hygiene care as a nursing intervention could enable nurses to impact oral health outcomes and possibly prevent systemic diseases in older patients.

A quality assurance study to assess the one-day prevalence of delirium in elderly hospitalized patients.

BACKGROUND: Research indicates that 40% of hospital-acquired delirium cases may be preventable. However, despite its clinical significance, delirium often goes unrecognized or is misdiagnosed. The purpose of this study was to assess the need for delirium education in acute care hospitals in Hamilton, Ontario. METHODS: Approximately 100 health professionals were trained as delirium screeners. On 'Delirium Day', all patients ≥ 65 years of age in non-critical care areas in all acute care sites in Hamilton were identified. Those willing to take part in the prevalence study were assessed for delirium using the Standardized Mini-Mental State Examination and the Confusion Assessment Method. The Research Ethics Boards at Hamilton Health Sciences and St. Joseph's Healthcare Hamilton approved this quality assurance project. RESULTS: Of the 562 patients eligible for screening, eight were excluded and six did not have sufficient data collected to assess for delirium. Of the 548 individuals screened for delirium, 10.6% screened positive. Prevalence estimates ranged by site from 0% to 21% and type of unit from 3.8% to 16%. Recognition of delirium by nursing staff was fair; but, documentation was usually absent. CONCLUSION: While the prevalence rates were somewhat lower than in other studies, the results support the need for education among health-care providers in the prevention, identification, and management of delirium.

The evaluation of an interdisciplinary pain protocol in long term care.

OBJECTIVES: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents. DESIGN: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data. SETTING: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group. PARTICIPANTS: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group. INTERVENTION: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities. MEASUREMENTS: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews. RESULTS: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol. CONCLUSIONS: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.

An action-based approach to improving pain management in long-term care.

PURPOSE: The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC. METHODS: A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management. RESULTS: The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers. CONCLUSIONS: This model can guide the development of innovative approaches to improving pain management in LTC settings.

Nurses' perceived barriers to optimal pain management in older adults on acute medical units.

Nurses' perceptions of barriers preventing optimal pain management in older adults on acute medical units and the extent to which they perceived they had adopted four evidence-based practices related to pain assessment and management were often incongruent with actual practice. Eliciting reports of pain, offering pro re nata pain relief regularly, utilizing pain assessment tools in patients with cognitive impairment, redesigning documentation tools and processes, making nonpharmacological alternatives accessible, and helping patients and families manage side effects would target the 12 barriers having the biggest impact.

Pain management practices with older adults on acute medical units.

Persistent pain is a significant problem for older hospitalized adults and their health care team. A better understanding of the approach to pain management in the clinical setting will provide guidance for the development of improvements in clinical management. The purpose of this study was to determine the prevalence of pain and to examine the current state of pain assessment and management in older adults on the six acute medical units of an academic health sciences centre. Findings revealed that 70% of older patients were in pain, nurses had limited awareness of their patients' pain, documentation of pain assessment and management was lacking, and pain was under-treated. Utilization of practice guidelines related to management of persistent pain in older adults in acute care settings is recommended, and an approach to their implementation, including identifying and overcoming the barriers to such best practices, is warranted.