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1.  Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study 
The Gerontologist  2011;52(1):24-33.
Purpose:
Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.
Design and methods:
Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.
Results:
Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.
Implications:
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
doi:10.1093/geront/gnr107
PMCID: PMC3265555  PMID: 22048811
Abuse/neglect; Behavior; Long-term care; Aggression
2.  Resident-to-Resident Aggression in Long-Term Care Facilities: An Understudied Problem 
Resident-to-resident aggression (RRA) between long-term care residents includes negative and aggressive physical, sexual, or verbal interactions that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Although this problem potentially has high incidence and prevalence and serious consequences for aggressors and victims, it has received little direct attention from researchers to date. This article reviews the limited available literature on this topic as well as relevant research from related areas including: resident violence toward nursing home staff, aggressive behaviors by elderly persons, and community elder abuse. We present hypothesized risk factors for aggressor, victim, and nursing home environment, including issues surrounding cognitive impairment. We discuss methodological challenges to studying RRA and offer suggestions for future research. Finally, we describe the importance of designing effective interventions, despite the lack currently available, and suggest potential areas of future research.
doi:10.1016/j.avb.2007.12.001
PMCID: PMC2741635  PMID: 19750126
aggressive behavior; nursing homes; dementia; epidemiology
3.  Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter? 
Background
Currently there is a lot of debate about the advantages and disadvantages of for-profit health care delivery. We examined staffing ratios for direct-care and support staff in publicly funded not-for-profit and for-profit nursing homes in British Columbia.
Methods
We obtained staffing data for 167 long-term care facilities and linked these to the type of facility and ownership of the facility. All staff were members of the same bargaining association and received identical wages in both not-for-profit and for-profit facilities. Similar public funding is provided to both types of facilities, although the amounts vary by the level of functional dependence of the residents. We compared the mean number of hours per resident-day provided by direct-care staff (registered nurses, licensed practical nurses and resident care aides) and support staff (housekeeping, dietary and laundry staff) in not-for-profit versus for-profit facilities, after adjusting for facility size (number of beds) and level of care.
Results
The nursing homes included in our study comprised 76% of all such facilities in the province. Of the 167 nursing homes examined, 109 (65%) were not-for-profit and 58 (35%) were for-profit; 24% of the for-profit homes were part of a chain, and the remaining homes were owned by a single operator. The mean number of hours per resident-day was higher in the not-for-profit facilities than in the for-profit facilities for both direct-care and support staff and for all facility levels of care. Compared with for-profit ownership, not-for-profit status was associated with an estimated 0.34 more hours per resident-day (95% confidence interval [CI] 0.18–0.49, p < 0.001) provided by direct-care staff and 0.23 more hours per resident-day (95% CI 0.15–0.30, p < 0.001) provided by support staff.
Interpretation
Not-for-profit facility ownership is associated with higher staffing levels. This finding suggests that public money used to provide care to frail eldery people purchases significantly fewer direct-care and support staff hours per resident-day in for-profit long-term care facilities than in not-for-profit facilities.
doi:10.1503/cmaj.1040131
PMCID: PMC550634  PMID: 15738489
4.  STAFF PERCEPTIONS OF RESIDENTS ACROSS THE LONG-TERM CARE LANDSCAPE 
Journal of advanced nursing  2005;49(4):377-386.
Background
While various efforts have described the ramifications of staff-resident interactions in nursing homes, few studies identify the factors that potentially influence staff members' perceptions of residents in multiple long-term care settings.
Aims
This paper reports a study to determine how facility-, resident-, family-, and staff-level indicators are empirically associated with staff members' perceptions of residents in nursing homes, assisted living facilities, and family care homes.
Methods
The participants were 41 care staff located in 5 nursing homes, 5 assisted living facilities, and 16 family care homes randomly selected in the United States of America. Face-to-face and telephone interviews were conducted with care staff, residents in their care, family members of residents, and administrators of participating facilities. Telephone interviews measured staff perceptions of residents on two domains: cohesion (perceived feelings of closeness between staff and residents) and knowledge of residents' personal lives and care needs.
