Month: March 2015

Oral health for living better with dementia in residential care settings is a whole person affair

Shibley Rahman 0 Comments

Whole person care involves mental health, physical health and social care. It is not easy to see at once how oral health fits into this.

The need for good oral health is significant with older adults for a variety of reasons. The progression of dementia varies enormously, as does the ability to cope with dental treatment. Some people are comfortable with a visit to the dentist, while others find the whole experience very distressing. The dentist, together with the person with dementia and their family or carers, will discuss treatment needs and agree on the best treatment plan. A dentist can provide guidance and support on how to assist in cleaning another person’s teeth. The technique will vary depending on the individual concerned. Oral health in nursing homes has sometimes been described as “deplorable” with evidence that “a high proportion of elderly nursing home residents suffer from poor oral hygiene and oral health neglect”. Oral problems are partially, perhaps, a result of barriers to dental services and changed self-perception of oral health on the context of multi-morbidity.

There are two main types of dental disease – gum (periodontal) disease and tooth decay (dental caries, more commonly known as cavities). Gum disease can cause inflamed and bleeding gums, gum recession (where the gum tissue is reduced, causing the roots of the teeth to become exposed), loose teeth and bad breath. Both can cause discomfort or pain and can lead to the development of infection. Indeed both pain and infection can worsen the confusion associated with dementia.

Oral neglect, as well as poor oral health and oral hygiene, is highly prevalent among the institutionalised elderly. Residents with dementia, who are functionally dependent and cognitively impaired, appear to be worst affected. This is a challenge to the dental profession as the proportion of frail elderly with dementia and disabilities is projected to rise over the coming decade in most developed countries of the world.

Problems swallowing (dysphagia) and bad oral health have been found to be strongly associated with aspiration pneumonia in frail people. Consequently, adequate oral health care in care home residents with dysphagia may decrease the number of respiratory pathogens and diminish the risk of aspiration pneumonia.Furthermore, improvement of oral health care may improve the swallowing and cough reflex sensitivity. Risk factors of aspiration pneumonia, such as dysphagia, should be prevented in frail older people whenever possible. Aspiration pneumonia, an inflammatory condition of lung parenchyma usually initiated by the introduction of bacteria into the lung alveoli, is causing high hospitalisation rates, morbidity, and often death in frail older people. There are therefore clear repercussions of bad oral health and physical dis-ease.

It is argued that in the last three decades, the oral health of nursing home residents has worsened as a consequence of inadequate mouth care. The trend toward worsening oral health among nursing home residents is complicated by the rising numbers of persons entering nursing homes with some or all of their natural dentition; more than half of all nursing home residents are dentate. Residents, especially those with dementia, require meticulous daily mouth care because they often lack access to routine dental care. Older adults form plaque more quickly than their younger counterparts when mouth care is not routinely performed; this may be due to gingival recession, which exposes more tooth to the oral environment, and to reduced salivary flow.

The majority of nursing home residents arrive dentate. As their dementia progresses, the person may lose the ability to clean their teeth, or lose interest in doing so, and carers may need to take over this task. Older adults experience faster plaque production than younger adults because of the dual effects of gingival recession and reduced saliva production. The reasons for the poor oral health of nursing home residents may be multifactorial. Physical and cognitive impairment makes oral hygiene difficult, making residents increasingly dependent on other people and often resulting in poor oral cleanliness. Because reduced cognitive functioning frequently results in greater levels of dependency, including for oral care, carer are of crucial importance in maintaining oral health.

Poor oral hygiene causes periodontal disease which in turn creates tooth loss. The remaining teeth shift, causing loss of occlusal surfaces and subsequent chewing and swallowing problems. These problems place older adults at risk for malnutrition. Other systemic diseases associated with poor oral hygiene include aspiration pneumonia, diabetes, and coronary artery disease. The need for good oral hygiene is complicated by the dependence many nursing home residents have on others to provide basic care. Most require assistance in at least one activity of daily living while more than half are dependent on others for all activities of daily living, including mouth care. In addition, dental treatment provision to nursing home residents tends to be emergency-based, with little time spent on prevention, especially among vulnerable residents with cognitive and physical impairment. Oral health is therefore intimately linked to living better with dementia in residential care settings.

