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USING INTERNATIONAL COLLABORATIONS TO SHAPE RESEARCH AND INNOVATION INTO CARE HOMES IN BRAZIL: A WHITE PAPER

 

A.F. Jacinto1, W. Achterberg2, P.A. Wachholz3, T. Dening4, K. Harrison Dening5, R. Devi6, D. Oliveira7, I. Everink8, P.S. Azevedo3, P.J.F .Villas Boas3, K. Hinsliff-Smith9, M. Hoedl10, J.M.G.A. Schols8, V. Shepherd11, A.C.M. Gratao12, R.C. de Melo13, H.A.W. Watanabe14, M.S. Zazzetta15, C. Goodman16,17, K. Spilsbury6, A.L. Gordon18,19

 

1. Disciplina de Geriatria e Gerontologia, Departamento de Medicina, Escola Paulista de Medicina – Universidade Federal de São Paulo (UNIFESP), Brazil; 2. Department of Public Health and Primary care, Leiden University Medical Center, Leiden, The Netherlands; 3. Disciplina de Clínica Médica, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu – Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Brazil; 4. Division of Psychiatry & Applied Psychology, University of Nottingham, UK; 5. Dementia UK, London, UK; School of Health Sciences, University of Nottingham, UK; 6. School of Healthcare, University of Leeds, Leeds, UK; 7. Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Brazil; 8. Maastricht University, Care and Public Health Research Institute, Department of Health Services Research, Maastricht, The Netherlands; 9. De Montfort University, Health and Life Sciences Faculty. Edith Murphy Building, Room 3.09, Leicester LE1 9BH, UK; 10. Institute of Nursing Science, Medical University of Graz, Graz, Austria; 11. Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS UK; 12. Department of Gerontology, Federal University of São Carlos (UFScar), Brazil; 13. Escola de Artes, Ciências e Humanidades – Universidade de São Paulo (USP), Brazil; 14. School of Public Health, University of São Paulo (USP), Brazil; 15. Departamento de Gerontologia, Universidade Federal de São Carlos (UFScar), Brazil; 16. Centre for Research in Public Health and Community Care, University of Hertfordshire, UK; 17. NIHR Applied Research Collaboration – East of England (ARC-EoE), Cambridge, UK; 18. Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK; 19. NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK. Corresponding author: Alessandro Ferrari Jacinto, Rua Castanheiro, 16 – Vila Mariana, São Paulo – SP – 04023-040 – Brazil, E-mail: alessandrojacinto@uol.com.br, Phone:+55 (11)55752692,  https://orcid.org/0000-0002-1977-5880, Twitter: @JacintoFerrari

Jour Nursing Home Res 2020;6:109-113
Published online November 27, 2020, http://dx.doi.org/10.14283/jnhrs.2020.28

 


Abstract

The Brazilian care home sector is underdeveloped, and the limited available evidence suggests that care quality falls below international standards. Development of the Brazilian care home sector could be associated with better outcomes for those receiving care, and more efficient use of resources across health and social care. Research has an important role to play. This article summarises research priorities for Brazilian long-term care homes developed as part of an international workshop held in Brazil and the UK, and attended by 71 clinicians and researchers from 6 Brazilian Universities, supported by an international faculty of 8 Brazilian, 8 British, 2 Dutch and 1 Austrian academics. The research priorities identified were: understanding and supporting multidisciplinary working in care homes, with emphasis on describing availability of multidisciplinary teams and how they operate; dignity and sensitivity to cultural needs, with emphasis on collating accounts from Brazilian stakeholders about dignity in care and how it can be delivered; enriching the care home environment with art, music and gardens, with a focus on developing arts in the care home space in a way that is sensitive to Brazilian cultural identity; and benchmarking quality of care, with emphasis on exploring how international quality benchmarking tools can be adapted for use in Brazilian care homes, taking account of new initiatives to include person-centred outcomes as part of benchmarking. Instrumental to research in these priority areas will be establishing care home research capacity in Brazil.

Key words: Long-term care, aged, Brazil, research.


 

Introduction

In common with other BRICS (Brazil, Russia, India, China and South Africa) countries, Brazil is affected by rapid population ageing. In 2014, 14.6% of Brazilians were aged over 60 years, a proportion projected to grow to 33.5% by 2060 (1). Increases in average life expectancy have been accompanied by higher prevalence of multimorbidity and functional dependency, and unmet need for health and social care amongst older people.
All Brazilian citizens can access free healthcare at the point of delivery through a national health care system, the ‘Sistema Único de Saúde’ (SUS, or Unified Health System). This system, however, does not cover long-term care in care homes.
Care homes are facilities which provide 24 hour care, with or without specialist nursing input (2). They are a feature of most developed, and many developing, health and social care economies. They provide capacity to look after people with 24-hour care needs through support from dedicated staff, something which even the most generously funded healthcare systems struggle to reimburse in people’s own homes.
In Brazil, a small number of care homes (7%) are state-funded (3). A small and developing private sector provides care in facilities, akin to residential or nursing homes seen in high income countries, but these remain beyond the means of many (4) The bulk of current provision comes from small, localised organisations which are funded precariously through a combination of older people’s retirement benefits, community charities, and funding from municipalities.
The current estimated capacity of 100,000 beds across 3,549 institutions represents 0.03 beds per head of population over 80 years of age in Brazil (5). This differs considerably from England and the Netherlands, which have 0.12 and 0.23 beds per head of population over the age of 80 years respectively (6).
All Brazilian care homes are led by Technical Directors, many of whom do not have a healthcare degree. There is no requirement for health professionals (doctors, nurses and allied health professionals) to be employed by care homes, and the structure of healthcare input to care homes is highly variable. Healthcare in Brazilian care homes is mostly provided by doctors without any formal postgraduate training in primary care, geriatric medicine, gerontology or old age psychiatry. A cross-sectional study using objective quality indicators adapted from the United States found that quality of care in Brazilian care homes was variable and fell some way short of international standards (7).
Research in Brazilian care homes is underdeveloped, has not been a particular focus of the academic community and has not been supported or funded in a strategic way. Against this background, the Improving care in LOng-Term Care InstitUtionS in Brazil and Europe through Collaboration and Research (LOTUS) consortium was formed to develop research in Brazilian care homes through international learning and collaboration. It comprised two workshops, the first held at UNESP Medical School, Botucatu, Brazil, in April 2019, and the second held at University of Nottingham, United Kingdom (UK), in August 2019.
The workshops comprised visits to Brazilian and UK care homes and round-table sessions to identify priorities for future research in Brazilian care homes, harnessing links with international institutions to accelerate progress. We present here a summary of the identified priorities, in part as a manifesto to drive our research programme forward, and in part to inform similar collaborations around long-term care between high-, low- and middle-income countries elsewhere.

 

Choosing the priority areas

Workshop attendance was free-of-charge. Delegates were invited using e-mail lists for Brazilian national gerontology and geriatric medicine organisations. Registration was via a public webpage in English and Portuguese, which was publicised using Twitter. Brazilian organisers, comprising eight academics from a range of disciplines, consulted widely to ensure the programme represented a broad constituency with an interest in care homes. Using this approach we recruited 71 clinicians and academics from six Brazilian universities, including healthcare professionals, social scientists, demographers, gerontologists, designers and architects. Eleven academics from six UK, two Dutch and one Austrian universities were invited based upon expertise which matched the programme prepared by the Brazilian committee. The first two days comprised small group workshops and plenary sessions which enabled delegates to share experiences, with a focus on opportunities and challenges that could be addressed by research. At the end of day 2, delegates were presented with a list of nine possible research domains drawn from discussions, which they were asked to rank in terms of priority. The topics chosen were discussed and developed more fully over the remaining one day of Brazilian and two days of UK-based workshops.

 

Priority area 1 – Understanding and Supporting Multidisciplinary Working in Care Homes

Caring for older people with complex needs requires a multi-domain approach recognising the contributions of mental and physical wellbeing, functional capabilities, social networks and environment to overall health and wellbeing. From a nursing and social care perspective this is reflected in the evidence-base for person- and relationship-centred care (8) From a medical perspective, it is expressed through the evidence for comprehensive geriatric assessment (CGA) (9). Whilst person-centred care and CGA have exponents in Brazil, they are not yet widely accepted. The extent to which care homes are set-up to deliver them is not clear.
Comprehensive care approaches draw upon expertise of multiple professionals working as a team. In high income countries, multidisciplinary teams can be based in and employed by care homes – as in the Netherlands – or can be composed of numerous visiting professionals – as in the UK and Austria. The latter scenario can present challenges around co-ordinating assessments by different professionals and managing their inputs to ongoing care, with the need to take account of remote working and asynchronicity of inputs (10).
Surveys of care homes in Brazil have focussed mainly on the structure of institutions and the profile of the residents who receive care, particularly focussing on health status, falls and frailty (11–13). Data have not been collected hitherto on how such institutions are staffed, in terms of the disciplinary background of staff involved in care, or how such staff integrate into a multidisciplinary team.
Following the LOTUS workshops, we have commenced a survey to establish how multidisciplinary teams operate across ten care homes, five not-for-profit/philanthropic and five for-profit, spread across five Brazilian cities in São Paulo State (Botucatu, São Paulo City, Ourinhos, São Carlos and Campinas). Following this we propose more detailed qualitative research to understand in greater detail how professionals from multiple backgrounds connect and interact in care homes. Given the variation in geography, climate, culture and economic resource between Brazilian states, an explanatory approach will be required to accommodate and understand variability.

 

Priority area 2 – Dignity and Sensitivity to Cultural Needs

Dignity is defined in the Oxford English Dictionary as ‘the quality of being worthy or honourable; worthiness, worth, nobleness, and excellence’. The challenge lies in translating fine sentiments about maintaining dignity into care practice. Dignity can be complicated. For example, is it something that can be observed and measured objectively by meeting certain standards, or is it subjective and perceived at an individual or interpersonal level? Two people may observe the same interaction, such as a visit to the toilet, and come to different conclusions about how dignified it was.
Three main interactional qualities have been described (14) that help to preserve care home residents’ sense of dignity: experiencing love and confirmation; experiencing social inclusion and fellowship; and experiencing humane warmth and understanding within a caring culture, while being met as an equal human being.
There are several important cultural aspects of dignity (15). Staff and residents of care homes are often of differing backgrounds. This may include different socio-economic status, ethnic origins, speaking different languages, having differing sexualities or gender identities, or being of different faith. The linguistic issue, present in many countries due to dependence on migrant workers in long term care, can be particularly challenging in Brazil because, although Portuguese is the predominant language, the country is multi-lingual and not all older people speak Portuguese. Even where this is not the case, a care home of reasonable size will contain a diverse group of residents, with different educational and occupational experiences. They are likely to have different care preferences and needs. Some may observe a religion, others not. These aspects of individuality need to be understood and respected to support dignity in care.
Dignity is an important part of the realpolitik of care homes in developed countries. In the UK, for example, charitably funded national initiatives led by academics in partnership with care homes focus on dignity, whilst legislative and regulatory frameworks explicitly emphasise residents’ right to dignified care. The concept of dignity is less established in Brazilian care homes. There is a high level of stigma attached to care homes and their residents. Stigma leads to ageism, exertion of power, isolation, seclusion, poor quality care, and high professional turnover, all of which may impact upon provision of dignified care and impair the ability of staff to see individuals behind negative labels and stereotypes. Dignity is not used as a measure of care quality in Brazil.
We need to understand the levers required in Brazil to promote culture change from the current preoccupation with meeting physical care needs to a more person- and relationship-centred approach. It is likely that the answer will lie in staff feeling empowered and valued, so that they can prioritise dignity in care (16). There will be organisational and cultural issues specific to Brazil that influence how to empower and support staff and residents. Research needs to examine the perceptions of different stakeholders about what constitutes dignity and what different priorities for change may be. We propose that the first step should be a scoping review of the Brazilian literature of long-term care and dignity, followed by qualitative interview studies.

 

Priority area 3 – Enriching the Care Home Environment with Art, Music and Gardens

The proportion of care home residents with dementia, internationally, ranges from 30-60% (17). Activities such as art interventions are helpful in supporting people with dementia (18) and are one of the few effective non-pharmacological strategies in dementia care. Music, for example, is associated with improvement in cognitive performance and mood of care home residents (19).
There is evidence that residents from Brazilian care homes are less able to access stimulating recreational activities than in higher income countries (20). This could relate, again, to the emphasis placed on physical needs within Brazilian care homes. Initiatives that have developed around recreational activities have been led by research teams. One such project involved working with participants from two care homes and two day centres using museum objects as a focus (21). Sensory strategies like smell, tactile and sound experiences were explored in addition to reminiscence. Eight to 15 people participated every week, with additional trips to museums every two months. This museum project also incorporated a music experience, using exhibits and photos in the museum. Although similar to initiatives conducted in other countries, a key learning point was how evocative and stimulating the smells, flavours and sounds of Brazil were for residents living with dementia. The smell of coffee, and the sound of “serestas” were associated with a particularly strong affective response.
Further work is required to work out how to enrich care home environments in ways which are sensitive to Brazilian culture and hence work. It is also clear that research is central to establishing such approaches in the mainstream of Brazilian care homes.