Results
Regression models found that staff who were married, reported more positive attitudes toward family members, and worked in smaller facilities reported greater staff-resident cohesion. In addition, staff who cared for a higher percentage of residents with learning difficulties indicated greater knowledge of residents.
Conclusion
The findings emphasize the need to consider elements of staff-family relationships when considering staff perceptions of residents. The results also imply that clinical interventions designed to enhance social relationships in nursing homes can be extended across the long-term care landscape to positively influence the staff-resident-family triad.
doi:10.1111/j.1365-2648.2004.03301.x
PMCID: PMC2365472  PMID: 15701152
Long-term care; Residential homes; staff; residents; relatives; nursing
5.  Elderspeak’s Influence on Resistiveness to Care: Focus on Behavioral Events 
Resistiveness to care (RTC) in older adults with dementia commonly disrupts nursing care. Research has found that elderspeak (infantilizing communication) use by nursing home staff increases the probability of RTC in older adults with dementia. The current analysis used GSEQ software to analyze behavior sequences of specific behavioral events. We found that older adults with dementia most frequently reacted to elderpeak communication by negative vocalizations (screaming or yelling, negative verbalizations, crying). Since negative vocalizations disrupt nursing care, reduction in elderpeak use by staff may reduce these behaviors thereby increasing quality of care to these residents. The results clearly demonstrate that sequential analysis of behavioral events is a useful tool in examining complex communicative interactions and targeting specific problem behaviors.
doi:10.1177/1533317509341949
PMCID: PMC2836897  PMID: 19692706
dementia care; communication; problem behaviors; resistiveness to care
6.  R-RAS2 overexpression in tumors of the human central nervous system 
Molecular Cancer  2013;12:127.
Malignant tumors of the central nervous system (CNS) are the 10th most frequent cause of cancer mortality. Despite the strong malignancy of some such tumors, oncogenic mutations are rarely found in classic members of the RAS family of small GTPases. This raises the question as to whether other RAS family members may be affected in CNS tumors, excessively activating RAS pathways. The RAS-related subfamily of GTPases is that which is most closely related to classical Ras and it currently contains 3 members: RRAS, RRAS2 and RRAS3. While R-RAS and R-RAS2 are expressed ubiquitously, R-RAS3 expression is restricted to the CNS. Significantly, both wild type and mutated RRAS2 (also known as TC21) are overexpressed in human carcinomas of the oral cavity, esophagus, stomach, skin and breast, as well as in lymphomas. Hence, we analyzed the expression of R-RAS2 mRNA and protein in a wide variety of human CNS tumors and we found the R-RAS2 protein to be overexpressed in all of the 90 CNS cancer samples studied, including glioblastomas, astrocytomas and oligodendrogliomas. However, R-Ras2 was more strongly expressed in low grade (World Health Organization grades I-II) rather than high grade (grades III-IV) tumors, suggesting that R-RAS2 is overexpressed in the early stages of malignancy. Indeed, R-RAS2 overexpression was evident in pre-malignant hyperplasias, both at the mRNA and protein levels. Nevertheless, such dramatic changes in expression were not evident for the other two subfamily members, which implies that RRAS2 is the main factor triggering neural transformation.
doi:10.1186/1476-4598-12-127
PMCID: PMC3900289  PMID: 24148564
RAS family proteins; R-RAS2; CNS tumors; TC21
7.  Resident-Directed Long-Term Care: Staff Provision of Choice During Morning Care 
The Gerontologist  2011;51(6):867-875.