Additionally, the rate of edentulism is declining; the current generation of elderly has more teeth than previous generations and will live longer than their parents. Many older patients have no remaining teeth and are termed edentulous. These patients may or may not be wearing full or complete dentures and complete denture wearing may be rendered more difficult with the advent of dementia. Tooth loss from periodontal disease causes the remaining teeth to shift to the point where occlusal surfaces no longer articulate, interfering with chewing and swallowing functions and placing residents at risk for malnutrition. The reason for this is that successful (complete) denture wearing depends to a great extent of what is termed neuromuscular control. It is not uncommon, therefore, for carers of edentulous patients who are living well with dementia to request that new dentures be made for such patients. In reality, new dentures may not result in an optimal outcome, although the concept of template or copy dentures makes it easier for patients to adapt to new dentures.

The combination of increased dependency and increased retention of teeth will lead to a high-risk cohort with complex dental needs and more prone to dental diseases. Residential aged care facilities are residential facilities provided to frail elderly whose care needs are such that they no longer remain in their homes. Not only does the nature of the disease result in deterioration of oral health; anticholinergics and neuroepileptics used for its treatment result in salivary gland hypo-function that increases the risk for oral and pharyngeal diseases. One of the main side-effects of these drugs is a dry mouth. Saliva acts as a lubricant and dry mouth can cause problems with dentures, including discomfort and looseness.

Moreover, care-workers have reported several “barriers” in caring for elderly with cognitive impairment and behavioural difficulty, with oral hygiene among the most difficult care-giving task. This might reflect differences in culture between dental and nursing staff. It is possible that the dental professionals’ knowledge about the consequences of neglected oral care make them believe that oral care is a more important part of total care than do other health professionals. In addition, many nursing homes aim not to use force or restraint. The law says that before a legal decision about the use of force or restraint is made, trust-giving behaviour should be attempted.

Nevertheless, there is emerging evidence that there is a lack knowledge of the specific oral hygiene requirements of people living with dementia, or do not have the time needed for adequate oral care. Nursing home culture change aims to improve resident quality of life and staff well-being by aligning structures and processes of care with residents’ needs and preferences. It embraces a comprehensive philosophy so as to structure practices and policies such that they are consistent with individuals’ welfare. Within this whole person approach, discrete components of culture change practice are many, and include promoting the resident’s meaningful engagement The ultimate vision of a person-centred culture change is that individualised care will improve quality of life and outcomes. Outcomes of interest include those of both a psychosocial nature (e.g., boredom, helpless) and, increasingly, of a health-related nature (e.g., physical function, pain, pressure ulcers). What may be missing from the promotion of culture change is the incorporation of individualised, evidence-based protocols shown to improve daily care. And there is a strong social component to the effects of oral health malaise.

So, oral health in living better with dementia in the residential care setting is very much a whole person affair.

Tommy Whitelaw and Chris Roberts at Goodmayes Hospital

Shibley Rahman 0 Comments

On February 23rd 2015, I travelled down with Chris Roberts and Jayne Goodrick to see Tommy Whitelaw speak at Goodmayes Hospital. Tommy had been invited by the @BHRUT_Dementia team.

We only just made it in time.

Chris gave an introduction. Chris Roberts (@mason4233), living well with a mixed dementia (Alz and vascular), had travelled from North Wales to Goodmayes Hospital especially.

Barking, Havering and Redbridge University Hospitals NHS Trust operates across two main sites at Queen’s and King George hospitals serving a population of around 700,000 from a wide range of social and ethnic groups, making it one of the largest acute hospital trusts in England.

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I was very impressed by another introductory talk by Matthew Hopkins, the Chief Executive. Matthew (@M_J_Hopkins) has gone via Addenbrooke’s Hospital where I indeed was a junior house officer in general medicine on Prof Tim Cox’s firm.