 

Priority area 4 – Benchmarking quality of care

Care provider organisations have a duty of care to protect the safety of clients and to ensure that care meets, and exceeds, minimum acceptable standards. Approaches to quality control and governance in care homes internationally vary and include: professionalism-based regulatory systems, where groups of professionals or provider organisations take responsibility for quality control; inspection-based regulatory systems, where statutory providers send independent staff inspect care homes; and data measurement and reporting based regulatory systems, where audit of minimum dataset submissions are used (5).
Regardless of the approach adopted, there is increasing emphasis across high-income countries on reliable metrics about quality of care, which can enable providers to understand areas which require improvement and to act upon them. A highly established approach uses the international Resident Assessment Instrument (interRAI), an interlinked suite of resources, whereby resident-level assessment conducted by care home staff can inform care protocols and also generate institution level case-mix analyses and quality markers. There are, though, challenges associated with implementing such a detailed and comprehensive approach (22). A contrasting approach – adopted in the Netherlands, Austria, Switzerland, Turkey and one region of the UK – is the International Prevalence Measurement of Care Quality (in Dutch: Landelijke Prevalentiemeting Zorgkwaliteit, LPZ) – which takes a more straightforward, once-yearly audit-based approach to benchmarking and then uses the findings from these observations as the basis of quality improvement (23). These approaches are now being modified to take account of person- and relationship centred care, with inclusion of quality of care from the resident’s perspective included in the Individually Experienced Quality of Long-Term Care (INDEXQUAL) framework, and its adaptations to take account of professional caregivers’ and families’ perspectives (24).
Very little benchmarking data are available in the Brazilian care home sector. Benchmarking using a sub-component of the interRAI has been conducted on a small scale basis as part of a study in 35 homes conducted in Rio Grande do Norte State of Brazil (7). It is therefore feasible within the context of a cross-sectional research cohort study. Further work is required to consider the wider role of benchmarking, its feasibility, its implementation in routine practice, and how it can be used to drive quality improvement. As with other domains described above, the shift to resident- and relationship-centred benchmarking will need specific adaptation to the Brazilian cultural context.

 

Discussion

Each of the above priority areas is challenged by the relative under-development of the Brazilian care home sector. It is well established that effective research in care homes requires collaboration, and co-design, between residents and relatives, staff from the care home sector, and academics. There are specific challenges to recruitment and retention of care home staff and residents in research, and to data collection and analysis in care home cohorts, that require sector-specific expertise which takes time to develop.
There is good evidence that an established care home research network can help cultivate the necessary competencies in academic and care home staff, and that the resulting research can drive up standards of care, and generate the case for capacity in the care home sector (25). A highly structured model, such as the South Holland Nursing Home Research Network (26), may be challenged by the limited capacity and relative under-development of Brazilian long-term care as it stands. Other examples, though, are available, such as the UK National Institute of Health Research Enabling Research in Care Homes (EnRICH) model (27), where care homes are recruited as research opportunities become available, with a network slowly developing over time. This might better suit the Brazilian situation.
Most of the work required to address the above priority areas will comprise mixed-methods research. Whilst both positivist biomedical research and inductive qualitative approaches are established in Brazil, researchers from these different backgrounds have not frequently come together. Relationship and team building will be required. In addition, new approaches that can make sense of complex interactive systems, need to be imported. Realist enquiry, with its ability to describe how context affects the mechanisms at play within complex systems, to deliver outcomes that matter, could be useful (28). Implementation science, with its insights into how to implement and sustain evidence-based approaches to care, will be able to provide approaches which can make sense of the wide variation in approaches to care home services across Brazil (29).
As we write this paper, the world in general, and Brazil in particular, is still in the grip of the COVID-19 pandemic. This pandemic has been associated with significant mortality in the care home sector. We do not yet fully understand the extent to which it has impacted upon the Brazilian care homes (3) Internationally COVID-19 has challenged models of healthcare delivery to care homes, remuneration and funding models, how data are collected and collated on care home residents, how staff are trained, and how buildings are designed to maximise quality of life and wellbeing for residents (30). Most of these areas of uncertainty are highlighted by the research priorities which we had already identified in our workshop before the arrival of COVID-19. That they have been reinforced by the pandemic highlights how research to understand each of these domains is central to the development and delivery of good care. The pandemic has laid bare how devastating it can be for care home residents, and society more generally, if we do not prioritise and focus upon these research areas.

 

Implications for practice and research

This document is presented to provoke discussion and thought. It makes no claims to be representative of all Brazilian academics with an interest in care home research. The strengths of our approach included the use of two face-to-face workshops, one held in Brazil, free-to-attend and publicised through national academic and clinical practice networks. Advanced planning and an open discursive approach at the meeting was designed to give full voice to Brazilian academics from diverse backgrounds, and to enable them to set the agenda and priorities going forward. Limitations are that Brazil is a large country and running our workshop in one city in São Paulo State may have limited the ability of colleagues from more remote parts of the country to attend. Not all Brazilian representatives were able to attend the second workshop in the UK. Brazilian colleagues are not all fluent in English and the workshop may have given prominence to the ideas of those who were most conversant in this language. Laying out in this paper the ideas developed through the workshop programme, represents a further opportunity to discuss important topics and to generate dialogue. We hope that colleagues that we have not hitherto engaged with, will feel empowered to join the debate.
We have highlighted in this paper the need for rapid development in the Brazilian long-term care sector. Close collaboration between care providers and researchers has the potential to accelerate the development of the sector, drive up standards and improve efficiency and effectiveness of care. International collaboration can help accelerate the development of a Brazilian care home research community to support this process.

 

Funding: The workshops were funded by the UK The Academy of Medical Sciences, Global Challenges Research Fund, reference number AAM 128769. The participation of Paula S Azevedo was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. Adam Gordon and Claire Goodman are supported by the NIHR Applied Research Collaborations for East Midlands and East of England respectively. Professor Goodman also receives NIHR support as a NIHR Senior Investigator. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Conflict of interest: The authors have no conflict of interest to declare.

Ethical standards: This international collaborative workshop was exempt from the need for ethical approval under the guidelines of the host countries (Brazil and UK)

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

 

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ELECTROLYTE IMBALANCES IN NURSING HOME RESIDENTS: A REVIEW OF PREVALENCE, MANAGEMENT AND CONSIDERATIONS

 

L. Pickenhan1, C. Rungg1, N. Schiefermeier-Mach1

 

1. FH Gesundheit, Department of Healthcare and Nursing, Innsbruck, Austria. Corresponding author: Dr. Natalia Schiefermeier-Mach, Deputy Scientific Director, PI, FH Gesundheit, Innrain 98, A-6020 Innsbruck, Austria, Tel. +43 512 5322 75482, Fax +43 512 5322 75200, natalia.schiefermeier-mach@fhg-tirol.ac.at

Jour Nursing Home Res 2020;6:14-19
Published online May 13, 2020, http://dx.doi.org/10.14283/jnhrs.2020.3

 


Abstract

Background: Electrolyte imbalances strongly impact on morbidity and mortality rate in elderly adults. In particular, residents of long-term care facilities may develop life-threatening conditions as a result of altered serum electrolyte concentration. European nursing homes have restricted availability of general practitioner, therefore the role of nurses in medical care, prevention practices, early symptoms identification and communication with physicians is indispensable. Many of the risk factors associated with electrolyte imbalances are modifiable or preventable and have to be adequately recognized and managed by health professionals in nursing home settings. Objective: The aim of this review is to discuss prevalence and management of electrolyte imbalances in long-term care facilities with focus on nursing homes. Design: Narrative literature review. Methods: Search was performed in MEDLINE/PubMed and CINAHL databases. Key search terms associated with electrolyte imbalances including hyper- and hypo-states of sodium, potassium and magnesium were utilized in the subject search in combination with nursing homes, long-term care and older adults. Results and Conclusions: Published research studies reported higher prevalence of electrolyte imbalances and related mortality rate in nursing home residents when compared to older community adults. Serum sodium imbalances, hyponatremia and hypernatremia, were the most commonly identified. High incidence was also documented for hypomagnesemia and associated hypokalemia. Risk factors strongly associated with electrolyte imbalances included nursing home resident’s dietary/ hydration status, presence of comorbidities and type of prescribed medications. In this review we also summarise early signs of electrolyte imbalances and assessments that can be performed locally by nursing personnel. Strengthening awareness for electrolyte imbalances is an important quality-improvement effort from the perspective of nursing home residents and their families that might lower unnecessary hospital transfers, EI complication rates and residents’ mortality.

Key words: Nursing homes, fluid and electrolyte balance, long-term care.


 

Introduction

The European population aged 65 years and older has grown from 10% in 1960 to 19% in 2015 and is expected to further increase (1). This remarkable rise is predicted to be a significant driver for the expansion for long-term care (LTC) and care in nursing homes (NHs). According to European Health Information Gateway, numbers of nursing and elderly home beds in EU account for more than 3 million with the highest numbers in Germany (902.882 beds) and in France (642.168 beds) (2). NH residents are often in a weak health condition, have multiple co-morbidities and strong cognitive impairments and therefore are repeatedly admitted into the hospital (3). Higher incidence of acute hospital admissions among NH residents versus community dwellers has been reported (4). However, a systematic review by Arendts and Howard (5) showed that 40% of NH residents after being transferred to an emergency department were sent back to the NH without admission to hospital. Other published data on avoidable hospital admissions varies from 1.6% to 77% in different countries and settings (6), an Austrian study performed in 2015, reported a 22% rate of avoidable NH-to-hospital transfers (7, 8). Fluid and electrolyte imbalances (EI) are among health conditions that can be often prevented and to some extend managed locally at the NH. It has been previously acknowledged that prevention of electrolyte disorders in LTC facilities decreases unnecessary rehospitalisation rates (9–11).
In NHs, prevention of electrolyte imbalances goes hand in hand with prevention of other nonspecific complications such as malnutrition, dehydration, depression, cognitive decline or falls. However, there exist important nursing considerations that are explicit to the EI management. The aim of this review is to discuss the EI specificities, prevention, monitoring and perspectives in long-term care facilities with focus on NHs.

 

Specificities of Electrolyte Imbalances in Nursing Home Residents

Prevalence

Fluid and electrolyte imbalances have strong impact on morbidity and mortality rates in older adults. Hypo- as well as hyper states of sodium and potassium are often forms of EI, whereas other electrolyte disorders are less abundant (12, 13). Older people with diagnosed EI repeatedly attend the emergency department, exhibit increased hospitalization and a higher admission rate to NHs (14–17).
Decreased serum sodium, hyponatremia, is the most common EI in hospitalized patients (18) that is associated with high morbidity and mortality (19) and is particularly frequent in the institutionalized older adults (15). Choudhury and co-authors examined NH and older community residents with diagnosed hyponatremia during hospitalization and analyzed risk factors for adverse outcome of this EI. It was found that NH residents were 43-fold more likely to be hospitalized with hyponatremia (Na <135mmol/L) and 16-fold more likely to be admitted with serum Na <125mmol/L than older community patients (14). Miller et al. reported 18% prevalence of hyponatremia among NH residents, whereas solely a prevalence of 8% was recorded in the age-matched ambulant population. The incidence in this study for hyponatremia in NH residents was detected with 53% (20).
Hypernatremia (Na>145mmol/L) is another common EI associated with a high mortality rate (21, 22). In most cases increased serum sodium reflects total body water loss (23–25). In NH residents, hypernatremia is considered avoidable as it goes hand in hand with the prevention of dehydration. Despite this, dehydration was shown as a common reason of admission to hospital in NH residents (26, 27). Wolff et al. collected data from 21.610 emergency patients older than 65 years and determined a 10-fold higher prevalence of hypernatremia (Na>145mmol/L) in patients admitted from NHs compared to those living at their private homes. These NH patients were dehydrated at admission to the hospital and, as a result, appear to be at a significantly greater risk of in-hospital mortality (28).
High serum potassium, hyperkalemia (K>5.0 mmol/L), is a life-threatening electrolyte disorder that can lead to arrhythmias and sudden cardiopulmonary arrest (29). Previous studies in older adults with chronic kidney disease showed up to 50% incidence of hyperkalemia (30). However, no prevalence of hyperkalemia was directly acquired in NH residents so far and this disorder is mainly discussed in association with chronic kidney impairment and RAAS-targeting medications (renin-angiotensin-aldesterone system) (31). Hypokalemia (K<3.5 mmol/L) is occasionally seen in elderly patients and is often attributed to decreased potassium intake, loss through the gastrointestinal tract or urinary loss as a side effect of diuretic medication (21, 32, 33).
Hypokalemia is often associated with hypomagnesemia and hypocalcemia (34). Hypomagnesemia (Mg< 0.66 mmol/L) does not lead to clinically important symptoms until serum levels fall below 0.5 mmol/L. Life-threatening complications of hypomagnesemia arise when associated with hypostates of other electrolytes, such as calcium, phosphorus and potassium (35). The hypomagnesemia was found in 36% of the LTC patients; and amongst them 18% had severe hypomagnesemia (36). The same study found strong association between hypomagnesemia, hypokalemia, hypophosphatemia and hypokalemia and also increased mortality rates in EI-affected residents (36).

Dietary and hydration status

Dehydration and malnutrition were often reported in older adults (24, 37). Thirst response, taste sensation, appetite and food consumption decline with increasing age. Older people are less hungry, consume a smaller amount of meals, eat more slowly, have fewer snacks between meals and become satiated more rapidly after meals. NH residents may not like the offered food due to visual appearance, lack of variety or the inability to address individual food preferences (13). It was suggested that also social factors and psychological stress contribute to malnutrition and decreased fluid intake (38).
Dehydration is acknowledged as a frequently occurring issue among NH residents (39). Dehydration was also reported as one of the most common reasons for emergency hospitalization of NH residents (40). Impairments of mental health, such as dementia, can also affect the sense of thirst resulting in an insufficient liquid supply. A further contributing factor is the immobility to independently gain access to drinks (24). Even with adequate drinking, fluid volume deficits may result from polyuria related to chronical diseases like kidney failure or diabetes (41). Additionally to the abovementioned factors, NH residents may fail to obtain enough liquids as they are depended on water supply and the support in drinking by nursing personnel (28, 42). Contributing psychological factors like a new living situation or shame and fear to express intimate needs may lead to dehydration (40). Several excellent reviews describe the essential importance of drinking and eating especially for older adults and NH residents and thus addressing the complex and challenging matter for nurses to ensure the aforementioned (38, 43).