Purpose: To develop an observational protocol to assess the quality of staff–resident communication relevant to choice and describe staff–resident interactions as preliminary evidence of the usefulness of the tool to assess current nursing home practices related to offering choice during morning care provision. Design and Methods: This study included 73 long-stay residents in 2 facilities. Research staff conducted observations for 4 consecutive morning hours during targeted care activities (transfer out of bed, incontinence, dressing, and dining location). Observations were conducted weekly for 12 consecutive weeks. Staff–resident interactions were measured related to staff offers of choice and residents’ responses. Results: Interrater agreement was achieved for measures of staff offers of choice (kappa = .83, p < .001), type of choice provided (kappa = .75, p < .001), and resident requests related to choice (kappa = .72, p < .001). Observations over 2,766 care episodes during 4 aspects of morning care showed that staff offered residents choice during 18% of the episodes. Most observations (70%) were coded as staff offering “no choice.” Implications: Nursing home staff can use a simplified version of this standardized observational tool to reliably measure staff–resident interactions related to choice during morning care provision as a first step toward improving resident-directed care practice.
doi:10.1093/geront/gnr066
PMCID: PMC3220665  PMID: 21719629
Long-term care; Quality of care; Measurement; Quality of life; Assessment of conditions/people; Consumer-directed care
8.  Person-Environment Interactions Contributing to Nursing Home Resident Falls 
Although approximately 50% of nursing home residents fall annually, the surrounding circumstances remain inadequately understood. This study explored nursing staff perspectives of person, environment, and interactive circumstances surrounding nursing home falls. Focus groups were conducted at two nursing homes in the mid-Atlantic region with the highest and lowest fall rates among corporate facilities. Two focus groups were conducted per facility: one with licensed nurses and one with geriatric nursing assistants. Thematic and content analysis revealed three themes and 11 categories. Three categories under the Person theme were Change in Residents’ Health Status, Decline in Residents’ Abilities, and Residents’ Behaviors and Personality Characteristics. There were five Nursing Home Environment categories: Design Safety, Limited Space, Obstacles, Equipment Misuse and Malfunction, and Staff and Organization of Care. Three Interactions Leading to Falls categories were identified: Reasons for Falls, Time of Falls, and High-Risk Activities. Findings highlight interactions between person and environment factors as significant contributors to resident falls.
doi:10.3928/19404921-20090527-02
PMCID: PMC3042855  PMID: 20077985
9.  Culture Change in Long-term Care: Participatory Action Research and the Role of the Resident 
The Gerontologist  2010;51(2):212-225.
Purpose: This study's purpose was to advance the process of culture change within long-term care (LTC) and assisted living settings by using participatory action research (PAR) to promote residents’ competence and nourish the culture change process with the active engagement and leadership of residents. Design and Methods: Seven unit-specific PAR groups, each consisting of 4–7 residents, 1–2 family members, and 1–3 staff, met 1 hour per week for 4 months in their nursing home or assisted living units to identify areas in need of improvement and to generate ideas for community change. PAR groups included residents with varied levels of physical and cognitive challenges. Residents were defined as visionaries with expertise based on their 24/7 experience in the facility and prior life experiences. Results: All PAR groups generated novel ideas for creative improvements and reforms in their communities and showed initiative to implement their ideas. Challenges to the process included staff participation and sustainability. Implications: PAR is a viable method to stimulate creative resident-led reform ideas and initiatives in LTC. Residents’ expertise has been overlooked within prominent culture change efforts that have developed and facilitated changes from outside-in and top-down. PAR may be incorporated productively within myriad reform efforts to engage residents’ competence. PAR has indirect positive quality of life benefits as a forum of meaningful social engagement and age integration that may transform routinized and often ageist modes of relationships within LTC.
doi:10.1093/geront/gnq099
PMCID: PMC3140257  PMID: 21163911
Institutional care; Ageism; QOL; Age integration; Competence; Helplessness
10.  Cost-effectiveness of nutrition interventions in nursing home residents: A pilot intervention 
Objectives
Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents’ snack foods and fluids between meals to increase caloric intake.
Design
Randomized, controlled trial.
Setting
Three long-term care facilities.
Participants
Sixty-three long-stay residents who had an order for nutrition supplementation.
Intervention
Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption.
Measurements
Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents’ caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention.
Results
Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention.
Conclusions
Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.