I truly found Tommy’s talk inspiring. I know Tommy will have given the talk many times, but it gave it his all. It must be emotionally exhilarating for Tommy to retrace these steps.

What I particularly found inspirational about Tommy’s talk was how it will remind individuals in the NHS and care workforce what is important; care for real people rather than anonymous patients. I strongly believe in the notion of personhood, that everyone is fashioned by his or her past and present, and environment including relationships and wider environment.

“Person centred care” is a over-rehearsed phrase, but Tommy’s approach is one of great power.

I explained in my comment that I did not wish to bombard the event with policy. When members of the public think about the wider economy, they tend to be less interested in the mechanics behind the GDP figures, but more concerned how the economy might relate to a zero-hours contract or standard of living.

Similarly, I don’t think it’s helpful to be bogged down in a morass of policy detail. People are people.

But it does happen that Tommy does raise wider issues in general. Everyone has a life story for example. As Tommy explains, his mother had unmet needs; and the subtext here is that Joan did not want to go into residential care, so it is important to have her needs addressed.

Tommy did in the end find support from a medical consultant and a district nurse. Quite often whom you meet can totally alter the nature of your personal experiences about a situation.

And yet Tommy does embrace the wider 6Cs, currently English nursing police: care, compassion, competence, communication, courage, commitment.

Tommy would be the first to explain that he felt relatively under-prepared for the caring rôle he would ultimately take in looking after Joan; this is not unusual with many caregivers not thinking of themselves as ‘caregivers’, and often wondering whether they’re doing things right.

But people like Tommy, I feel, are not only doing things right but doing the right things. This means that Tommy is not just managing the situation with Joan, but he is showing true leadership.

The law looks behind the substance behind the name. That many thousands have given personal pledges for Tommy, including the Chief Nursing Officer Jane Cummings, means that Tommy has created a highly formidable social movement.

This is not just called a ‘social movement’. It is a social movement.

Tommy Whitelaw: “No one asked”

 

Goodmayes

Designing residential environments for living better with dementia

Shibley Rahman 0 Comments

Care providers need to move from a negative disabling approach to a more positive enabling mind-set that respecting residents as adults who have rich histories and can live meaningful lives. A ‘dementia friendly’ environment is argued to compensate for disability and should consider both the importance for the person with dementia of his/her experiences within the environment. Such environments aim at building on what people living with dementia, rather what they cannot do, allow them to experience the highest possible quality of life.  A literature on designing facilities for people with dementia, which has accumulated over the last 40 years, or so, provides support for the inclusion of a number of features into care homes that accommodate people with dementia. There is converging evidence that intelligent design of buildings, if regarded as a therapeutic resource, can promote well-being and functioning of people with dementia.

There has been increasing interest, overall, in the use of non-pharmacological interventions to improve dementia symptoms and the wellbeing of residents with dementia and their carers.  Previous studies examining modifications to the built environment have drawn from a number of design principles and frameworks for dementia care homes and suggest that purposeful design of one’s surroundings may play an active role in promoting a sense of well-being and improved functionality. The increased sensitivity of persons with dementia to environmental conditions occurs because the illness can reduce the individual’s ability to understand the implications of sensory experiences in residential care settings. As a result, agitated behaviours, increased confusion, delusions, and other psychiatric disturbances are readily triggered by environmental stimuli.

Inappropriate physical environment of the dining room is one of the most frequent concerns voiced by staff in nursing homes. Dining rooms are often loud and overstimulating places in care homes. In terms of physical environments, designs which provide balanced and controlled stimulation, and features that assist orientation, compensate for disability, and promote involvement in everyday activity are sought. With the aging population, research in home environments has developed a new focus of “environmental geriatrics” which includes professionals with backgrounds in anthropology, architecture, geography, occupational therapy, psychiatry, psychology, and other fields, as well as people living with dementia and caregivers. But dementia is not just about old people.