Multimorbidity

The prevalence of multimorbidity in NH residents was shown to reach up to 82% (44). The presence of multimorbidity strongly increases the risk to develop EI (45, 46). Clearly, acute and chronic kidney diseases lead to imbalances of all body electrolytes (24, 47). Diabetes mellitus was shown to be associated with hyponatremia and hypomagnesemia (48). Both hypertension and hypotension are strong risk factors for development of EIs. Chronic hypertension was identified as a significant risk factor for hypokalemia and hyponatremia (47, 48). Hypertension itself may also be not a cause, albeit a consequence of hypernatremia, hypercalcemia and hypomagnesaemia (49).The syndrome of inadequate antidiuretic hormone secretion is strongly associated with hyponatremia in the older population (24). Serious hypernatremia and hypomagnesemia may also be a result of an increased loss of water in course of acute infections, emesis or diarrhea (50). Among other important factors, swallowing difficulty (dysphagia), dental problems, alcohol abuse, impaired mental cognition (for example dementia), should alert nurses as these conditions are associated with an increased risk of developing EIs and dehydration (51). Another recurrent problem, urine and bowel incontinence, is a common condition in NH residents and a significant health problem. The prevalence of incontinence worldwide is ranging from 3% to 17% with a high rate of unrecorded cases (52). Frequently going to the toilet, particularly at night, can result in a heavy burden for older NH residents. Feelings of shame or anxiety can lead, consciously or unconsciously, to little or no drinking in order to reduce incontinence and toilet use. As a consequence this may lead to dehydration and sodium imbalance (16, 38).

Polypharmacy

NH residents with chronical diseases receive multiple medications. It was shown that more than 70% of NH residents from eight European countries obtain five or more medications regularly (53). Many medications commonly used in NHs may cause strong EIs: diuretic drugs, medicaments against cardiovascular diseases, analgesics, non-steroidal anti-inflammatory drugs, laxatives and antidepressants were shown to cause EIs (48, 54). It was revealed that administration of psychotropic drugs (phenothiazines, butyrophenones, benzodiazepines, tricyclics, serotonin-reuptake inhibitors), anti-epileptic drugs (carbamazepine, oxcarbazepine), anti-cancer drugs (prostaglandin-synthesis inhibitors, cyclophosphamide), opiate derivatives, thiazide diuretics and desmopressin are associated with hyponatremia, whereas lithium, vasopressin V2 receptor antagonists, loop diuretics and mannitol may induce hypernatremia (55). Thiazide and loop diuretics were also linked to hypokalemia as well as hypomagnesemia (48). Medications to treat hypertension (angiotensin converting enzyme inhibitors, renin inhibitors, angiotensin receptor blockers), heparin and nonsteroidal anti-inflammatory drugs were shown to interfere with urinary excretion of potassium (55).

Management of Electrolyte Imbalances in Nursing Homes

In many European countries, NHs are not required to employ GP and are not equipped with diagnostic and therapeutic resources (7, 8, 56). In Norway for instance, roles or duties of physician in NH are not specified in legal protocols and they are not obliged to provide medical service at all times (57). In Germany and Austria, NH residents can choose their physician freely but the availability of GP is often limited (8, 57, 58). Only 25% of German NHs were reported to have a contract with GP and accessibility of physician outside working hours is not organized (57). Thus, nursing personnel is solely responsible for residents’ care, prevention practices, early symptoms identification and communication with physician. Current EI management and perspectives in the NH setting are summarized in Figure 1 and discussed below.

Figure 1
Prevention and early detection of electrolyte imbalances. Risk assessment categories, additional tests currently available at NH, perspectives and outcome of EI management are illustrated

EI – electrolyte imbalance, NH – nursing home, BIA – bioelectrical impedance analysis, DRAC – Dehydration Risk Appraisal Checklist, MNA – Mini Nutritional Assessment, RAI-MDB – Resident Assessment Instrument RAI-MDB

 

Initial Management

A new admission into a NH is the essential moment to review and document resident’s medical history. In case of unclear documentation and/or cognitive impairment of residents, it is important to contact the family and GP. Medical history records have to include questions about chronic diseases, injuries, use and dosage of specific medication received up to the day of NH admission. In some cases existing prescription of medication might be reconsidered to decrease strong side effects and optimize the NH resident’s quality of life (59). Thorough analysis of NH resident medical history and protocol of current health status will not only support the estimation of a given risk for EI, but also in many cases help nurses to prevent potential future problems.
In clinical practice, it is recommended to regularly monitor serum electrolytes in diseased and older adults. Laboratory tests are performed in hospital settings or are prescribed by GP. However, diagnostic options, medical care and availability of GP at NHs vary among different countries and even within one county. Therefore, it should be recommended to perform blood/urine biochemical testing short after NH admission and also plan future monitoring schedules.

Monitoring and Prevention Practices

Regular practices should be applied locally in the NH settings in order to avoid unnecessary stress of hospital transfer. Moreover, NH nurses cannot rely on one-time procedure/test, but instead they should have the possibility to perform electrolyte EI checks at a regular basis in order to monitor changes. Thus, compared to hospital settings, the system of EI management in NHs may be absent or not clearly stated.
Nursing considerations in EI management include recognition of multiple factors, in case of noticed abnormalities interaction with/report to GP is obligatory:
• Assessment of hydration and nutrition status
dehydration and malnutrition can be prevented and to some extend improved by nursing stuff, assessment and monitoring can be performed in NH
assessment includes monitoring of food and fluid intake/output, body weight measurements, checking vital signs as well as skin, mouth and eye assessments, blood pressure and pulse rate, capillary and foot vein refill, and analysis of urine colour and volume (43);
hydration status can be also assessed by bioelectrical impedance analysis (BIA) and checklists /assessment tools such as Dehydration Risk Appraisal Checklist (DRAC) (60), The Mini Nutritional Assessment (MNA) (61) or as a part of more general assessment tools, for instance Resident Assessment Instrument RAI-MDB (62)
assessment can be performed monthly/weekly or more often according to the GP prescription for the high risk residents;

• Clinical signs and symptoms of dehydration
checking of dehydration clinical signs and symptoms can be performed in NH (see above); clinical signs include dryness of tongue, oral mucosa and/or lips, decreased saliva, dryness of skin and loss of elasticity, hypotonia of ocular globes, changes in urine including low volume, dark colour, increased pulse rate, low blood pressure, increasing confusion, lethargy, agitation or headache.

• Monitoring of kidney function
additional to weight/fluid monitoring, renal function laboratory values should be checked annually, interaction with GP is required for monitoring schedules and prescription

• Cardiovascular symptoms
blood pressure, pulse and heart rhythm measurements can be performed in NH

• Vital signs and neurological assessment
regular monitoring of vital signs can be performed in NH, nurses should be educated also about neurological signs of EIs and encouraged to check recurrently for warning signs

Education and Training

Since the capacity of NHs to manage EIs can be limited due to the absence of diagnostic equipment and lack of GP professional input, the role of nurses becomes indispensable (7,8,56). Nurses are often responsible for the decision-making of resident transfer to hospital. Previous studies showed that registered nurses (RNs) and to some extend assistant nurses (ANs) possess a high degree of self-responsibility in ensuring NH medical care and hospital transfer (63).
Insufficient geriatric knowledge of nurses results in difficulties in early sign interpretation and delays in symptom recognition. A critical review of nursing staff education showed a strong need to improve training in NH settings (64, 65). It has been documented that the professional knowledge of fluid and electrolyte balance amongst nurses is insufficient (66, 67). There is a major gap in the way EIs are managed (68) and nursing staff fail to appreciate the susceptibility of NH residents with electrolyte abnormalities to poor health outcomes (69). Our preliminary data from a survey performed among Austrian NH staff (RNs and ANs) revealed that 86% of nurses described their knowledge about body electrolytes as “insufficient” and 93% of participants have high interest in further professional training to this topic (our unpublished data).
Under these circumstances, prevention and early detection become crucial. As long as there is no legal obligation to organize regular presence of physician, more emphasis should be given on educational initiatives for NH nurses. Training courses should include information and advice relating the risk factors for EIs, drinking and dietary principles as well as possible complications. Nurses also need decision-support tools, strong interprofessional communication skills and possibility to contact GP at any time. Residents with re-occurring EI or recognized high risk to develop the latter should undergo regular assessments, which are preferably performed within the NH. Availability of point-of-care testing could provide a good opportunity for consistent electrolyte monitoring. Consequently, revision of the dietary plan and drinking protocols should be addressed. It is important not only to monitor for symptomatic improvement or signs of deterioration but also to track the rate of correction. It may also be suggested to establish robust outcome measures to assess the EI management within NH including hospital transfer rates, complication rates, residents’ mortality and costs calculation.

 

Conclusions and Perspectives

Older residents of NH are at high risk to develop EIs. Compared to hospital settings, EI prevention and management in NH is the responsibility of nursing personal. Regular assessments performed locally in NH, additional educational and training initiatives for nursing personnel and improved interprofessional communication are strongly suggested to ensure good quality of long-term care in NH settings.

 

Methods, Data Sources: Search was performed in MEDLINE/PubMed and CINAHL databases. Key search terms associated with electrolyte imbalances including hyper- and hypo-states of sodium, potassium and magnesium were utilized in the subject search in combination with nursing homes, long-term care and older adults. The full texts of research papers were reviewed prior to their inclusion according to the Strobe guidelines.

Conflict of Interest Disclosure: All participating authors declare no conflict of interest

Acknowledgment: We want to thank Dr. Sandra Schaffenrath for writing assistance, language editing, and proofreading of the manuscript.

 

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DERMATOLOGICAL CONSULTATIONS IN A NURSING HOME

 

M.S. Klapwijk1,3, S.T.P. Kouwenhoven2, W.P. Achterberg1, M.H. Vermeer4

 

1. Department of Public Health and Primary Care, Leiden University Medical Center, the Netherlands; 2. Mohs Klinieken, Dordrecht, the Netherlands; 3. Marente, Leiden, the Netherlands; 4. Department of Dermatology, Leiden University Medical Center, the Netherlands. Corresponding author: Maartje S. Klapwijk, Leiden University Medical Center, Department of Public Health and Primary Care, P.O. Box 9600, 2300 RC Leiden, the Netherlands, E-mail: m.s.klapwijk@lumc.nl, Telephone number: +31715268444

Jour Nursing Home Res 2019;5:56-59
Published online October 1, 2019, http://dx.doi.org/10.14283/jnhrs.2019.10

 


Abstract

Abstract: Skin diseases are predominantly non-lethal, but can have a significant impact on quality of life in older people living in a nursing home. This short report shows the results of consultations of a dermatologist visiting people in a nursing home. The frequency of the visits was 3-4 times a year, from June 2013 to December 2016. This is the description of all consultations of fifty residents, seen during eleven visits, 53 treatment plans were made. Sixty percent of consults were on suspected oncological conditions and treatment decisions were often more reticent due to impairment in mobility, life expectancy and comorbidities. The model (visiting dermatologist in nursing home) was evaluated as very valuable complementary care alongside normal dermatological care provided by the physician in the nursing home and the possibility of telemedicine. This type of palliative dermatological care in cooperation between a hospital and a nursing home is worth being studied.

Key words: Dermatological care, long-term care, dementia care, nursing home medicine, palliative care.


 

 

Introduction

Increasing age is associated with several dermatological problems (1). Even though skin diseases are predominantly non-lethal, they can have a significant impact on the quality of life in older persons. The different needs for older adults with dermatological problems have to be addressed (2, 3), also for those who are residing in a nursing home (4). The dermatological care of this specific group demands a type of care that might differ from (inter)national guidelines due to an impaired life expectancy, comorbidities and extensive functional impairments. Many nursing home residents are unable or unwilling to visit a hospital or outpatient dermatology clinic because of these impairments. Furthermore, only a minority of dermatologists visit patients in a nursing home, barriers found were lack of time and/or financial compensation (5).
This study explored whether regular site visits by a dermatologist to a nursing home facility, sometimes in combination with a short visit of the patient to the outpatient clinic, could provide a time and cost-effective dermatological care model for this vulnerable group. This short report evaluates the experiences of this three-year project. In particular, it describes the dermatological conditions that were diagnosed and what treatment options had been chosen, and with what results.

 

Methods

We describe demographics, diagnosis, method of treatment and follow-up of dermatological consultations in a 180-residents nursing home from June 2013 to December 2016.
The nursing home had six different wards for 30 patients each; one for geriatric rehabilitation, two for chronically ill people, two for people with dementia and one for gerontopsychiatric care.
All the residents received medical care by an elderly care physician that gave geriatric care medical care, including routine dermatological care (6).
A dermatologist from a nearby hospital visited the nursing home 3 to 4 times a year to see all residents that needed consultation together with one of the nursing home’s physicians. This physician decided who needed consultation and all patients were consulted in their own room with one of the nurses from the ward present.
In the large majority of the cases (n=41) the dermatological diagnosis was made by the dermatologist based on the clinical presentation. In 12 cases biopsies were made. Depending on comorbidities, mobility, medication, treatment wishes (resident/relative) and life expectancy, a treatment plan was made jointly by the dermatologist and the elderly care physician in consultation with resident and relatives. All diagnoses were subdivided in oncology, inflammatory or other. The clinical data that were used for this study were routine care data, and were anonymously placed in a separate file for evaluation purposes. Therefore, no ethical approval was needed. Demographic statistics were calculated using SPSS, version 24.

 

Results

From April 2013 to December 2016, 50 residents were visited by a dermatologist, an elderly care physician and nurse during eleven moments of consultations in one nursing home. In total, 53 visits were made to eleven male patients and 39 female patients, two males and one female had two different consultations. The mean patient age was 86 years, see table 1. The distribution of consulted patients was as follows; ten visits to people on the dementia special care unit, 28 visits to people on the units for chronically ill people, five visits to people admitted to the geriatric rehabilitation unit and ten visits to people admitted to the gerontopsychiatric unit. The reason for admittance to the nursing home varied from dementia, cardiovascular diseases, neurological disorders, diseases of the musculoskeletal system to other less common comorbidities. The total number of people that was diagnosed with dementia in the entire group was 21.

Table 1
Baseline characteristics of the study population, 53 consultations in the nursing home (50 residents)

SD=Standard deviation

 

At least 37 patients (70%) were bedridden and/or wheelchair bound and were dependent on other parties (e.g. ambulance, wheelchair taxi service) than family, friends or relatives to visit a hospital or outpatient clinic.
The dermatologist was most frequently consulted for suspected oncological conditions, including pre-malignancies (n=32, 60%). Fourteen cases of actinic keratosis and five M. Bowen were diagnosed. Three of the M. Bowens cases were treated with excision, while all of the actinic keratosis cases were treated with cryotherapy at the moment of consultation. Basal cell carcinoma (BCC) was found seven times. Two BCC were radically excised with adequate free tumour margins, while five cases were not treated after consultation between elderly care physician, dermatologist, patient and/or family. All of the four squamous cell carcinomas (SCC), that were initially diagnosed clinically, were treated with surgical excision in a single visit to the hospital. The diagnosis was histologically confirmed in all of the excised tumours. Two of the clinically extensive SCC’s were excised irradically. In both cases this was to be expected, due to extensive growth and clinically immobile in relation to the underlying tissue, see figure 1.