PMCID: PMC3686278  PMID: 20424804
nursing homes; weight loss; intervention; nutrition supplementation
11.  Influenza vaccination in Alberta long-term care facilities 
Background
Canada's National Advisory Committee on Immunization recommends that both staff and residents of long-term care facilities be vaccinated against influenza. This paper describes the influenza vaccination policies and programs, as well as vaccination rates, for staff and residents of long-term care institutions in Alberta. Such data have not previously been reported.
Methods
Data were collected by means of an anonymous mail survey (with 2 reminders) sent to Alberta nursing homes and auxiliary hospitals in spring 1999.
Results
Of 160 facilities providing long-term care during the study period, 136 responded to the survey (85%). Of these, only 85 provided data on staff vaccination rates, whereas 118 provided data on resident vaccination rates. For institutions reporting this information, the median proportion of staff vaccinated was 29.9% and the median proportion of residents vaccinated was 91.0%. Only 2 facilities reported that staff vaccination was mandatory; however, only one of these had a written policy consistent with the self-report period. Using a travelling vaccination cart, offering vaccination on night shift, and monitoring and providing feedback about staff vaccination rates were infrequently employed as elements of staff vaccination programs, although all were positively correlated with staff vaccination rates. Standing orders for resident vaccination were reported by only 84 facilities. Fourteen institutions required written consent for vaccination from the resident or a relative. Facility requirements for consent to vaccinate from the resident or a relative were significantly associated with mean vaccine coverage: 90.5% coverage for institutions requiring verbal consent, 86.5% coverage for institutions requiring written consent and 95.0% for institutions not requiring written or verbal consent.
Interpretation
Staff vaccination rates in Alberta long-term care facilities are unacceptably low. Changes in staff vaccination programs may improve the situation even in the absence of mandatory vaccination or work exclusion rules. Requirements for written consent for vaccination of residents of long-term care facilities may be a barrier to immunization.
PMCID: PMC81068  PMID: 11387914
12.  Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial 
Background
Antibiotics are frequently prescribed for older adults who reside in long-term care facilities. A substantial proportion of antibiotic use in this setting is inappropriate. Antibiotics are often prescribed for asymptomatic bacteriuria, a condition for which randomized trials of antibiotic therapy indicate no benefit and in fact harm. This proposal describes a randomized trial of diagnostic and therapeutic algorithms to reduce the use of antibiotics in residents of long-term care facilities.
Methods
In this on-going study, 22 nursing homes have been randomized to either use of algorithms (11 nursing homes) or to usual practise (11 nursing homes). The algorithms describe signs and symptoms for which it would be appropriate to send urine cultures or to prescribe antibiotics. The algorithms are introduced by inservicing nursing staff and by conducting one-on-one sessions for physicians using case-scenarios. The primary outcome of the study is courses of antibiotics per 1000 resident days. Secondary outcomes include urine cultures sent and antibiotic courses for urinary indications. Focus groups and semi-structured interviews with key informants will be used to assess the process of implementation and to identify key factors for sustainability.
doi:10.1186/1472-6963-2-17
PMCID: PMC128823  PMID: 12207826
13.  Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities 
BMC Geriatrics  2005;5:13.
Background
Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.
Methods
The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332).
Results
The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.
Conclusion
Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.
doi:10.1186/1471-2318-5-13
PMCID: PMC1310539  PMID: 16280091
14.  Physical restraint use among nursing home residents: A comparison of two data collection methods 
BMC Nursing  2004;3:5.
Background
In view of the issues surrounding physical restraint use, it is important to have a method of measurement as valid and reliable as possible. We determined the sensitivity and specificity of physical restraint use a) reported by nursing staff and b) reviewed from medical and nursing records in nursing home settings, by comparing these methods with direct observation.
Methods
We sampled eight care units in skilled nursing homes, seven care units in nursing homes and one long-term care unit in a hospital, from eight facilities which included 28 nurses and 377 residents. Physical restraint use was assessed the day following three periods of direct observation by two different means: interview with one or several members of the regular nursing staff, and review of medical and nursing records. Sensitivity and specificity values were calculated according to 2-by-2 contingency tables. Differences between the methods were assessed using the phi coefficient. Other information collected included: demographic characteristics, disruptive behaviors, body alignment problems, cognitive and functional skills.