The focus of long-term care settings for the elderly has gradually changed from curing diseases to improving their quality of life, especially in countries which have been experiencing the aging of the population. In terms of the concept of care, the term “person-centered care” has already generated a lot of attention. Many terms (e.g., resident-centered care, individualised care, consumer-directed care, patient-centered care, self-directed care) share the same basic concepts and definitions. A person-centred approach is considered to emphasise residents’ unique personal preferences and needs in order to guide caregivers, thus enabling the individualisation of care plans and care routines to improve quality of life and compensate for their impairment. Person-centered dementia care requires shift in attitudes, behaviours, and systems replacing the traditional model of care that primarily focuses on the “tasks.” This is a best practice concept guiding efforts to improve residents’ quality of life in long-term care facilities. The care philosophy recognises that individuals have unique values, personal history, and personality.

Kitwood who advocated for the critical importance of personhood stressed the importance of taking a holistic perspective in relating to and caring with the person with dementia. For example, including a person with dementia in conversations at mealtimes would be considered as “positive person work”, as it contributes to recognising that person as a valued person. Dawn Brooker also illustrated Kitwood’s philosophy of person-centered care using a “VIPS” framework—“V” as valuing the individual as a full member of society, “I” as providing individualised approach, “P” as understanding the perspective of the person living with dementia, and “S” as providing a social environment that supports well-being of the person.

The environment needs to be able to support remaining ability rather than operate to diminish it, and to support the development and maintenance of relationships. The design of physical environments within residential aged care facilities (RACFs) can improve or worsen wellbeing in people with dementia irrespective of level of care from nursing staff. In Australia, the Building Quality for Residential Services Certification guides the building quality of RACFs in general, but this legislation does not offer any standards catered specifically to a person-centred dementia unit design. A groundbreaking assessment tool for the ward environment was developed in collaboration with NHS trusts participating in “The King’s Fund’s Enhancing the Healing Environment” (EHE) programme. Since then over 70 care organisations have been involved in field testing the tools. These tools have been informed by research evidence, best practice and over 300 survey responses from those who have used the tools in practice. Each of the sections draws on this evidence to develop a rationale for effecting change in care environments. This rationale also addresses, to some extent, the visuospatial experiences often associated with dementia. Making accommodations for the cognitive problems which people with dementia face is a fundamental aspect of overcoming disAbilities: for example the intelligent use of signage in care homes can make a tremendous difference. It’s also known, further, that intelligent use of colours and textures can enhance the lived experience of people living with dementia in residential care settings.

From the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for. Care provided by family and friends in the community on the one hand saved costs of formal care but on the other hand cause informal care costs, which more than outweigh the savings (König et al., 2014). Innes, Kelly and Dincarslan (2011) have reported on a study to evaluate the reliability and validity of two tools: The Design Audit Tool and the Environmental Audit Tool developed to audit how dementia-friendly internal and external environments (specifically care homes) are for people with dementia. Analysis of the home reports identifies variation and variability in meeting “dementia-friendly principles” as specified by both tools. Areas of variability included wayfinding, the use of colour and contrast, access to outside spaces, individualisation of personal and communal spaces, lighting and opportunities to engage with the environment.

“Household model units” are often created from traditional ward type environments. They, for example, are distinguished by having approximately 16 residents, a functioning kitchen, their own front door entrance and a separation of the bedrooms from the main communal living rooms. There is a philosophy of facilitating “person-centred care”, as opposed to institutional routines, supported by a consistent team of care workers providing much of the unit management and decision making for each household. They encourage domestic style relationships between residents, staff and relatives.

On the other hand, the policy of “aging in place”, meaning the ability of individuals to remain in their home in the community, is a consistent wish and expectation of middle aged and older people. Home adaptations (environmental improvements, or in the disability legislation, reasonable adjustments) and assistive technology provision are an increasingly attractive means of helping older people to maintain their independence and enhancing their quality of life. There has been, frustratingly, little systematic research into the feasibility and cost of pursuing such a policy. The lack of definitive evidence of a link between the quality of the environment and the wellbeing of people with dementia living in that environment is somewhat surprising given the evidence that is available on the beneficial effects of specific environmental interventions. “Housing with care”, such as extra care and continuing care housing, is becoming a preferred alternative amongst commissioners of adult social care to care homes for people with dementia. Contemporary research suggests that many people with dementia can lead good quality lives in extra care housing, at least in the mild to moderate stages.