Figure 1
Example of one of the residents with an SCC before and after excision. Wound closure with a full thickness skin graft

(We have permission for publication from the relative)

 

Two tumours that were excised under suspicion of a BCC appeared to be cases of actinic keratosis, meaning that, retrospectively, these patients were overtreated. Benign skin abnormalities, classified as other diagnoses, were found in four patients (8%). Two of these lesions (e.g. seborrheic keratosis) were treated with cryotherapy at the time of the consultation, because the patients appeared to scratch or traumatise the lesions and wanted these to be treated.
Seventeen of the consultations concerned a heterogeneous group of inflammatory dermatoses, see table 1.
There were no surgical complications. The only registered complications occurred after cryotherapy and consisted of blistering (two cases) and superficial infection (one case) that was treated effectively with topical antibiotics.
One year after the last consultation 15 of the 50 consulted patients were still alive. None of the 35 deceased patients passed away as a result of the dermatological condition or related complications.

 

Discussion

The burden of dermatological diseases in the aging population is rising. This is, to our knowledge, the first study to describe the dermatological consultation in a large group of residents living in a nursing home. The strategy of dermatologic consultations in a frequency of three or four times a year in local nursing homes to treat a variety of (pre-)malignancies and inflammatory skin diseases seems to be a feasible way to provide population-specific care for the often immobile, nursing home resident. The majority of the consultations were about (pre-)malignancies. This type of population-specific healthcare, divergent from guidelines or protocols, led to a good disease free survival and an ignorable risk of complications. Only the treatment of malignancies that were thought to cause significant harm like pain or ulceration and infection (like the example), required a single visit to the hospital.
One frequently used option in the Netherlands, also in nursing homes, is teledermatological care, when question and picture(s) are sent to a dermatologist using a store and forward (SAF) technique, with a safe online connection (7, 8). We believe that the consultation care model is valuable next to the teledermatological care. Sometimes consultation by a dermatologist is necessary due to non-responsiveness of the initiated treatment, uncertainty about the diagnosis via a picture, or treatment that requires specific dermatological skills, for instance in case of a suspected malignancy. Interestingly, there were no consultations regarding pressure sores, which may be related to the quality of prevention and management present in the nursing home.
In the regular setting in the dermatology department, patients are referred to the outpatient clinic for a visit. A skin biopsy is performed for histology for diagnosis or – in the event of a clinically evident malignancy – to determine the feasible treatment, depending on the growth pattern or subtype. The diagnosis and treatment options are given a week later and subsequently a treatment plan is offered that often includes surgical excision. In other cases, a malignancy is excluded on clinical grounds and the patient can be reassured. This practice conforms to national and international guidelines (9).
The model (visiting dermatologist in the nursing home) was evaluated as very valuable complementary care alongside the regular dermatological care provided by the physician in the nursing home and the possibility of telemedicine, as already suggested by Lubeek and colleagues (10, 11). The point of view and opinion on possible treatment options of the patient and his/her family/caretaker needs to be respected and, preferably, be clear before the consultation. Five out of seven basal cell carcinomas were left completely untreated with informed consent following communication between elderly care physician, dermatologist, patient and family. However, we also found two cases of potential overtreatment in two residents with visual suspicion of a BCC, which histologically appeared to be actinic keratosis.
Our results show the potential and need for tailored dermatological care, in a cooperation model between hospitals and long-term care facilities.
We believe this type of dermatological care can help residents in nursing homes to obtain a quick diagnose and treatment plan without extra visits to the hospital. This kind of dermatological care in the nursing home should be further studied, also regarding the feasibility of organization and cost-effectiveness.

 

Conclusions and Implications

This type of (palliative) dermatological care in cooperation between a hospital and a nursing home can be very valuable for older adults in nursing homes and is worth being studied in order to be organized on a structural basis.

 

Conflict of interest: All the authors declare that there are no conflicts of interest. The work presented here has not been published elsewhere.

Funding: This research did not receive any funding.

 

References

1.    Chang AL, Wong JW, Endo JO, Norman RA: Geriatric dermatology review: Major changes in skin function in older patients and their contribution to common clinical challenges. Journal of the American Medical Directors Association 2013, 14(10):724-730.
2.    Linos E, Chren MM, Covinsky K: Geriatric Dermatology-A Framework for Caring for Older Patients With Skin Disease. JAMA dermatology 2018.
3.    Garcovich S, Colloca G, Sollena P, Andrea B, Balducci L, Cho WC, Bernabei R, Peris K: Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology. Aging and disease 2017, 8(5):643-661.
4.    Lubeek SF, van der Geer ER, van Gelder MM, Koopmans RT, van de Kerkhof PC, Gerritsen MJ: Current Dermatologic Care in Dutch Nursing Homes and Possible Improvements: A Nationwide Survey. Journal of the American Medical Directors Association 2015, 16(8):714.e711-716.
5.    Lubeek SF, Van Der Geer ER, Van Gelder MM, Van De Kerkhof PC, Gerritsen MJ: Dermatologic care of institutionalized elderly patients: a survey among dermatologists in the Netherlands. European journal of dermatology : EJD 2015, 25(6):606-612.
6.    Koopmans RT, Lavrijsen JC, Hoek JF, Went PB, Schols JM: Dutch elderly care physician: a new generation of nursing home physician specialists. Journal of the American Geriatrics Society 2010, 58(9):1807-1809.
7.    Lubeek SF, Mommers RJ, van der Geer ER, van de Kerkhof PC, Gerritsen MJ: [Teledermatology within Dutch nursing homes]. Tijdschrift voor gerontologie en geriatrie 2016, 47(3):117-123.
8.    Trettel A, Eissing L, Augustin M: Telemedicine in dermatology: findings and experiences worldwide – a systematic literature review. Journal of the European Academy of Dermatology and Venereology : JEADV 2018, 32(2):215-224.
9.    Kim JYS, Kozlow JH, Mittal B, Moyer J, Olencki T, Rodgers P: Guidelines of care for the management of basal cell carcinoma. Journal of the American Academy of Dermatology 2018, 78(3):540-559.
10.    Lubeek SF, van der Geer ER, van Gelder MM, van de Kerkhof PC, Gerritsen MJ: Improving Dermatological Care for Elderly People Living in Permanent Healthcare Institutions: Suggestions from Dutch Dermatologists. Acta dermato-venereologica 2016, 96(2):253-254.
11.    Lubeek SF, van Gelder MM, van der Geer ER, van de Kerkhof PC, Gerritsen MJ: Skin cancer care in institutionalized elderly in the Netherlands: a nationwide study on the role of nursing home physicians. Journal of the European Academy of Dermatology and Venereology : JEADV 2016, 30(12):e236-e237.

EVALUATING THE IMPACT OF SAFE PATIENT HANDLING AND MOVEMENT LAWS ON NURSING HOME WORKER INJURIES

 

B.M. Jesdale1, S.A. Chrysanthopoulou1,2, C.E. Dubé1, Kate L. Lapane1

 

1. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; 2. Department of Statistics, Center for Statistical Sciences, Brown University, Schoolf of Public Health.  Corresponding author: Kate L. Lapane, Albert Sherman Center 6th floor, Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester MA 01655, USA, Email: Kate.Lapane@umassmed.edu, Phone: 508-856-8965, Fax: 508-856-8993

Jour Nursing Home Res 2018;4:36-41
Published online November 14, 2018, http://dx.doi.org/10.14283/jnhrs.2018.8

 


Abstract

Objectives: We estimated the impact of safe patient handling legislative efforts to reduce nursing home worker injuries, and examined potential impacts among specific nursing home types. Design: Difference-in-difference analysis. Setting: 2,034 nursing homes in 8 states enacting safe patient handling and movement legislation from 2004 to 2007 and 5,901 nursing homes in 36 comparator states. Measures: Reductions in reported work-related injuries and illnesses resulting in Days Away from work, Restricted job activities, or Transfer (DART) rates per 100 full time equivalents (FTE’s). Facility characteristics included size, profit orientation, chain membership, nursing staffing measures, and location (urbanicity). Results: Among nursing homes in 8 states that enacted legislation, there was a 23.5% decrease in mean DART rate from 7.53 per 100 FTE’s in the pre-enactment period (2002-2003) to 5.76 per 100 FTE’s in the post-enactment period (2008-2010) whereas in 36 comparator states, there was a 24.4% decrease in the mean DART rate, from 8.54 to 6.46 per 100 FTE’s. After adjustment for nursing home and aggregated resident characteristics, a difference-in-difference model showed that DART rates were similar in states with and without legislation (adjusted estimate: 1.03; 95% confidence interval: 0.96 to 1.11), with estimates similar across a range of nursing homes characteristics. Conclusions: The promise of enacting safe patient handling and movement legislation to reduce nursing home worker injuries has yet to be realized. In a context of rapidly declining injury rates, substantial financial incentives, other forms of assistance, and/or enforcement activities may be needed to improve the effectiveness of legislative initiatives.

Key words: Nursing homes, long-term care, staff injuries, occupational health, regulation.


 

 

Introduction

Worker injury rates in nursing homes are among the highest among occupational sectors in the United States (1). Although worker training alone appears to have little impact (2), comprehensive interventions at the nursing home level to reduce the burden of nurse injuries have reduced not only staff injuries, but also lost workdays, and workers’ compensation costs (3-8). Training and hiring replacement staff has high costs (9) as does losing seasoned staff to preventable injuries (10).
Numerous states have enacted legislation designed to reduce worker injuries in the health care sector, including nursing homes. The content and extent of these legislative efforts varies widely, from the funding of demonstration projects (Ohio, 2004) (11), to aspirational statements (Hawaii, 2005) (12). We have described these legislative efforts in detail elsewhere (13).
Declines in nursing home worker injury rates in selected nursing homes located in Ohio (14, 15) and New York (16) were seen after implementation of Safe Patient Handling and Movement (SPHM) legislation. Statewide, compensable injury rates among workers in hospitals in Washington state declined, but not more so than in Idaho, a neighboring state with no SPHM enactment (17). In a nationwide analysis, injury rates among health care and social assistance workers declined in most, but not all, states enacting SPHM legislation in the year following implementation (18). Aside from the Washington study (17), none of these analyses accounted for rapidly declining trends in injury rates in unaffected states (19).
We sought to estimate the effect of state-level SPHM legislation on nursing home worker injury rates, accounting for declining worker injury rates in the nursing home sector nationwide, and adjusting for potential shifts in resident characteristics over time. Further, we investigated whether the apparent effect of SPHM legislation would differentially affect nursing homes according to pre-specified nursing home characteristics, namely: bed size, profit orientation, chain membership, nurse:bed ratio, staff mix (ratio of registered nurses to other nursing staff), and urbanicity.

 

Methods

This study was approved by the Institutional Review Board at our institution.

Data sources

Appendix 1 reviews the data sources considered for conducting this study. We included private sector nursing homes not affiliated with a hospital and in operation throughout the study period (2002-2010) with identifiable data from three sources: the Centers for Medicare and Medicaid Services Provider of Service (POS) annual files (addresses, hospital affiliation, profit orientation, chain membership, bed size, the number of staff full time equivalents (FTEs), and workforce composition), the Occupational Health and Safety Administration’s OSHA Data Initiative (ODI) (annual nursing home-level injury rates, addresses), and the Minimum Data Set (MDS) (annual distribution of resident-level characteristics). Urbanicity was assigned to nursing homes using a six-level urbanicity code developed by the National Center for Health Statistics (20).
The ODI contains establishment-level, work-related injury and illness rates reported by work establishments, including nursing homes from 1996 to 2011. Government-owned nursing homes were usually exempt from reporting requirements, as were nursing homes with fewer than 10 employees. Seven states were waived from ODI reporting requirements for two or more consecutive years during our study period (Alaska, Arizona, Oregon, South Carolina, Virginia, Washington, Wyoming), and are not included in our analyses.
Collected by federal mandate in all Medicare/Medicaid certified homes, the MDS is a standardized resident assessment instrument completed at admission, quarterly, annually, readmission, and when there is a significant change in clinical status. The MDS collects a wide range of clinical and functional data, including height and weight of residents, mobility status, and functional capacity. We calculated quarterly aggregates of resident characteristics using MDS version 2.0 (1/1/2002 to 9/30/2010), then averaged these quarterly aggregates to obtain annual descriptors of resident characteristics.

Sample

We identified 11,491 nursing homes using the POS files. See Supplementary Table 2 and Appendix 2 for details regarding the matching procedures of the data sources. Eligible nursing homes were those that were open throughout 2002-2010, not government-owned, not hospital affiliated, and located in one of the 43 states or the District of Columbia (DC) that collected ODI data. The ODI does not contain a unique identifier for nursing homes, but includes self-reported name, address, and industrial sector codes which were used to match 10,584 (92.6%) of the nursing homes above to ODI data for at least one year. Of all eligible nursing homes collecting ODI data, 11,425 (99.4%) were successfully merged with their resident data in the MDS. To be eligible, information on more than 9 residents for a nursing home was required for each study year. To reduce missing data, we further restricted our sample to 7,935 nursing homes with all of the following:  1) ODI data for at least one year in the period from 2000 to 2004 (before any state enacted SPHM legislation); 2) ODI data for at least one year in the period 2008-2011 (after all states had enacted SPHM legislation); and 3) no more than 5 consecutive years of missing ODI data in 2002-2010. Of otherwise eligible nursing homes 69.5% were excluded (see Supplementary Tables 3 and 4 for a comparison of excluded nursing homes to the otherwise eligible sample).

Exposure periods

Eight states with ODI injury rate reporting enacted SPHM legislation between 2004 and 2007 (Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island, Texas). No states had enacted SPHM legislation before this period, and no others enacted SPHM legislation directed towards nursing homes before 2010. We defined three periods for legislation enactment in the SPHM legislation states: a pre-enactment period from 2002 to 2003, an enactment period from 2004 to 2007, and a post-enactment period from 2008 to 2010.