Results
Compared to direct observation (gold standard), reported restraint use by nursing staff yielded a sensitivity of 87.4% at a specificity of 93.7% (phi = 0.84). When data was reviewed from subjects' medical and nursing records, sensitivity was reduced to 74.8%, and specificity to 86.3% (phi = 0.54). Justifications for restraint use including risk for falls, agitation, body alignment problems and aggressiveness were associated with the use of physical restraints.
Conclusions
The interview of nursing staff and the review of medical and nursing records are both valid and reliable techniques for measuring physical restraint use among nursing home residents. Higher sensitivity and specificity values were achieved when nursing staff was interviewed as compared to reviewing medical records. This study suggests that the interview of nursing staff is a more reliable method of data collection.
doi:10.1186/1472-6955-3-5
PMCID: PMC526298  PMID: 15488144
15.  Preferences versus Practice: Life-Sustaining Treatments in Last Months of Life in Long-Term Care 
Purpose
To determine the prevalence and correlates of decisions made about life-sustaining treatments among residents in long-term care settings, including how often decisions were honored and characteristics associated with decisions not being followed.
Design and Methods
Retrospective interviews with one family caregiver and one facility staff member for each of 327 decedents who received end-of-life care in 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in four states were analyzed with respect to decedent demographics, facility characteristics, prevalence of decisions made about medical interventions, proportion of residents whose decisions were heeded, and characteristics associated with decisions not being heeded.
Results
Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in five of seven (71.4%) of resuscitations, one of seven feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, p= 0.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared to 32.8% of those whose decision were concordant (p=0.034).
Implications
Most respondents reported decision-making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.
doi:10.1016/j.jamda.2009.07.005
PMCID: PMC3692740  PMID: 20129214
Advance directives; end-of-life care; nursing home; assisted living
16.  The effect of foot massage on long-term care staff working with older people with dementia: a pilot, parallel group, randomized controlled trial 
BMC Nursing  2013;12:5.
Background
Caring for a person with dementia can be physically and emotionally demanding, with many long-term care facility staff experiencing increased levels of stress and burnout. Massage has been shown to be one way in which nurses’ stress can be reduced. However, no research has been conducted to explore its effectiveness for care staff working with older people with dementia in long-term care facilities.
Methods
This was a pilot, parallel group, randomized controlled trial aimed at exploring feasibility for a larger randomized controlled trial. Nineteen staff, providing direct care to residents with dementia and regularly working ≥ two day-shifts a week, from one long-term care facility in Queensland (Australia), were randomized into either a foot massage intervention (n=9) or a silent resting control (n=10). Each respective session lasted for 10-min, and participants could receive up to three sessions a week, during their allocated shift, over four-weeks. At pre- and post-intervention, participants were assessed on self-report outcome measures that rated mood state and experiences of working with people with dementia. Immediately before and after each intervention/control session, participants had their blood pressure and anxiety measured. An Intention To Treat framework was applied to the analyses. Individual qualitative interviews were also undertaken to explore participants’ perceptions of the intervention.
Results
The results indicate the feasibility of undertaking such a study in terms of: recruitment; the intervention; timing of intervention; and completion rates. A change in the intervention indicated the importance of a quiet, restful environment when undertaking a relaxation intervention. For the psychological measures, although there were trends indicating improvement in mood there was no significant difference between groups when comparing their pre- and post- scores. There were significant differences between groups for diastolic blood pressure (p= 0.04, partial η2=0.22) and anxiety (p= 0.02, partial η2=0.31), with the foot massage group experiencing greatest decreases immediately after the session. The qualitative interviews suggest the foot massage was well tolerated and although taking staff away from their work resulted in some participants feeling guilty about taking time out, a 10-min foot massage was feasible during a working shift.