The availability of gardens or outdoor areas in residential homes may offer a range of benefits for people living well with dementia, including opportunities for active engagement with gardening, walking in an outdoor environment, and sitting in soothing surroundings.

The physical environment is therefore now emerging as an important determinant of psychosocial and health outcomes for older persons with dementia of the Alzheimer type and other dementias. Among demented residents of long-term care facilities, environmental factors have been linked to agitation, intellectual deterioration, orientation, and even sleep patterns. With more people with dementia living in care homes in the UK than ever before, there is growing recognition that the design of such internal and external spaces should meet dementia friendly principles. The availability of gardens or outdoor areas in residential homes may offer a range of benefits for people with dementia, including opportunities for active engagement with gardening, walking in an outdoor environment, and sitting in soothing surroundings.

This field is promisingly now moving fast, giving some meat to the bones of ‘dementia friendly communities’.

 

 

References

Innes A, Kelly F, Dincarslan O. Care home design for people with dementia: What do people with dementia and their family carers value? Aging Ment Health. 2011 Jul 1;15(5):548-56. doi: 10.1080/13607863.2011.556601.

König HH, Leicht H, Brettschneider C, Bachmann C, Bickel H, Fuchs A, Jessen F, Köhler M, Luppa M, Mösch E, Pentzek M, Werle J, Weyerer S, Wiese B, Scherer M, Maier W, Riedel-Heller SG; AgeCoDe Study Group. The costs of dementia from the societal perspective: is care provided in the community really cheaper than nursing home care? J Am Med Dir Assoc. 2014 Feb;15(2):117-26. doi: 10.1016/j.jamda.2013.10.003. Epub 2013 Dec 8.

Better care homes for living with dementia?

Shibley Rahman 0 Comments

Health care systems are complex adaptive systems that are resistant to change. Around 423 000 care home places are provided by the private and voluntary sector in England and Wales. When the Nuffield Trust came to consider new organisational forms for healthcare providers, in appraising the “Dalton Review”, attention was drawn to struggling providers, learning from approaches internationally, and learning from other sectors.  And emerging themes appeared to be leadership and management, ownership and governance, policy, legal and regulatory issues, culture and values, infrastructure and assets, and efficiency and costs.

Whilst the Dalton Review was primarily concerning itself with hospitals, I feel that a similar approach can be validly taken to care homes. The regulator of care homes, the Care Quality Commission (CQC), has, traditionally, primarily focused on the quality of social care provision. We need to understand the underlying facilitators and barriers in achieving the best and most appropriate healthcare for patients. From such an understanding, recommendations could then be made for the design of future provision.

We know from the Care Quality Commission’s seminal report “Cracks in the pathway”, published October 2014, striking statistics about poor care:

“In 29% of care homes and 56% of hospitals we found aspects of variable or poor care regarding how a person’s needs were assessed. In 34% of care homes and 42% of hospitals we found aspects of variable or poor care regarding how the care met people’s physical and mental health and emotional and social needs. In 27% of care homes and 56% of hospitals we found aspects of variable or poor care regarding staff’s understanding and knowledge of dementia care.”

Leadership is important for the implementation of nursing practice. However, the empirical knowledge of positive leadership in processes enhancing the person-centred culture of care in nursing homes is limited.  By strengthening the leadership skills of nursing home leaders, it may be possible to achieve and sustain improvements that are essential to promote a better quality of life for the residents.  Under-performing homes should take corrective action to improve clinical leadership, communication processes, teamwork, and timeliness of information transfer before embarking on major quality improvement initiatives. Good leadership plays a key role in developing nurses’ understanding of patients’ needs and values and the acceptance of new innovations to obtain successful change and a positive care culture. A number of recent reports from health and care have converged upon the need to speak out safely about poor care. For example in a document entitled, “Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS,  the need for strong leadership was identified:

“However, there are encouraging signs that there is a genuine will to make progress, and a growing awareness of the contribution staff can make when encouraged to speak up. For example, the Dalton Review made clear that leaders should listen and respond to the insights of staff and recognise that ideas for improvement are generally found within their own organisations.”