Outcome assessment

ODI data are reported as the DART rate (reported work-related injuries or illnesses resulting in Days Away from work, Restriction of job activities, or Transfer to another position, per 100 FTE’s). In general, nursing homes were required to report injury and illness rates every three years, with nursing homes reporting a high injury rate usually required to report again the following year. Following previous literature (21-23), we treated DART rates higher than 50 per 100 FTE’s (0.08% of reported values) as likely outliers, and re-set these to missing.

Imputation of missing values

Among the 7,935 nursing homes included in the 9 years of the analysis, 74.4% of nursing home-years were populated with reported ODI data. A relatively low injury and illness rate in the previous year strongly predicted missing data; of those with an observed DART rate under 5.00 per 100 FTE’s, 51.1% had missing data in the following year, compared to only 13.9% of those with an observed DART rate of 5.00 per 100 FTE’s or higher. Missing data increased over time, from 8.9% in 2002 to 50.5% in 2010. State-level missing data varied from 11.8% of nursing home-years in Maine to 47.2% in the District of Columbia. Missing data were modestly associated with some nursing home-level characteristics (see Supplementary Table 5).
We used multiple imputation to estimate the natural logarithm of DART rates from 1996 to 2011, in which injury rates of 0 were replaced with ln(0.5) (post-imputation exponentiated values of 0.5 or lower were set to 0). To restrict DART rate imputations to plausible values, an upper limit of ln(100) (twice the cut-point for re-assigning a reported value to missing) was applied. Details regarding the imputation method are provided in the Supplementary Imputation Appendix 3.
The analysis and imputation unit is the nursing home. For the imputation we used 16 measured variables potentially related to DART rates and missingness, including the region of the country (10 Medicare regions), the urbanicity of the nursing home’s county (6 categories), profit orientation in 2002 and 2010 (2 categories at each time point), and chain membership in 2002 and 2010 (2 categories at each time point). We also included the mean values across the 9 years for the number of beds, staffing levels, and nursing home-level aggregates of resident characteristics, including resident age, weight, and proportions of residents with clinical, demographic, and care-related factors. We also included the mean values across the 9 years for number of beds, staffing levels, and nursing home-level aggregates of resident characteristics including resident age, weight, and proportions of residents with clinical, demographic, and care-related factors. We produced 50 imputed datasets using PROC MI in SAS, version 9.4 (SAS Institute, Inc., Cary, NC), using the fully conditional specification (FCS) method with 100 burn-in imputations.

Analytic strategy

We estimated the impact of SPHM legislation on nursing home-level DART rates using the Generalized Estimating Equations (GEE) method to fit a Poisson model including status (SPHM legislation state or not), the three exposure periods, and an interaction between these terms. The exponentiated coefficient of the interaction term comparing the post-enactment period to the pre-enactment period is interpreted as the difference between the average injury rate (per 100 FTE’s) observed in enactment states relative to what would be expected if the same temporal trend had been held as in comparator states; a ratio greater than 1 indicates a higher injury rate than expected, and a ratio between 0 and 1 indicates a lower injury rate than expected. We weighted observations by the total number of FTE’s among full and part time employees in the nursing home in each year. We also adjusted this analytic model with a subset of the variables included in the imputation model (see footnote in Table 3).
To estimate the effect of SPHM legislation within subgroups of nursing homes, we repeated the analyses above after nesting the main effects within pre-specified nursing home characteristics, namely: bed size (under 100 beds, 100-299 beds, 300+ beds), profit orientation (yes, no), chain membership (yes, no), nurse:bed ratio (0.05 to 0.50, 0.50 to 0.70, 0.70 to 2.51), ratio of registered nurses to other nursing staff (0.01 to 0.15, 0.15 to 0.25, 0.25 to 2.59), and urbanicity (large metropolitan areas of 1 million or higher population, medium or small metropolitan areas of 100,000 to 999,999 population, or micropolitan and rural areas). We compared our findings with a complete-case analysis (no imputed values).

Sub-analyses

We conducted sub-analyses to further investigate the impact of legislation under alternate specifications: 1) a “high contrast” comparison restricting the SPHM states to the four enacting the most comprehensive forms of legislation (Maryland, Minnesota, New Jersey, Rhode Island), and excluding three states that enacted SPHM legislation after our study period; 2) a comparison of 7 SPHM legislation states (excluding Hawaii) to 18 states neighboring at least one SPHM legislation state; and 3) an analysis using a naïve single imputation method (linear interpolation from 2002-2010, or carry last observation forward after the last observed DART rate).

 

Results

Nursing homes in the 8 states with safe patient handling and movement (SPHM) legislation differed from those in the 36 comparator states in several respects (Table 1). Nursing homes in the states that enacted SPHM legislation were more frequently large homes (11% vs. 2% with 300 or more beds), for-profit in orientation (66% vs. 73%), part of a chain (43% vs. 58%), or located in a central county, large metropolitan area (33% vs. 20%).

Table 1
Nursing Home Characteristics in 2002, by Safe Patient Handling and Movement (SPHM) Legislation Status

* Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island and Texas; † Percents are weighted by size of nursing home staff.

 

Table 2 shows that DART rates in SPHM legislation enacting-states declined from an average of 7.53 per 100 FTE’s in the pre-enactment period (2002-2003), to 6.50 per 100 FTE’s in the enactment period (2004-2007), and further to 5.76 per 100 FTE’s in the post-enactment period, an average drop of 1.77 work-related injuries and illnesses per 100 FTE’s. DART rates were, on average, higher in the comparator states, declining from 8.54 per 100 FTE’s in the pre-enactment period to 7.37 per 100 FTE’s in the enactment period to 6.46 per 100 FTE’s in the post-enactment period, an average drop of 2.08 per 100 FTE’s. Wide variation between homes is also apparent.

Table 2
Distribution of Injury and Illness Rates by Enactment Period and Safe Patient Handling and Movement (SPHM) Legislation Status

* DART rate: work-related injuries and illnesses resulting in Days Away from work, Restriction of job activities, or Transfer to another position, per 100 FTE’s per year. † Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island and Texas. ‡ Averages, medians, 25th and 75th percentiles are weighted by the staff size of the nursing homes. § During the pre-enactment period (2002-2003), no states had yet enacted SPHM legislation. All 8 SPHM states enacted  legislation between 2004 and 2007. No states enacted SPHM legislation during the post-enactment period (2008-2010)

 

Table 3 shows crude and adjusted estimates for the effect of enacting SPHM legislation on DART rates. In the unadjusted analysis, we estimate that DART rates were 6% higher in SPHM legislation-enacting states in the post-enactment period than they would have been had they followed the same secular trend as seen in comparator states [Rate Ratio (RR)=1.06, 95% Confidence Interval (CI): 0.93 to 1.20]. After adjustment for a wide range of static and time-varying nursing home and aggregated resident characteristics, our estimates were similar: DART rates were 3% higher than expected [RR=1.03, 95% CI: 0.96 to 1.11] . Table 3 also shows difference-in-difference estimates for various subsets of nursing homes. These subsets show similar patterns to those in the whole population of nursing homes studied, especially after adjustment.

Table 3
Difference in difference estimates for the impact of safe patient handling and movement (SPHM) legislation

* Ratio of work-related injury and illness rates during the post-enactment period (2008-2010) to the pre-enactment period (2002-2003) among SPHM states relative to the ratio during the post-enactment period to the pre-enactment period in states with no SPHM legislation. Pooled across 50 multiply imputed datasets, weighted by the staff size of the nursing homes, and with a generalized estimating equation specification (m-dependent correlation matrix) to account for repeated measures for each nursing home. 95% confidence intervals generated from model-based standard error estimates; † As above, and adjusted for state, year, urbanicity, calendar year, and the following time-varying covariates: profit orientation, chain membership, nursing home bed size, nurse:bed ratio, ratio of registered nurses to other nursing staff, mean resident weight, mean resident age, percent of residents with: severe activities of daily living limitations, require mechanical lifting, resist care and are not easily modified, have conflicted relationships with staff, restrained, loss of movement in one or both legs, had fallen in the previous 30 days and/or had a hip fracture in the previous 180 days, had dementia and/or Alzheimer’s, had bipolar depression, had a high grade (2-4) pressure ulcer, used antipsychotics in the previous week, and resident proportion Asian, proportion Black, and proportion Hispanic residents.

 

Complete-case (Supplementary Table 9) and sub-analyses resulted in similar results (see Supplementary Tables 7, 8, and 10); restricting the analysis to a “high contrast” comparison between 4 states that enacted comprehensive SPHM legislation and after excluding three states from the comparator group that enacted SPHM after our observation period (Supplementary Table 7); restricting the comparator group of states to those with at least one SPHM legislation-enacting neighbor (Supplementary Table 8); or using a naïve single imputation model (Supplementary Table 10).

 

Discussion

These findings were contrary to our expectation. We hypothesized that injury rates in SPHM legislation-enacting states would have declined more so than comparator states. Several alternate explanations for these findings should be considered. Publicity around the enactment of SPHM legislation may have increased the proportion of worker injuries and illnesses reported to employers, and/or have encouraged employers to more faithfully record reported worker injuries and illnesses. If this were the case, then a lower rate or proportion of serious injuries might be expected in the SPHM legislation-enacting states. Unfortunately, we did not have the data to evaluate this. Likewise, several states required nursing homes to enact written SPHM policies, which may have increased worker knowledge and use of reporting mechanisms increasing reported injuries which may have been previously unreported. We do not have specific evidence to support or refute these possibilities.
Another possibility arises from the nature of the SPHM legislation itself. In most cases, these state-wide enactments included no appropriations to assist nursing homes with enacting SPHM policies, purchasing lift equipment, or even to offset the paperwork burden of compliance with the new regulations. Furthermore, most included no compliance enforcement provisions (13). Although our analysis of states enacting more comprehensive legislation produced similar results to our overall findings, these legislative efforts may have fallen short of providing sufficient incentives or disincentives to motivate lasting, integrated, efforts to reduce worker injuries. Several studies have found that provision of lift equipment alone or provision of worker training alone fail to produce a lasting impact on worker injury rates. A multicomponent approach to reducing worker injuries appears to be required within individual nursing homes or hospitals  (3, 6, 8, 24, 25) and within an entire healthcare delivery system (26).
While convincing evidence of efficacy exists for the impact of legislative actions to generate change in nursing homes in some settings (27, 28) it is not unusual for efforts to assess legislative efficacy to fail to document substantive change (29). For example, state-level restrictions on feeding tube use in severely cognitively impaired residents appear to have a small impact on preventing their use (30, 31) while legislation designed to increase staffing by qualified social workers has largely been circumvented, failing to produce improvements in quality of care (32), and legislation to improve overtime payments for nurses appears to paradoxically have reduced care quality by encouraging nursing homes to substitute contract workers for experienced staff (33). The extent of state efforts to enforce legislation appears to have a sizeable impact on the efficacy of the legislation as well (34), as does the infrastructure capacity of legislative bodies themselves (35). It is also possible that the legislative enactments intended to reduce worker injuries that were included in our analysis were not sufficiently enforced to produce marked reductions.
Finally, these legislative efforts occurred during a period of rapidly declining worker injury rates, both in nursing homes (19), and in the nation’s workplaces as a whole (36). Overlapping legislative efforts, shifts in worker compensation systems, and a growing focus on occupational injuries in general (37, 38) may have affected nursing homes in states that did not enact SPHM legislation during this time period.

 

Conclusion

The promise of enacting safe patient handling and movement legislation to reduce nursing home worker injuries has yet to be realized. In a context of rapidly declining worker injuries nationwide, 36 states enacting SPHM legislation had somewhat slower declines in reported worker injury rates than comparator states. Furthermore, estimates for a range of nursing home subtypes failed to demonstrate markedly different responses. National or state-level legislation including substantial financial incentives, other forms of assistance, and/or enforcement activities may improve the efficacy of legislative initiatives. Wider enactment of these more comprehensive laws would be required to evaluate the potential for greater efficacy.

 

Acknowledgements: This study was funded by a grant from the National Institute For Occupational Safety And Health.

Conflict of Interest: None

Ethical Standard: Approval by the University Massachusetts Medicals School Institute at Review Board.

