Therapeutic Activities With the Impaired Elderly

Phyllis M. Foster, Phyllis M. Foster

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317840138
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

This highly practical volume presents valuable insights for all professionals who provide activities for the impaired elderly. It will serve as a helpful resource for both those who work directly with the aged in institutional settings, as well for those who train activities counselors.Therapeutic Activities With the Impaired Elderly addresses a number of pertinent issues and provides useful information on designing and implementing recreation and socialization programs, memory improvement classes, sign language activities, and leisure education and counseling.

The Relationship Between Nursing Home Residents’ Perceptions of Nursing Staff and Quality of Nursing Home Care

Shayna Stein

Margaret W. Linn

Elliott M. Stein

Dr. Shayna Stein is Social Science Researcher, Veterans Administration Medical Center, and Adjunct Instructor with the Department of Psychiatry, University of Miami School of Medicine, Miami, FL. Dr. Linn is Director, Social Science Research, Veterans Administration Medical Center, and Professor of Psychiatry at the University of Miami School of Medicine. Dr. Elliot Stein is Director of Psychiatric Services of The Douglas Gardens Community Mental Health Center of Miami Beach, and Clinical Assistant Professor with the Department of Psychiatry, University of Miami School of Medicine.

This project was funded by Veterans Administration Health Services Research and Development Grant No. 547.

ABSTRACT. The purpose of the study was to determine if nursing home patients’ perception of nursing staff members were associated with quality of nursing home care. Three hospital professional staff members who were familiar with the homes in the study rated the 10 homes on a 1 = excellent to 4 = poor quality. Patients (N = 239) admitted to the 10 homes provided assessments after they had been in the nursing home for one month of the nursing staff activities. Homes were classified by the four levels of care and responses of the patients were compared by multivariate analysis of variance. Patient responses differed significantly among the four levels of quality, with significantly more favorable responses in the excellent homes and the least favorable in the poor homes. In poorer homes, patients perceived less respect, communication, response from calls, concern, and also believed staff members did not like their work. In addition, when asked how the staff would respond to specific situations, patients in poorer quality homes less often selected the more favorable behaviors. The study demonstrates that patients are able to assess quality by their perceptions of nursing staff and suggests that patients’ assessments should be included in evaluations of homes. Further, it points up the need for in-service training in attempting to enhance the quality of care.

Nursing homes represent one of the most exciting frontiers for change in medical and nursing care today. No one can realistically doubt that the increased need for nursing home beds and the economic constraints of our society will combine to require creative and intelligent planning if future health care delivery for the infirm elderly is to be responsive and humane. Already change is evident. Over the last 15 years, the importance of assessing the quality of nursing home care has gained added attention^1–3 with some research linked to specific interventions and their outcomes.⁴ Studies concerning nursing home utilization,^{5, 6} manpower needs,⁷ effects of innovative programming,⁸ family involvement in care,^9,10 and patient outcomes over time¹¹ have been among those contributing information of potential benefit to nursing home patients.

Most of the literature evaluating nursing home care has focused on patient adjustment by examining a variety of physical and psychological factors. There has been little attention paid to the residents’ own perceptions of the nursing home environment. One notable exception to this is a study of stress, coping, and survival by Lieberman and Tobin.¹² Results showed that environmental factors were crucial to the well being of a less “docile” subgroup of institutionalized patients. These factors included warmth and recognition. Patients showing less “aged” behavioral patterns were most responsive to environmental qualities. In another study by Simms et al.,¹³ outcomes showed that the residents’ perceptions of the nursing home influenced their subsequent adjustment.

Quality of extended, long-term, or nursing home care has received relatively little research attention compared with hospital care. Nursing home studies vary by their definitions of quality. Early studies measured quality by observation,¹⁴ social climate,¹⁵ physician hours,¹⁶ panels of judges using specific weighted criteria,¹⁷ interactions between staff and patients,¹⁸ and available resources in the home.¹⁹ The bricks-and-mortar-type variables were considered a “structural” type of evaluation and used alone were generally an unsatisfactory indicator of quality, given the fact that certain minimal structural elements were met. At the other end of the quality of care measurement continuum was “patient outcome” types of evaluation. Studies of outcomes of nursing home patients,^20,21 however, were long-term and expensive, with outcomes including such factors for assessment as death, disease, disability, discomfort, and dissatisfaction, referred to by White²² as the five D’s of evaluation. Between the structural and outcome types of evaluation fall “process” methods. Process type of assessment assumes that persons responsible for organizing care can agree on what constitutes high quality without actual measuring outcome. As might be expected, process evaluation has recieved considerable attention, including such methods as quality audits through peer review, utilization studies, cost studies, or direct observations.