Conclusions
This pilot trial provides data to support the feasibility of the study in terms of recruitment and consent, the intervention and completion rates. Although the outcome data should be treated with caution, the pilot demonstrated the foot massage intervention showed trends in improved mood, reduced anxiety and lower blood pressure in long-term care staff working with older people with dementia. A larger study is needed to build on these promising, but preliminary, findings.
Trial registration
ACTRN: ACTRN12612000659808.
doi:10.1186/1472-6955-12-5
PMCID: PMC3598869  PMID: 23414448
Anxiety; Blood pressure; Care staff; Complementary and alternative medicine; Dementia; Long-term care; Massage; Mood state; Pilot; Randomized controlled trial
17.  Sampling Challenges in Nursing Home Research 
Background
Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging.
Objectives
To compare characteristics of nursing homes that dropped from study to those that completed the study.
Methods
102 nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at two points in time, and from decedents’ family members in a telephone interview.
Results
17 of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team.
Discussion
Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.
doi:10.1016/j.jamda.2012.08.015
PMCID: PMC3534936  PMID: 23041332
Sampling; nursing homes; end-of-life care
18.  Pneumonia care and the nursing home: a qualitative descriptive study of resident and family member perspectives 
BMC Geriatrics  2006;6:2.
Background
Nursing home residents are frequently sent to hospital for diagnostic tests or to receive acute health care services. These transfers are both costly and for some, associated with increased risks. Although improved technology allows long-term care facilities to deliver more complex health care on site, if this is to become a trend then residents and family members must see the value of such care. This qualitative study examined resident and family member perspectives on in situ care for pneumonia.
Methods
A qualitative descriptive study design was used. Participants were residents and family members of residents treated for pneumonia drawn from a larger randomized controlled trial of a clinical pathway to manage nursing home-acquired pneumonia on-site. A total of 14 in-depth interviews were conducted. Interview data were analyzed using the editing style, described by Miller and Crabtree, to identify key themes.
Results
Both residents and family members preferred that pneumonia be treated in the nursing home, where possible. They both felt that caring and attention are key aspects of care which are more easily accessible in the nursing home setting. However, residents felt that staff or doctors should make the decision whether to hospitalize them, whereas family members wanted to be consulted or involved in the decision-making process.
Conclusion
These findings suggest that interventions to reduce hospitalization of nursing home residents with pneumonia are consistent with resident and family member preferences.
doi:10.1186/1471-2318-6-2
PMCID: PMC1379645  PMID: 16430782
19.  A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial 
Background
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
Objectives
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
Design
The design was a prospective cluster randomized trial with randomization at the unit level.
Methods
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
Results
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
Conclusions
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
doi:10.1016/j.ijnurstu.2012.10.010
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
20.  Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study 
BMC Nursing  2013;12:24.
Background
Research evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes.
Methods
The study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes.
Results
Two major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization.
Conclusions
The perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.
doi:10.1186/1472-6955-12-24
PMCID: PMC3849937  PMID: 24074157
Nurse practitioner; Long term care; Qualitative descriptive; Perceptions; Residents; Family members; Person-centred care
21.  Nursing Home Staff Adherence to Evidence-Based Pain Management Practices 
The purpose of this study was to determine the extent to which nursing home staff adhere to current evidence-based guidelines to assess and manage persistent pain experienced by elderly residents. A retrospective audit was conducted of the medical records of 291 residents of 14 long-term care facilities in western Washington State. Data revealed a gap between actual practice and current best practice. Assessment of persistent pain was limited primarily to intensity and location. Although prescribing practices were more in line with evidence-based guidelines, a significant number of residents did not obtain adequate pain relief. Nonpharmacological pain management methods were rarely implemented. Nursing home staff and administrators must critically examine both system and individual staff reasons for failure to comply with best pain management practices. Research is needed to determine factors that contribute to less-than-optimal adherence to evidence-based guidelines for pain management, as well as the best methods for implementing practice change.
doi:10.3928/00989134-20090701-02
PMCID: PMC2834947  PMID: 19650621
22.  Explaining Direct Care Resource Use of Nursing Home Residents: Findings from Time Studies in Four States 
Health Services Research  2007;42(2):827-846.
