Enhancing Nursing Leadership in Long-Term Care

Harvath, Theresa A.; Swafford, Kristen; Smith, Kathryn A.; Miller, Lyndsey M.; Volpin, Miriam; Sexson, Kathryn; White, Diana L.; Young, Heather A.

doi:10.3928/00220124-20091301-06

Cited by 47 publications

(32 citation statements)

References 21 publications

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“…Consistent with the international literature, our study also demonstrates that leadership in care homes remains key to the sustainability of service improvements in care homes, [219][220][221] with additional benefits to stabilisation in the workforce. 222 Also consistent with the literature, 223 supervision from a specialist was seen as important, but in this case care is needed to avoid the negative effects on staff of reduced supervision and support from their own managers in the home. 224 Organisational investment in improving leadership and management skills is therefore recommended for staff productivity, stability and good resident outcomes.…”

Section: Discussionsupporting

confidence: 57%

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Moniz–Cook

Hart

Woods

et al. 2017

Programme Grants Appl Res

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BackgroundDementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.ObjectivesTo study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.Review methodsCochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.DesignResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.SettingsResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.ParticipantsResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.InterventionAn online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.Main outcome measuresResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.ResultsResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.LimitationsFunctionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.ConclusionsA Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.Future workThere is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.Trial registrationCurrent Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

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Section: Discussionsupporting

confidence: 57%

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Moniz–Cook

Hart

Woods

et al. 2017

Programme Grants Appl Res

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“…Although initiatives have begun to define competencies in geriatrics and gerontology needed by physicians, nurses, social workers, and other health professionals who care for older adults, 21,38 efforts to define the specific competencies needed to practice in long-term care settings are at a very early stage. The lack of core competencies for direct care workers has also been recognized, leading to a call for the development of competency standards and training programs that are competency-based.…”

Section: Principle 4: Defining Needed Competenciesmentioning

confidence: 99%

“…Organizations including the National Council of State Boards of Nursing and the American Nurses Association have acknowledged the importance of developing competencies and training programs for supervisory nurses, to facilitate the safe empowerment of direct care workers through appropriate coaching and guidance. 21 The increasingly complex health and functional issues of older adults with long-term care needs also present new challenges for the longterm care workforce. The presence of multiple chronic conditions and dementia in long-term care recipients exacerbates the already difficult problem of effectively managing their transitions back and forth across settings: hospitals, nursing homes, assisted living, and home care.…”

Section: Principle 3: Responding To New Philosophies and Models Of Carementioning

confidence: 99%

Improving The Long-Term Care Workforce Serving Older Adults

2010

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There is a worsening shortage of competent, committed, paid long-term care workers who are able to meet the needs of older adults. Efforts to address the shortage must be informed by a conceptual framework that acknowledges the unique circumstances affecting these workers. These include nontraditional market forces, low compensation and prestige, limited career opportunities, and inadequate preparation for evolving roles and responsibilities. Applying this framework, we identify strategies that can reverse current trends by expanding worker supply; improving education, training, and developmental activities; and making delivery of long-term care services and supports to older people a more attractive alternative to employment in acute and primary care settings.O ne essential element of long-term care policy has, until recently, received relatively little attention: ensuring the availability of a competent paid workforce to deliver needed long-term services and supports. The empirical and policy literature, and the authors' observations and many years of experience in long-term care policy development and research, suggest that future workforce planning and improvement initiatives should be guided by four principles. These are as follows:(1) Conventional rules of supply and demand and traditional sources of labor cannot be counted on to resolve future workforce shortages.(2) To compete for and properly develop workers, long-term care must be recognized as a distinct sector within the larger health care sector.(3) Workforce roles and responsibilities must be responsive to a new array of service delivery models and to the increasingly complex and diverse needs of clients.(4) The competencies that are needed to work in the long-term care field must be defined and put into practice before careers in long-term care can be widely recognized as worthy, and workers accorded a status equal to that of their peers employed in acute and primary care.In keeping with these principles, we present a framework for improving the supply of paid workers available to deliver long-term care services and supports to people age sixty-five and older. Such people differ somewhat from younger populations with respect to needs, preferences, and goals-particularly in the areas of school participation and employment-and, therefore, merit separate consideration. Yet several of the points raised, and recommendations offered in the following pages, are as applicable to paid caregivers serving children and workingage adults as to those serving older adults. Who Provides Paid Care To Older Adults?The paid ("formal") long-term care workforce serving America's elderly population is made up of licensed professionals and unlicensed direct care workers who manage and deliver longterm care services in nursing homes, assisted living facilities, other residential and commu-

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“…I tillegg avviker studentrollen i stor grad fra yrkesrollens krav om pasientansvar (3,6,7). Studier indikerer at bevissthet omkring ledelsesansvar som sykepleier kan bidra til å sikre kvalitet på pasientbehandling og omsorg (7)(8)(9). Mye tyder på at kompetanse i sykepleiefaglig ledelse vil bli enda viktigere for sykepleierens funksjon i framtiden.…”

Section: Introduksjonunclassified