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Relatively little is known about the relationship between organisational culture and quality of long-term care and studies found focus on different aspects of quality of care. Care staff who have attitudes that are more ‘person-centred’ have been shown to have a greater recognition of dementia in residents. Organisational culture relates to the assumptions, values, attitudes, and beliefs that are shared among significant groups within an organisation. In research on culture in general health care, many attempts have been made to elucidate any possible linkages between organisational culture and organisational performance.  A strong, positive culture has been reported to contribute to quality of care. Yet, other studies in general health care report no associations at all. A strong framework of organisational culture that is often applied in healthcare research is the competing values framework. But the report “Transforming care: A national response to Winterbourne View Hospital Department of Health Review: Final Report”, a particularly noteworthy low point in care homes, revealed the following:

“The abuse revealed at Winterbourne View hospital was criminal. Staff whose job was to care for and help people instead routinely mistreated and abused them. Its management allowed a culture of abuse to flourish. Warning signs were not picked up or acted on by health or local authorities, and concerns raised by a whistleblower went unheeded. The fact that it took a television documentary to raise the alarm was itself a mark of failings in the system.”

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From another jurisdiction (Australia),  Dr Lynn Chenoweth, Professor, Aged & Extended Care Nursing, University of Technology Sydney, provides a description of the perfect “perfect storm” (Chenoweth et al., 2014)

In parallel with reduced nurse numbers, changes in health-care policy have seen cost minimization, resource utilization and risk management conflicting with community expectations of health outcomes for older people . Safe, effective health care for persons with age-related conditions, such as dementia, depends upon recruitment and retention of qualified nursing staff. Concerns for qualified nurse sufficiency and stability worldwide occur at a time of decreasing nursing authority, and prevailing dissatisfaction with the pace of change in working conditions produces poor recruitment and greater attrition. Problems in qualified nurse recruitment and retention in Australia are exacerbated in residential aged care facilities (RACFs) by complex care demands, high workloads, poor workplace conditions, lower professional and community status and poor pay parity. Nurse attrition in this sector is associated with under-resourcing and unsupportive management systems. Data comparing the 2007 RACF workforce with 2003 showed total workforce growth from 76 006 to 78 849 full-time equivalent positions to cater to the increased number of residents, but a concomitant fall in qualified nurse numbers of around 3% had a significant impact on workload and job satisfaction.

In trying to improve the quality of care provided to people with dementia, researchers have primarily looked at establishing a better understanding of care staff attitudes and workplace experiences in the hope that, by developing ways in which these can be changed, practice can be improved. This is clearly a question of specialist staff training, rather than vague concepts of being ‘friendly’. For example, there is also evidence to suggest that positive care staff attitudes, particularly ones focused on ‘person-centredness’, are related to better job satisfaction and that staff who report higher levels of satisfaction provide better care. Negative attitudes towards the person with dementia are regarded as an obstacle to care and can result in staff focusing on the resident’s physical deficits. In addition, continued high levels of staff stress can lead to burnout, which causes more negative attitudes towards the person with dementia

There have been mixed findings from studies evaluating the effectiveness of staff training programs, the majority of which have utilised uncontrolled research methodologies, and have often recruited small samples from only one or two facilities. Training programs that provide staff with both information-based sessions and additional support to help facilitate change appear to be more likely to promote continued improvement in skills. This approach typically includes extended on-the-job training to enhance learning of new skills, through ongoing expert consultation, modelling of appropriate practices, or supervision and feedback by specialists.