 

Appendix

 

References

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16.    Safe Patient Handling Workgroup, New York State Department of Health. Report to the Commissioner of Health. (undated). Accessed 31 May 2016. Available at: https://www.health.ny.gov/statistics/safe_patient_handling/docs/sph_report.pdf
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18.    Wrightson K, Lincoln T, Harley S, Sanoian B. Uplifting an Industry? State-Based Safe Patient Handling Laws Have Yielded Improvements But Are Not Adequately Protecting Health Care Workers. Washington, DC: Public Citizen’s Congress Watch, 2105. Accessed 31 May 2016. Available at: https://www.citizen.org/sites/default/files/part-three-state-health-care-worker-safety-laws-uplifting-industry.pdf
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28.    Teno JM, Branco KJ, Mor V et al. Changes in advance care planning in nursing homes before and after the Patient Self-Determination Act: report of a 10-state survey. J Am Geriatr Soc 1997;45:939-944.
29.    Wiener JM. An assessment of strategies for improving quality of care in nursing homes. Gerontologist 2003;43:19-27.
30.    Teno JM, Mor V, DeSilva D et al. Use of feeding tubes in nursing home residents with severe cognitive impairment. JAMA 2002;287:3211-3212.
31.    Ahronheim JC, Mulvihill M, Sieger C et al. State practice variations in the use of tube feeding for nursing home residents with severe cognitive impairment. J Am Geriatr Soc 2001 49:148-152.
32.    Bowblis JR, Smith AC. Occupational licensing of social services and nursing home quality: a regression discontinuity approach. Stanford, CA: Social Science Research Network, 2018. Accessed 1 Feb 2018. Available at: https://ssrn.com/abstract=3096268
33.    Lu SF, Lu LX. Do mandatory overtime laws improve quality? Staffing decisions and operational flexibility of nursing homes. Management Sci 2016;63:3566-3585.
34.    Bowblis JR, Crystal S, Intrator O, Lucas JA. Response to regulatory stringency: the case of antipsychotic medication use in nursing homes. Health Econ 2012;21:977-993.
35.    Boehmke FJ, Shipan CR. Oversight capabilities in the states: are professionalized legislatures better at getting what they want? State Politics Policy Q 2015;15:366-386.
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37.    Bhushan A, Leigh JP. National trends in occupational injuries before and after 1992 and predictors of workers’ compensation costs. Pub Health Rep 2011;126:625-634.
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EVALUATING THE IMPACT OF SAFE PATIENT HANDLING AND MOVEMENT LAWS ON NURSING HOME WORKER INJURIES

 

B.M. Jesdale1, S.A. Chrysanthopoulou1,2, C.E. Dubé1, Kate L. Lapane1

 

1. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; 2. Department of Statistics, Center for Statistical Sciences, Brown University, Schoolf of Public Health.  Corresponding author: Kate L. Lapane, Albert Sherman Center 6th floor, Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester MA 01655, USA, Email: Kate.Lapane@umassmed.edu, Phone: 508-856-8965, Fax: 508-856-8993

 

Jour Nursing Home Res 2018;4:36-41
Published online October 18, 2018, http://dx.doi.org/10.14283/jnhrs.2018.7

 


Abstract

Objectives: We estimated the impact of safe patient handling legislative efforts to reduce nursing home worker injuries, and examined potential impacts among specific nursing home types. Design: Difference-in-difference analysis. Setting: 2,034 nursing homes in 8 states enacting safe patient handling and movement legislation from 2004 to 2007 and 5,901 nursing homes in 36 comparator states. Measures: Reductions in reported work-related injuries and illnesses resulting in Days Away from work, Restricted job activities, or Transfer (DART) rates per 100 full time equivalents (FTE’s). Facility characteristics included size, profit orientation, chain membership, nursing staffing measures, and location (urbanicity). Results: Among nursing homes in 8 states that enacted legislation, there was a 23.5% decrease in mean DART rate from 7.53 per 100 FTE’s in the pre-enactment period (2002-2003) to 5.76 per 100 FTE’s in the post-enactment period (2008-2010) whereas in 36 comparator states, there was a 24.4% decrease in the mean DART rate, from 8.54 to 6.46 per 100 FTE’s. After adjustment for nursing home and aggregated resident characteristics, a difference-in-difference model showed that DART rates were similar in states with and without legislation (adjusted estimate: 1.03; 95% confidence interval: 0.96 to 1.11), with estimates similar across a range of nursing homes characteristics. Conclusions: The promise of enacting safe patient handling and movement legislation to reduce nursing home worker injuries has yet to be realized. In a context of rapidly declining injury rates, substantial financial incentives, other forms of assistance, and/or enforcement activities may be needed to improve the effectiveness of legislative initiatives.

Key words: Nursing homes, long-term care, staff injuries, occupational health, regulation.


 

 

Introduction

Worker injury rates in nursing homes are among the highest among occupational sectors in the United States (1). Although worker training alone appears to have little impact (2), comprehensive interventions at the nursing home level to reduce the burden of nurse injuries have reduced not only staff injuries, but also lost workdays, and workers’ compensation costs (3-8). Training and hiring replacement staff has high costs (9) as does losing seasoned staff to preventable injuries (10).
Numerous states have enacted legislation designed to reduce worker injuries in the health care sector, including nursing homes. The content and extent of these legislative efforts varies widely, from the funding of demonstration projects (Ohio, 2004) (11), to aspirational statements (Hawaii, 2005) (12). We have described these legislative efforts in detail elsewhere (13).
Declines in nursing home worker injury rates in selected nursing homes located in Ohio (14, 15) and New York (16) were seen after implementation of Safe Patient Handling and Movement (SPHM) legislation. Statewide, compensable injury rates among workers in hospitals in Washington state declined, but not more so than in Idaho, a neighboring state with no SPHM enactment (17). In a nationwide analysis, injury rates among health care and social assistance workers declined in most, but not all, states enacting SPHM legislation in the year following implementation (18). Aside from the Washington study (17), none of these analyses accounted for rapidly declining trends in injury rates in unaffected states (19).
We sought to estimate the effect of state-level SPHM legislation on nursing home worker injury rates, accounting for declining worker injury rates in the nursing home sector nationwide, and adjusting for potential shifts in resident characteristics over time. Further, we investigated whether the apparent effect of SPHM legislation would differentially affect nursing homes according to pre-specified nursing home characteristics, namely: bed size, profit orientation, chain membership, nurse:bed ratio, staff mix (ratio of registered nurses to other nursing staff), and urbanicity.

 

Methods

This study was approved by the Institutional Review Board at our institution.

Data sources

Appendix 1 reviews the data sources considered for conducting this study. We included private sector nursing homes not affiliated with a hospital and in operation throughout the study period (2002-2010) with identifiable data from three sources: the Centers for Medicare and Medicaid Services Provider of Service (POS) annual files (addresses, hospital affiliation, profit orientation, chain membership, bed size, the number of staff full time equivalents (FTEs), and workforce composition), the Occupational Health and Safety Administration’s OSHA Data Initiative (ODI) (annual nursing home-level injury rates, addresses), and the Minimum Data Set (MDS) (annual distribution of resident-level characteristics). Urbanicity was assigned to nursing homes using a six-level urbanicity code developed by the National Center for Health Statistics (20).
The ODI contains establishment-level, work-related injury and illness rates reported by work establishments, including nursing homes from 1996 to 2011. Government-owned nursing homes were usually exempt from reporting requirements, as were nursing homes with fewer than 10 employees. Seven states were waived from ODI reporting requirements for two or more consecutive years during our study period (Alaska, Arizona, Oregon, South Carolina, Virginia, Washington, Wyoming), and are not included in our analyses.
Collected by federal mandate in all Medicare/Medicaid certified homes, the MDS is a standardized resident assessment instrument completed at admission, quarterly, annually, readmission, and when there is a significant change in clinical status. The MDS collects a wide range of clinical and functional data, including height and weight of residents, mobility status, and functional capacity. We calculated quarterly aggregates of resident characteristics using MDS version 2.0 (1/1/2002 to 9/30/2010), then averaged these quarterly aggregates to obtain annual descriptors of resident characteristics.

Sample

We identified 11,491 nursing homes using the POS files. See Supplementary Table 2 and Appendix 2 for details regarding the matching procedures of the data sources. Eligible nursing homes were those that were open throughout 2002-2010, not government-owned, not hospital affiliated, and located in one of the 43 states or the District of Columbia (DC) that collected ODI data. The ODI does not contain a unique identifier for nursing homes, but includes self-reported name, address, and industrial sector codes which were used to match 10,584 (92.6%) of the nursing homes above to ODI data for at least one year. Of all eligible nursing homes collecting ODI data, 11,425 (99.4%) were successfully merged with their resident data in the MDS. To be eligible, information on more than 9 residents for a nursing home was required for each study year. To reduce missing data, we further restricted our sample to 7,935 nursing homes with all of the following:  1) ODI data for at least one year in the period from 2000 to 2004 (before any state enacted SPHM legislation); 2) ODI data for at least one year in the period 2008-2011 (after all states had enacted SPHM legislation); and 3) no more than 5 consecutive years of missing ODI data in 2002-2010. Of otherwise eligible nursing homes 69.5% were excluded (see Supplementary Tables 3 and 4 for a comparison of excluded nursing homes to the otherwise eligible sample).

Exposure periods

Eight states with ODI injury rate reporting enacted SPHM legislation between 2004 and 2007 (Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island, Texas). No states had enacted SPHM legislation before this period, and no others enacted SPHM legislation directed towards nursing homes before 2010. We defined three periods for legislation enactment in the SPHM legislation states: a pre-enactment period from 2002 to 2003, an enactment period from 2004 to 2007, and a post-enactment period from 2008 to 2010.

Outcome assessment

ODI data are reported as the DART rate (reported work-related injuries or illnesses resulting in Days Away from work, Restriction of job activities, or Transfer to another position, per 100 FTE’s). In general, nursing homes were required to report injury and illness rates every three years, with nursing homes reporting a high injury rate usually required to report again the following year. Following previous literature (21-23), we treated DART rates higher than 50 per 100 FTE’s (0.08% of reported values) as likely outliers, and re-set these to missing.

Imputation of missing values

Among the 7,935 nursing homes included in the 9 years of the analysis, 74.4% of nursing home-years were populated with reported ODI data. A relatively low injury and illness rate in the previous year strongly predicted missing data; of those with an observed DART rate under 5.00 per 100 FTE’s, 51.1% had missing data in the following year, compared to only 13.9% of those with an observed DART rate of 5.00 per 100 FTE’s or higher. Missing data increased over time, from 8.9% in 2002 to 50.5% in 2010. State-level missing data varied from 11.8% of nursing home-years in Maine to 47.2% in the District of Columbia. Missing data were modestly associated with some nursing home-level characteristics (see Supplementary Table 5).
We used multiple imputation to estimate the natural logarithm of DART rates from 1996 to 2011, in which injury rates of 0 were replaced with ln(0.5) (post-imputation exponentiated values of 0.5 or lower were set to 0). To restrict DART rate imputations to plausible values, an upper limit of ln(100) (twice the cut-point for re-assigning a reported value to missing) was applied. Details regarding the imputation method are provided in the Supplementary Imputation Appendix 3.
The analysis and imputation unit is the nursing home. For the imputation we used 16 measured variables potentially related to DART rates and missingness, including the region of the country (10 Medicare regions), the urbanicity of the nursing home’s county (6 categories), profit orientation in 2002 and 2010 (2 categories at each time point), and chain membership in 2002 and 2010 (2 categories at each time point). We also included the mean values across the 9 years for the number of beds, staffing levels, and nursing home-level aggregates of resident characteristics, including resident age, weight, and proportions of residents with clinical, demographic, and care-related factors. We also included the mean values across the 9 years for number of beds, staffing levels, and nursing home-level aggregates of resident characteristics including resident age, weight, and proportions of residents with clinical, demographic, and care-related factors. We produced 50 imputed datasets using PROC MI in SAS, version 9.4 (SAS Institute, Inc., Cary, NC), using the fully conditional specification (FCS) method with 100 burn-in imputations.

Analytic strategy

We estimated the impact of SPHM legislation on nursing home-level DART rates using the Generalized Estimating Equations (GEE) method to fit a Poisson model including status (SPHM legislation state or not), the three exposure periods, and an interaction between these terms. The exponentiated coefficient of the interaction term comparing the post-enactment period to the pre-enactment period is interpreted as the difference between the average injury rate (per 100 FTE’s) observed in enactment states relative to what would be expected if the same temporal trend had been held as in comparator states; a ratio greater than 1 indicates a higher injury rate than expected, and a ratio between 0 and 1 indicates a lower injury rate than expected. We weighted observations by the total number of FTE’s among full and part time employees in the nursing home in each year. We also adjusted this analytic model with a subset of the variables included in the imputation model (see footnote in Table 3).
To estimate the effect of SPHM legislation within subgroups of nursing homes, we repeated the analyses above after nesting the main effects within pre-specified nursing home characteristics, namely: bed size (under 100 beds, 100-299 beds, 300+ beds), profit orientation (yes, no), chain membership (yes, no), nurse:bed ratio (0.05 to 0.50, 0.50 to 0.70, 0.70 to 2.51), ratio of registered nurses to other nursing staff (0.01 to 0.15, 0.15 to 0.25, 0.25 to 2.59), and urbanicity (large metropolitan areas of 1 million or higher population, medium or small metropolitan areas of 100,000 to 999,999 population, or micropolitan and rural areas). We compared our findings with a complete-case analysis (no imputed values).

Sub-analyses

We conducted sub-analyses to further investigate the impact of legislation under alternate specifications: 1) a “high contrast” comparison restricting the SPHM states to the four enacting the most comprehensive forms of legislation (Maryland, Minnesota, New Jersey, Rhode Island), and excluding three states that enacted SPHM legislation after our study period; 2) a comparison of 7 SPHM legislation states (excluding Hawaii) to 18 states neighboring at least one SPHM legislation state; and 3) an analysis using a naïve single imputation method (linear interpolation from 2002-2010, or carry last observation forward after the last observed DART rate).

 

Results

Nursing homes in the 8 states with safe patient handling and movement (SPHM) legislation differed from those in the 36 comparator states in several respects (Table 1). Nursing homes in the states that enacted SPHM legislation were more frequently large homes (11% vs. 2% with 300 or more beds), for-profit in orientation (66% vs. 73%), part of a chain (43% vs. 58%), or located in a central county, large metropolitan area (33% vs. 20%).

Table 1
Nursing Home Characteristics in 2002, by Safe Patient Handling and Movement (SPHM) Legislation Status

* Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island and Texas; † Percents are weighted by size of nursing home staff.

 

Table 2 shows that DART rates in SPHM legislation enacting-states declined from an average of 7.53 per 100 FTE’s in the pre-enactment period (2002-2003), to 6.50 per 100 FTE’s in the enactment period (2004-2007), and further to 5.76 per 100 FTE’s in the post-enactment period, an average drop of 1.77 work-related injuries and illnesses per 100 FTE’s. DART rates were, on average, higher in the comparator states, declining from 8.54 per 100 FTE’s in the pre-enactment period to 7.37 per 100 FTE’s in the enactment period to 6.46 per 100 FTE’s in the post-enactment period, an average drop of 2.08 per 100 FTE’s. Wide variation between homes is also apparent.

Table 2
Distribution of Injury and Illness Rates by Enactment Period and Safe Patient Handling and Movement (SPHM) Legislation Status

* DART rate: work-related injuries and illnesses resulting in Days Away from work, Restriction of job activities, or Transfer to another position, per 100 FTE’s per year. † Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island and Texas. ‡ Averages, medians, 25th and 75th percentiles are weighted by the staff size of the nursing homes. § During the pre-enactment period (2002-2003), no states had yet enacted SPHM legislation. All 8 SPHM states enacted  legislation between 2004 and 2007. No states enacted SPHM legislation during the post-enactment period (2008-2010).