Process evaluation has been done by both implicit and explicit methods. Implicit judgments are usually global assessments of care provided from records or by observation. Explicit methods involve experts setting detailed criteria for quality of care related to specific diagnoses or types of care. In 1974, one of us studied²³ the relationship between implicit global judgements of six social workers about 40 nursing homes and explicit ratings obtained on structural and process variables recorded on a 71-item Nursing Home Rating Scale.²⁴ Using stepwise regression techniques, implicit ratings were predicted significantly from the explicit subscores that described the physical plant, dietary practices, administrative policies, and staff-patient ratios. Agreement between the six social workers’ implicit ratings was a Kendall W of .85. Thus, there was considerable agreement among the raters as well as between the methods of assessment. In a study of outcomes of 1,000 patients²⁰ placed in nursing homes, professional nursing hours per patient, dietary practices, and staff-patient ratios were associated with better patient outcomes. Therefore, the predictors of implicit ratings by explicit criteria were similar to those that were found to be related to patient outcome.

In the present study, quality was defined by implicit ratings made for a group of nursing homes by an external team. Nursing home residents’ perceptions of the nursing staff and specific behaviors of staff were collected in these homes. The purpose of the study was to determine whether the patients’ evaluations were associated significantly with the external evaluations of quality of care provided for the homes.

METHOD

Data collection took place over a three-year period in 10 community skilled nursing homes selected to provide variations in number of beds, staff members, and admissions per month. Homes were in Miami, Florida, and were visited by a research nurse who screened all patients admitted to the homes. Those who were not expected to remain for an extended time and those who were too sick to respond were excluded. Demographic information concerning age, sex, race, education, marital status, and income were collected. After the patients had been in the home for one month, they completed two scales evaluating nursing staff in the home. The first scale contained six items that concerned nursing staff responsiveness: treated with respect; likes their work; someone from staff that is special to the patient; how soon staff respond when called; staff liking you; and someone from staff with whom the person could talk. Patients rated each item from 1 to 5, with a higher score representing a less favorable rating. Principal component factor analysis of this scale showed all items loaded heavily (from .51 to .78) on one factor, allowing for the use of a total score or indicating high correlations among the variables. Thus, a general patient response to nursing staff was reflected by the ratings.

The second instrument asked for the patients to indicate what they thought the nurses in their homes would do if faced with three specific situations. Patients were asked to place a mark by the response which best represented what they believed the majority of nurses would do in their home if confronted by these situations: (1) if patient is feeling angry and expresses anger to the nurse, the nurse would probably (leave the room and give the patient time to calm down, point out all the things the patient has to be grateful for, or mention the anger and ask if they can help*); (2) sometimes sick people feel that they are being punished by God, and the patient says that this is the way he or she feels, the nurse would probably (mention God works in mysterious ways and no one can know his will, encourage the patient to talk about his or her feelings,* or tell patient not to talk that way because it will only make the feelings worse); and (3) the patient wants to know more about his physical condition and so asks the nurse, the nurse would probably (leave that up to the doctor, tell the patient not to dwell on the illness, or approach the patient and find out how ill he is feeling*). The asterisk after the response indicates the one selected as most often being the correct response. Thus, each of the three variables were scored 0 for incorrect and 1 for a correct response.

Two individuals were selected to independently rate the overall quality of care provided by the 10 homes in the study. A nurse who visited these and other community nursing homes regularly as a member of an inspection team was selected. In addition, two social workers who provided follow-up services to patients in nursing homes after placement from the hospital were chosen. The social workers had been seeing patients in the homes for about 10 years. All were staff members of the Veterans Administration Medical Center in Miami and were not involved in the present study in any other way. They were asked to rate the 10 homes in the study independently from 1 = excellent to 4 = poor overall quality. They were instructed to use their knowledge about all aspects of the home and care provided as a basis for the ratings. Agreement between one of the social workers and the nurse was high (r = .80 by intraclass correlation). Homes were grouped by quality ratings into four categories for analysis, with the other social worker’s rating serving as the deciding category for those homes in which there was not perfect agreement. Two homes were classified as excellent, four as good, two as fair, and two as poor quality. It should be mentioned that the homes in the sample probably could be considered as providing a broad range of care with none actually being the very worst in the nursing home industry or perhaps the very best.

Data were analysed in the following ways: (1) Patient characteristics were correlated (Pearson r’s) with responses to both patient scales. In addition, patient characteristics were compared between the four classifications of quality of care. That is, patients in excellent quality homes were compared with those in the good, fair, and poor homes. If significant relationships were found, covariance would have been used in further analyses comparing the quality of care groups (use of covariance adjusts for confounding effects of other variables correlated with the dependent variable²⁵). (2) Using multivariate analysis of variance, the patient responses in the four classifications of quality of care homes were compared to determine if patient responses differentiated significantly in the expected directions among the four groups.

RESULTS

Description of Patients and Relationship of Patient Characteristics to Scale Responses and Classifications of Homes. During the three years of study, 239 elderly patients entered the study and completed assessments after being in the homes for one month. Most (85%) had come directly from hospitals and had never been institutionalized before. Average age of the patients was 77 years with a standard deviation of 10 years. Fifty-one percent were male and 18 percent were married currently. Almost all (94%) were white. Last grade completed in school averaged 10 years with a standard deviation of four years. Weekly income averaged about $139 from all sources, and about half had been living alone before placement. None of the patient charact...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Therapeutic Activities with the Impaired Elderly: An Overview
• Book Reviews
• What’s New?