Objective
To explain variation in direct care resource use (RU) of nursing home residents based on the Resource Utilization Groups III (RUG-III) classification system and other resident- and unit-level explanatory variables.
Data Sources/Study Setting
Primary data were collected on 5,314 nursing home residents in 156 nursing units in 105 facilities from four states (CO, IN, MN, MS) from 1998 to 2004.
Study Design
Nurses and other direct care staff recorded resident-specific and other time caring for all residents on sampled nursing units. Care time was linked to resident data from the Minimum Data Set assessment instrument. Major variables were: RUG-III group (34-group), other health and functional conditions, licensed and other professional minutes per day, unlicensed minutes per day, and direct care RU (wage-weighted minutes). Resident- and unit-level relationships were examined through hierarchical linear modeling.
Data Collection/Extraction Methods
Time study data were recorded with hand-held computers, verified for accuracy by project staff at the data collection sites and then merged into resident and unit-level data sets.
Principal Findings
Resident care time and RU varied between and within nursing units. RUG-III group was related to RU; variables such as length of stay and unit percentage of high acuity residents also were significantly related. Case-mix indices (CMIs) constructed from study data displayed much less variation across RUG-III groups than CMIs from earlier time studies.
Conclusions
Results from earlier time studies may not be representative of care patterns of Medicaid and private pay residents. New RUG-III CMIs should be developed to better reflect the relative costs of caring for these residents.
doi:10.1111/j.1475-6773.2006.00627.x
PMCID: PMC1955363  PMID: 17362220
Nursing home; reimbursement; payment; case mix; hierarchical linear model
23.  Communication in Assisted Living* 
Journal of aging studies  2009;23(1):24.
This study of communication in an Assisted Living Facility (ALF) focuses on staff’s interpretive frameworks and situational tactics for managing elderly residents. It is based on interviews with staff and residents in an ALF together with ethnographic fieldwork. As in other quasi-total institutions, staff members engage in control as well as care, monitoring residents for compliance with rules and directives. Residents, aware of the threat of being moved to a nursing home, also monitor their own behavior and cognition in comparison to other residents. Other communication issues include the infantilization of the elderly by staff, and the race, class, and ethnic prejudices of residents.
doi:10.1016/j.jaging.2007.09.003
PMCID: PMC2811280  PMID: 20107612
24.  Nursing home research in Jinan, China: a focus group approach 
This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.
doi:10.1504/IJPP.2012.045869
PMCID: PMC3516409  PMID: 23227082
focus group; demand; supply; nursing home care; public policy; community-based needs; China
25.  Medicare Part D and the Nursing Home Setting 
The Gerontologist  2008;48(4):432-441.
Purpose
To explore how Medicare Part D's introduction is changing the operations of long-term care pharmacies (LTCPs) and nursing homes, as well as implications of those changes for nursing home residents.
Design and Methods
We reviewed existing sources of information and interviewed stakeholders across various perspectives. Thirty-one semi-structured, telephone interviews were conducted with key stakeholders between November 2006 and January 2007.
Results
Part D represents a substantial departure from how prescription drugs were previously financed and administered in nursing homes, and nursing home providers and LTCPs have struggled in adapting to some of these changes. Part D increased the variation around formularies and drug management processes for residents at the facility level, creating additional burden on clinical and pharmacy staff and introducing a tension between facilities' need to dispense medications quickly and assuring coverage for those drugs. Nursing home and LTCP stakeholders perceive wide variation across Part D plans in their ability to meet the needs of nursing home residents.
Implications
Although LTCPs, nursing homes and their clinicians, and Part D plans will gain experience with the benefit in the nursing home setting over time, stakeholders we interviewed identified a range of longer-term issues and questions that merit attention as the benefit proceeds.
PMCID: PMC2538577  PMID: 18728293
Medicare; Part D; nursing home; long-term care pharmacy

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