 

Table 3 shows crude and adjusted estimates for the effect of enacting SPHM legislation on DART rates. In the unadjusted analysis, we estimate that DART rates were 6% higher in SPHM legislation-enacting states in the post-enactment period than they would have been had they followed the same secular trend as seen in comparator states [Rate Ratio (RR)=1.06, 95% Confidence Interval (CI): 0.93 to 1.20]. After adjustment for a wide range of static and time-varying nursing home and aggregated resident characteristics, our estimates were similar: DART rates were 3% higher than expected [RR=1.03, 95% CI: 0.96 to 1.11] . Table 3 also shows difference-in-difference estimates for various subsets of nursing homes. These subsets show similar patterns to those in the whole population of nursing homes studied, especially after adjustment.

Table 3
Difference in difference estimates for the impact of safe patient handling and movement (SPHM) legislation

* Ratio of work-related injury and illness rates during the post-enactment period (2008-2010) to the pre-enactment period (2002-2003) among SPHM states relative to the ratio during the post-enactment period to the pre-enactment period in states with no SPHM legislation. Pooled across 50 multiply imputed datasets, weighted by the staff size of the nursing homes, and with a generalized estimating equation specification (m-dependent correlation matrix) to account for repeated measures for each nursing home. 95% confidence intervals generated from model-based standard error estimates; † As above, and adjusted for state, year, urbanicity, calendar year, and the following time-varying covariates: profit orientation, chain membership, nursing home bed size, nurse:bed ratio, ratio of registered nurses to other nursing staff, mean resident weight, mean resident age, percent of residents with: severe activities of daily living limitations, require mechanical lifting, resist care and are not easily modified, have conflicted relationships with staff, restrained, loss of movement in one or both legs, had fallen in the previous 30 days and/or had a hip fracture in the previous 180 days, had dementia and/or Alzheimer’s, had bipolar depression, had a high grade (2-4) pressure ulcer, used antipsychotics in the previous week, and resident proportion Asian, proportion Black, and proportion Hispanic residents.

 

Complete-case (Supplementary Table 9) and sub-analyses resulted in similar results (see Supplementary Tables 7, 8, and 10); restricting the analysis to a “high contrast” comparison between 4 states that enacted comprehensive SPHM legislation and after excluding three states from the comparator group that enacted SPHM after our observation period (Supplementary Table 7); restricting the comparator group of states to those with at least one SPHM legislation-enacting neighbor (Supplementary Table 8); or using a naïve single imputation model (Supplementary Table 10).

 

Discussion

These findings were contrary to our expectation. We hypothesized that injury rates in SPHM legislation-enacting states would have declined more so than comparator states. Several alternate explanations for these findings should be considered. Publicity around the enactment of SPHM legislation may have increased the proportion of worker injuries and illnesses reported to employers, and/or have encouraged employers to more faithfully record reported worker injuries and illnesses. If this were the case, then a lower rate or proportion of serious injuries might be expected in the SPHM legislation-enacting states. Unfortunately, we did not have the data to evaluate this. Likewise, several states required nursing homes to enact written SPHM policies, which may have increased worker knowledge and use of reporting mechanisms increasing reported injuries which may have been previously unreported. We do not have specific evidence to support or refute these possibilities.
Another possibility arises from the nature of the SPHM legislation itself. In most cases, these state-wide enactments included no appropriations to assist nursing homes with enacting SPHM policies, purchasing lift equipment, or even to offset the paperwork burden of compliance with the new regulations. Furthermore, most included no compliance enforcement provisions (13). Although our analysis of states enacting more comprehensive legislation produced similar results to our overall findings, these legislative efforts may have fallen short of providing sufficient incentives or disincentives to motivate lasting, integrated, efforts to reduce worker injuries. Several studies have found that provision of lift equipment alone or provision of worker training alone fail to produce a lasting impact on worker injury rates. A multicomponent approach to reducing worker injuries appears to be required within individual nursing homes or hospitals  (3, 6, 8, 24, 25) and within an entire healthcare delivery system (26).
While convincing evidence of efficacy exists for the impact of legislative actions to generate change in nursing homes in some settings (27, 28) it is not unusual for efforts to assess legislative efficacy to fail to document substantive change (29). For example, state-level restrictions on feeding tube use in severely cognitively impaired residents appear to have a small impact on preventing their use (30, 31) while legislation designed to increase staffing by qualified social workers has largely been circumvented, failing to produce improvements in quality of care (32), and legislation to improve overtime payments for nurses appears to paradoxically have reduced care quality by encouraging nursing homes to substitute contract workers for experienced staff (33). The extent of state efforts to enforce legislation appears to have a sizeable impact on the efficacy of the legislation as well (34), as does the infrastructure capacity of legislative bodies themselves (35). It is also possible that the legislative enactments intended to reduce worker injuries that were included in our analysis were not sufficiently enforced to produce marked reductions.
Finally, these legislative efforts occurred during a period of rapidly declining worker injury rates, both in nursing homes (19), and in the nation’s workplaces as a whole (36). Overlapping legislative efforts, shifts in worker compensation systems, and a growing focus on occupational injuries in general (37, 38) may have affected nursing homes in states that did not enact SPHM legislation during this time period.

 

Conclusion

The promise of enacting safe patient handling and movement legislation to reduce nursing home worker injuries has yet to be realized. In a context of rapidly declining worker injuries nationwide, 36 states enacting SPHM legislation had somewhat slower declines in reported worker injury rates than comparator states. Furthermore, estimates for a range of nursing home subtypes failed to demonstrate markedly different responses. National or state-level legislation including substantial financial incentives, other forms of assistance, and/or enforcement activities may improve the efficacy of legislative initiatives. Wider enactment of these more comprehensive laws would be required to evaluate the potential for greater efficacy.

 

Acknowledgements: This study was funded by a grant from the National Institute For Occupational Safety And Health.

Conflict of Interest: None

Ethical Standard: Approval by the University Massachusetts Medicals School Institute at Review Board.

APPENDIX

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THE CAPACITY OF FOOD SERVICE PROVIDERS AS NUTRITION CHANGE AGENTS IN NURSING HOMES

 

L. Matwiejczyk, O. Farrer, J. Hamilton, M. Miller

 

College Nursing and Health Sciences, Flinders University, South Australia, Australia. Corresponding author:Louisa Matwiejczyk BA (Hons) Dip. Nut & Diet, Adv APD, Lecturer, Nutrition & Dietetics, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia 5001. Tel: +61872218848 Email: louisa.matwiejczyk@flinders.edu.au

Jour Nursing Home Res 2018;4:20-26
Published online May 9, 2018, http://dx.doi.org/10.14283/jnhrs.2018.5

 


Abstract

Background: Despite the correlation between the food provided and nursing home residents’ food satisfaction, Quality of Life and health, the capacity of food service providers to enact positive nutrition-related changes is unknown. Objectives: Researchers explored (1) the experiences and perceptions of senior-level food service providers from nursing homes (NH) to elicit change prompted by participation in a national educational intervention (2) the barriers and enablers to eliciting change and (3) practice implications. Design: Using qualitative methodology, individual semi-structured interviews were conducted four months after the intervention and thematically analyzed. Participants: Participants were 23 senior-level food service providers from 21 NH in Victoria, Australia. Results:  Participants started with the necessary confidence, knowledge and skills for food provision and three themes that best represent food service providers’ perceived capacity and experience to affect food service changes included: (1) participants’ motivations as change agents (2) empowerment facilitated by external factors (organizational, external and ongoing peer-support) and (3) constraints to enacting change (local and system-wide). Conclusion: Understanding the motivations and experiences of senior food service providers to enact change provides important information on the barriers and enablers which can be used to augment intervention planning and reduce the implementation gap between evidence-based recommendations and practice. A number of underlying mechanisms were identified and recommendations for system-wide changes made. Improvement in food and dining experiences may help to improve residents’ satisfaction with food which has been correlated with improved life satisfaction, health and well-being.

Key words: Aging, food services, long-term care, nursing homes, quality of life.


 

Introduction

Population ageing is a significant concern for many countries (1, 2). Life expectancy, low fertility rates and changing demographics have resulted in an unprecedented increase in people aged 65 years and over in the last five decades (2, 3).  Those aged 85 years and older are increasing at the fastest rate and expected to more than triple between 2015-2050 (2, 3). The United States, Japan, Australia and Europe will continue to have one of the longest life expectancies in the world and the ageing population is expected to present challenges to the welfare and health system (2).  An increasing number of older people are assessed as not being able to continue to reside independently in their own home and move into supported accommodation in long-term care facilities (4), termed Nursing Homes (NH).
Nutrition is vital for maintaining the health and well-being of residents in NH (1, 5, 6). Ageing alters nutritional requirements (1) and Protein-Energy Malnutrition, Vitamin D deficiency, Vitamin B deficiency and other micronutrients are challenges for residents in nursing homes (1). Crucial to residents’ quality of life (QOL) is also the enjoyment of food (7-11). Satisfaction with food is associated with increased mental well-being, social improvement and life satisfaction among older people (7-10) and is of particular relevance to residents (8, 11, 12).
Central to the provision of residents’ nutrition is the role and responsibilities of food service providers (13).  Residents are dependent upon the provision of their food from their carers, particularly food service staff. Where once many residents would have decided what and when they would eat, and what was ‘good’ for them, in NH these decisions are made predominately by food service staff (8, 11).  ‘Good food’ is important to residents and has been defined as food which is familiar, ‘home-style’, cooked with fresh ingredients and easily recognizable on the plate (11). ‘Good food’ symbolizes comfort for residents and as such is an important QOL indicator (11). Residents’ experience or perception of ‘good food’ in NH, however, is not always positive (11-13) and is an ongoing issue in NH (12).
Residents’ perceptions (11, 12, 14, 15) and NH carers’ experiences (6, 10, 14) have been explored, but despite the pivotal role of key food service staff their perspective remains unknown.  It is recommended that more successful interventions incorporate the views of the user to mitigate the implementation science gap translating best practice knowledge into day-to-day positive behaviours (16). An understanding from foodservice providers’ perspective would provide insights into the barriers and enablers experienced and the motivations to enact change. This would identify underlying mechanisms which may lead to positive behaviour changes, help inform the feasibility of food service staff initiated change and address a limited understanding of how interventions in NH work (17). This in turn may inform program-planners, policy makers and NH management with what would be needed to improve residents’ food satisfaction and QOL.
In response to the link between ‘good food’,  life satisfaction and the nutritional needs of the  population, a not-for-profit Foundation (Foundation) has delivered an education program with industry and nutrition experts for food service providers to transform the food experience of residents in NH (21). Novel to this program (also referred to as an intervention) is it is celebrity-led by a philanthropic cook and aims to empower key NH chefs and cooks from across the nation to become change agents in their local facilities.
The purpose of this study was to address an evidence gap by: (1) exploring  the experiences and perceptions of senior-level foodservice providers to elicit change in their facility following participation in an intervention developed to empower senior NH food service staff, (2) identifying barriers and enablers to enacting change and (3) identifying practice implications.

 

Method

Study Design and Setting

The intervention was a 14-hour interactive, discussion-based and predominately experiential program described elsewhere for senior level foodservice providers in NH. The program is underpinned by Social Cognitive Theory and adult learning theories which assumes participants’ start confident, are self-directed learners, learn best through doing and problem-solving and learning is enhanced by drawing on a repertoire of experiences and used immediately, Unique to this program is that it is celebrity-led with expert support with a focus on increasing the capacity of NH foodservice providers to be change agents.
Qualitative research was used as it lends itself to understanding the lived experience of those translating the gains from the educational intervention into real-life changes (19). The focus was on senior-level food service providers who had the mandate to enact change. Researchers undertook phone interviews using semi-structured questions four months after participants had attended a 14 hour educational program over three days in June 2015. Interviews were conducted four months later after a time considered long enough by participants to elicit change. Approval for the study was granted by the Social and Behavioral Research Ethics Committee at Flinders University South Australia.

Participant recruitment

Participants were recruited from the program which was promoted through aged care networks and restricted to facilities in Victoria, Australia (n=387). Facilities paid for flights and accommodation over the three days but the program itself is offered at no cost. At the program, participants were given a plain English summary of the study, had an opportunity to ask questions of the researchers and then provided signed consent.
All but one of the authors of this qualitative study have a wide range of experience working with older people in residential long-term care, community-based settings, food services and health services research. Prior to this study, the authors were unknown to the participants or their facilities.

Data collection

Semi-structured questions were asked using an interview schedule developed from the literature and trialed with potential users for usability. Topics related to food service providers’ perception of what changes they had made, what was their experience of making these changes, barriers and enablers and what additional support could assist. Questions were semi-structured to allow participants to relate their experience as they have perceived it and to allow themes in the analysis to emerge. All interviews were recorded and transcribed verbatim. All participants were interviewed. This was more than necessary for data saturation but this allowed for insights across a variety of facilities geographically and in size and purpose.

Data analysis

Transcribed data were analyzed using inductive thematic analysis where common themes were identified using a six-step process (19). The lead author (LM) and one other (JH) familiarized themselves with the data by listening to the recordings, reading the transcripts and taking notes. The transcripts were coded manually, line-by-line. Coding was carried out independently and the results discussed for common codes and quotations. Following coding, the quotations were sorted into groups to reflect the emerging themes. Different themes and sub-sets of themes were further identified during the write up of the analysis. Consensus was achieved in each of these steps. Trustworthiness of data was ensured through members checking what was reported against their experience. Quotes representative of the findings were selected for each theme and sub-theme for reporting purposes.

 

Results

Twenty-three senior-level foodservice providers from 21 NH participated in the phone interviews which were undertaken four months after the program and lasted between 16-55 minutes. Seven of the 30 program participants were not interviewed because two had left the position, two were on extended leave and three could not be contacted. Of the 23 participants interviewed, the majority had a senior food service role or managed the food services and there was a mixture of organisations from metropolitan areas, regional country towns and rural sites.  Foodservice type and the number of places per facility also varied, reflecting the diversity in NH. Selected characteristics of the participants and facilities are listed in Table 1.
When sharing their experience three main themes emerged: (1) participants’ motivations as change agents (2) empowerment facilitated by organizational, external and ongoing peer-support and (3)   constraints to enacting change.  Within these main themes were a number of inter-related sub-themes which could also be described as enablers or constraints.