Whether termed knowledge “dissemination”, “disseminating innovations”, “knowledge transfer”, “knowledge translation”, or “diffusion of innovation”, the common goal is improved patient care enhancing the patient experience and patient safety. The NHS currently has objectives which includes adding life to years as well as adding, appropriately, years to life. Healthcare knowledge, generated by the scientific community, does not reach its full value until it moves from research to practice. This crucial transition is often fraught with challenges that result in healthcare performance that is less than optimal. Referring to this fundamental problem in healthcare, the Institute of Medicine (2001) stated in its report, “Crossing the Quality Chasm: A New Health System for the 21st Century”, that “between the health care that we have and the care we could have lies not just a gap, but a chasm.” In a review of nine clinical procedures, Balas and Boren (2000) found that it takes an average of 15 years after a landmark trial of a new procedure to reach a use rate of 50%.

But this is all hugely complicated, it turns out. By pointing out that “mastering the generation of good changes is not the same as mastering the use of good changes,” Berwick (2003) highlights the paradox inherent in the diffusion of innovations. Across healthcare disciplines and professions, nationally and internationally, concerns are being raised about the need to improve the transfer of knowledge from the scientist to the clinician.  The use of peer support groups represents an alternative approach to facilitate the development of staff skills that is not dependent upon the continued involvement of external specialists. In this approach, staff members are encouraged to meet regularly in small groups, to support each other in their day-to-day work and in the use of new skills for the management of residents with behaviours which suggest a failure of communication.

There is a paucity of extensive description of registered nurses’ education and their views on competence development in residential care. There is growing evidence that care home residents have unmet health needs, may be admitted to hospital unnecessarily and that their dignity may be affected by poor access to healthcare.  Many studies into educational programs for nursing staff in long term care settings have very small sample sizes, non randomised designs, designs without control groups or a low response rate. There has been much interest in England in promoting training among professionals working with people with dementia. This reflects concerns that people working in social care services providing support for people with dementia are the staff who are least likely to have been offered or to have attended any training.  The Quality Outcomes Framework, used by the National Health Service to ensure that primary care across the UK is systematic and evidence-based, does not address residents’ needs. On the other hand, there is much support for the need for  increased education for long term care staff. In addition to ongoing staff education, long term conditions care homes often turn to continuing education (CE) when faced with compliance issues. Managers can be keen to provide CE because of limited resources, including paying for the education and backfilling positions so that staff can attend.

However, for instance, a goal of the CARES® (Connect with the resident; Assess behavior; Respond appropriately; Evaluate what works; Share with the team) program has to provide a portable, self-paced, interactive training program to help nursing assistants and other nursing home staff acquire knowledge about effective treatment and management of dementia in long-term care settings. CARES® was designed to provide a cost-effective multimedia educational training program to nursing home and assisted living staff to improve dementia care practices.

Finally, Prof Henry Brodaty and colleagues have reported that approximately one in three nursing home staff members felt they did not have enough opportunities at work to discuss the psychological stress of their job. Peer support groups may help to address this unmet need, but so far have received little attention in the literature. Annual turnover of nursing home staff ranges from 40% to 96% in the United States of America. As there is a significant correlation between nurses’ occupational stress, turnover and job satisfaction, a better understanding of nurses’ strain and satisfaction in nursing homes may help in designing interventions or policy development to decrease turnover.

Residential homes are most likely to offer good care when they are firmly rooted in their communities, and where individuals are respected for the persons that they are. An enriching environment, perhaps with meaningful environment, effective design, and a person-centred culture might go a long way to achieve better care homes, and we need to know from research what this involves. But it’s crucial that this research into care, hopefully of high quality as well as good quantity, isn’t left on the shelf for too long, and is applied in service provision as soon as possible.

 

References

Balas EA, Boren SA. Managing clinical knowledge for healthcare improvement. Yearbook Med Inf. 2000:65–70.

Berwick DM. Disseminating innovations in healthcare. JAMA. 2003;289(15):1969–1975.

Chenoweth L, Merlyn T, Jeon YH, Tait F, Duffield C.Attracting and retaining qualified nurses in aged and dementia care: outcomes f rom an Australian study. J Nurs Manag. 2014 Mar;22(2):234-47. doi: 10.1111/jonm.12040. Epub 2013 Mar 7.