 

Table 1
Selected characteristics of Nursing Homes in Victoria, Australia (n=21) and senior-level food service providers (n=23) interviewed for their experience and perception of enacting food service changes

 

Participants’ Motivations as Change Agents

All of the participants described changes to food service practices four months post-program including; food provided through menus and recipes, the dining environment and interactions with other staff, management involvement and residents’ satisfaction. Some participants described the experience as transformational and their responses indicated a high degree of conviction to make changes over the long term.
I said I will be continuing to lobby for more funds, more staff…. Yea for me, even my second chef said to me she really likes the new motivated me (Head Chef IP-3)
Participant’s motivations for acting as change agents varied and included wanting to make a difference, empathy for the residents and/or upholding standards.
I think that the food needs to be more important…. it needs to be pushed more and be more in the public eye and it needs to, you know, we just need to do better. (Head Chef IP-3)
Participants’ were empathetic towards residents and recognized that food was a significant source of pleasure, had meaning to residents, was a conduit for socializing and contributed to residents’ health as well as quality of life.
We have people here who …. the family don’t even come and visit. Which I think is incredibly sad and I sort of think food, for a lot of us, is a fairly major part so why can’t we make it the best that we can make it.  Why can’t we serve restaurant quality meals? Instead of just ‘ah well, it is only old people’. (Head Chef IP-3)
For some participants, making a difference was very personal with participants reflecting on their grandparents, parents, other family or friends as residents in NH. Of equal value for many participants was the motivation to provide food of an exemplar standard.
We are building four aged care facilities so it is really crucial for me to get the right mould to go forward because I really want to set a good standard and drive the innovation into the future. (Food Service Manager IP-5)
For many participants, residents’ feedback motivated them to continue with their change agenda following the program
You know when I have residents come and knock on the door and tell me what a lovely meal it was today and things like that it makes it all worthwhile. … (Head Chef IP-3)
Four months later all of the participants were still inspired to make changes to further improve recipes, menus, the dining environment and dining experience and collaborative, working relationships.
I want to have the reputation that people say ‘wow’ we want to go there when we get old because we hear the food is so good (Head Chef IP-3)

Empowerment Facilitated By External Influences

Organizational support

A number of common factors were attributed to building participants’ capacity to effect change. Management support was common to all participants and unconditional to a few participants following participation in the program.
Anything I’ve wanted to try I’ve been able to purchase …. anything.  They’ve went out and bought one of those fancy whippers and….All these new little contraptions that we’ve seen there, they’ve went and bought all of it. (Catering Manager IP-2)
Some participants described how they involved key management personnel such as the Chief Executive and Board members in food service decision-making by attending meetings with management, inviting management to eat with residents, and sharing meals with management for feedback.
The majority of the participants reported that many or most of the kitchen staff was supportive of change and gave examples of how they had empowered staff and endeared their support through collaboration.  However the capacity of kitchen staff to enact their intentions was problematic for some.

External support

Participants reported high levels of confidence in their skills even before the program. Rather than improving skills, participants identified that the benefit of the celebrity status of facilitators, supported by experts, was for motivation and as influential advocates for change.
I think she is a really good person to drive this kind of thing. It needs somebody of her stature, her media profile and stuff like this to raise awareness with what is going on and what is achievable and what’s not and this sort of thing in the aged care.  (Head Chef IP-3)

Ongoing peer- support

All of the participants elaborated on how ongoing peer-support during and after the program facilitated their motivation to progress change. Active participation in a closed, social media group mediated by the Foundation was reported as facilitating and sustaining motivation and change. Participants shared photos of recipes, problems, solutions and advice. Some participants extended this support by making their facility available for visits and helping each other with events. Others were less active but monitored the posts regularly.
I get on there every night to see if somebody has cooked something different or if somebody has other comments.  (Head Chef IP-9)
The comradely, willingness to support each other and common ambitions and concerns, unified the participants as a community.
It’s ongoing and you feel important because you’re still part of it (Chef Manager IP-23)

Constraints to Enacting Change

Local-level structural constraints

Caveats such as costs, time constraints and food regulations were factors expressed by most participants as barriers to enacting change. Ingredients for the NH recipes were identified as costly and difficult to access, particularly as they were unavailable on the procurement lists negotiated for the state of Victoria and therefore not cost-competitive. Compounding this difficulty was the limited budget for meals per resident per day.
…….. the one nagging little thought in the back of my mind was that, yeah this is wonderful and we would love to do it but where is the money to do it …. the first moment they get the final  results back they have been told  “ooooh oooooh” this is costing us money so you better scale it back. (Manager Chef, IP-4)
Some participants attributed the restrictive budget to prioritizing costs rather than residents’ satisfaction.  Providing higher quality foods, more foods familiar to residents, more freshly sourced foods and foods to meet modified texture needs or specific nutritional needs of residents would incur additional costs beyond the set budget.
.. So you have got people making decisions based on the dollar rather then what is right for the kitchen, well what is the right care.  So this is where it has to change, the focus has to be on the care and food not the dollar; it should be secondary but not primary. (Food Service Manager IP-5)
Moreover, more than half of the participants identified that they needed more time sanctioned from management to rework recipes and redevelop menus. Support from NH management to develop new recipes, have the time to implement menu changes and change food service practices were identified as crucial to enabling participants. Also, a source of frustration was that some kitchen staff was resistant to change. Participants perceived this as; some staff not caring, some not seeing the relevance of changing, some entrenched in their ways and some not skilled or constrained by time and other workload demands.
..when I first started in aged care, you know it was just sort of nobody really cared. [The chef] had been here nearly 20 years and he was doing things the same way the day he left as the day he started and he couldn’t see an issue with that.  . (Head Chef IP-3)

System-wide constraints

Working within the national food regulations for aged care facilities were identified as a constraint by a few participants. Including more food variety and fresh ingredients was perceived as problematic given current food regulations which participants interpreted as increasing food contamination risk. Regulations also constrained some due to an uncertainty that they weren’t complying and favoured food wastage due to a rigid interpretation of the food safety regulations.
What is right? Not just someone saying they are taking the hardest line just to cover themselves (Food Services manager IP-5).
Some participants attributed different regulations between states, a lack of products on state-wide procurement lists and different interpretations of the food regulations by auditors and food service providers as barriers to enacting menu changes.
Participants elaborated that the time demands of providing meals were exacerbated by significant reforms within the aged care sector as facilities expanded to accommodate the ageing population.  Some participants also reflected concerns for finding time to develop menus for the next generation of ‘baby boomers’ with different food preferences and the pressure of implementing consumer-directed care where people will have more control and choice over the services provided.
We are introducing this household module more so the nurses will be doing more, so that’s putting a lot of stress on everyone. … That’s where I am finding it hard. That’s where you get burnt out you know. (Support Services Manager IP-8)
A few others perceived aged care reform as disempowering foodservice further where the priority is given to nursing care, cost-savings are sought from foodservices and food services are not considered part of the care team despite the importance of food to residents.
In contrast, aged care reform was also identified as an opportunity including possibly changing the role of food services from a support service to part of the care team
But we have people in business background now coming in, in charge of aged care facilities, this is a really positive change because they actually …. think of aged care facilities as hotels, with super services being a very important part, food being a very important part… (Manager Chef, IP-4)
Key enablers and constraints shared by the participants are summarised in Table 2.

Table 2
Barriers and enablers identified by senior food service providers (n=23) from Nursing Homes (n=21) in Victoria, Australia, four months after attending an education intervention

Barriers and enablers categorized according to three levels of influence as described in socio-ecological model for health behavior changes (29)

 

Discussion

Efforts to change or strengthen practices in NH food services must carefully consider food service providers’ motivations and perceived barriers and enablers. Empathy for residents, wanting to make a difference to people’s QOL and achieving high standards of service were all expressed as motivations in this study, which is absent in the literature. Within their facilities, senior foodservice providers appear to have the agency to make changes with management’s support and an inspired and skilled food service staff.  Local level factors such as meal costs, scheduled time and staff engagement were identified by participants as enablers or constraints. Quantitative studies have also acknowledged costs, time and staff resistance as significant barriers to enacting change in NH food services (20, 21).
In this study, celebrities supported by experts acted as the catalyst for change. Rather than increasing participants’ skills, their contribution was to increase participants’ self-efficacy to become change agents and their perceived influential standing with management and beyond. Celebrity chefs are recognized to enable changes in food services (22) and the popularity of celebrity chefs in food programming is well known to the public (23, 24). Also crucial was that the intervention acted as a conduit for isolated senior-level chefs to work together as a community. Learning as a community of practice is a well-known pedagogical approach (25) however it needs to be guided. Peer support is also well known as an enabler for supporting change (26) although there is a scarcity of this in the literature for NH.
While enablers such as external peer-support, organizational support and increased self-efficacy empowered chefs to enact local-level changes, barriers beyond the influence of individuals presented significant constraints. These included benchmarks for meal costs, restrictive state-wide procurement lists, subjective local food regulations and a lack of national NH food standards, all of which require system changes.
Difficulties sourcing affordable ingredients flagged the need for changes to the state’s procurement processes whereby many facilities are limited to purchasing products on this competitively-priced list. Likewise, discussions at the system level were called for regarding food regulations.  The safety of residents and protection from food contamination is paramount but some food service staff struggle with interpreting and using the regulations (12) and widening the scope for the use of more ‘home-style’ recipes made from fresh ingredients.
Similarly, a significant constraint was the lack of a minimum budget benchmark for meals per resident per day. Local benchmarks covered the minimum requirement for three meals per day plus mid-meals but were a barrier to introducing more variety, more choice, more acceptable modified textured meals and more fresh ingredients. These qualities have been correlated with residents’ satisfaction (11, 12, 27) which in turn influences QOL and nutritional status (6, 9, 17). Research is required to demonstrate whether meals which meet the nutritional needs of residents while satisfying other needs for ‘good food’ can be achieved at only a small cost increase or cost neutral with savings created from improved health outcomes.
National standards for food services in NH would justify minimum benchmarks for costing meals plus minimum requirements for nutritious meals recognized as ‘good food’ (11) that also contributed to residents’ QOL and enjoyment (8, 9). Australia does not have national food service standards for NH although most of the states and territories have developed voluntary standards for publically-funded facilities.
The issue of cost raised questions about the role of food services in NH. Some participants stated that the care of residents rather than the budget should drive decisions about food services. The low prioritization of food services in Australia is an issue in other studies (12, 20) and its perceived relegation to hotel services or support services means that outcomes are based upon meeting budgetary projections and volume of meals rather than being part of holistic care. Participants recognized that the food provided had a direct impact on residents’ satisfaction and QOL. Moreover, food service staff that interacted with residents noted that they were a channel for residents’ concerns and part of residents’ social lives. This phenomenon where commensality and social-interactions in NH influences residents’ QOL is well known (8, 10, 14). Some participants elaborated further that food services should be considered part of the care team rather than an adjunct support service. Participants’ motivation was predominately to improve the QOL of residents through food, and elevating food service management to be part of the care team would empower what is a traditionally disempowered group (20). Due to their celebrity-status and wider influence, and in the absence of a peak body for NH food services, participants believed that entities such as the Foundation have the potential to initiate discussions for system changes to support the transformation of aged care food services.

Practice Implications and Study limitations

While studies have explored the perceptions and experiences of residents and of care staff with NH food provision, this study focused on food service providers and is the first to the authors’ knowledge.  These results highlight the importance of including food service providers’ frontline experiences with enacting change and using this information on identified gaps, barriers and enablers to augment intervention planning. Food service staff providing ‘good food ‘which is consistent with national regulations face unique challenges (28). Enablers included being empowered by the attention of celebrity-led advocates, attending an educational program, ongoing peer support across NH and organizational support. Study findings are consistent with a socio-ecological perspective that presumes that human behaviour is a result of the interaction of environmental factors and individual characteristics (29). At the individual level foodservice providers would benefit from ongoing peer support as a community of practice, participation in a program that builds capacity to enact change rather than build foodservice knowledge and skills and stronger collaboration with upper management.  At the wider levels of influence, system-wide changes would benefit such as; national standards for NH food services, national benchmarking for costing meals, an expansion of the definition of nutritious, appropriate foods to include ‘good food’ and a revisit of national NH national food regulations and state-wide procurement lists as to how they are interpreted and enacted. From this study, reconsidering food services as part of the care team also appears warranted as aged care expands and more is known about the interface between residents’ QOL and food service providers.
Despite the range of NH types, sizes and geographical location there was commonality in what interviewees shared and saturation with no new themes or information from the analysis. However, a limitation of this study is that while qualitative research provides rich in-depth data, it cannot be generalized and the participants were likely to have been early adopters and not representative of all NH.  Given the universal importance of nutritious food provision in nursing homes and the central role of food service providers for residents’ food satisfaction and QOL, this warrants more research for generalisability.

 

 

Conclusion

Incorporating strategies that address the barriers and incorporate the enablers identified by senior food service providers are critical for successful interventions and change in NH. Within their facilities, food service providers have the agency to make changes with management’s support and a motivated food service staff. External enablers such as ongoing peer-support and attention from celebrity-status experts increase the self-efficacy of food service providers and empower them to enact the changes they are very motivated to do. The education part of the intervention and skill development is not central. Other factors, however, are beyond individual’s agency and require a systems approach. National benchmarks and standards for food regulation, meal-costing and ‘good food’, complemented with a change in role from support to care would enable this disempowered group.  This study has relevance to program developers but also to policymakers interested in enacting national regulations and system changes which ensure residents’ enjoyment of food, QOL and health.

 

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. All of the authors have nothing to disclose.

Acknowledgements: The authors wish to acknowledge the partnership with the not-for-profit Maggie Beer Foundation (MBF), particularly Maggie Beer, who engaged Flinders University to evaluate their national educational program. The MBF developed and delivered the ‘Creating an Appetite for Life’ programs in collaboration with food service experts and accredited foodservice dietitians. The MBF had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Conflict of interest: The authors including Professor Michelle Miller, Ms Olivia Farrar, Ms Jude Hamilton and Ms Louisa Matwiejczyk have no conflict of interests to disclose.

Ethical standards: Approval for the study was granted by the Social and Behavioral Research Ethics Committee at Flinders University South Australia.

 

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