Well-being and various forms of agitation in people with dementia can be improved in a person-cen... more Well-being and various forms of agitation in people with dementia can be improved in a person-centered long-term care setting. Data obtained during the Person-Centered Dementia Care and Environment (PerCEN) randomized controlled trial shed light on the factors that influenced the adoption and outcomes of person-centered interventions in long-term care from the perspective of study participants. Data were obtained from PerCEN participants: individual semi-structured interviews with care managers (29), nurses and care staff (70); telephone surveys with family members (73); staff reports of care approaches; and 131 field note entries recorded by the person-centered care and environment facilitators. Data were interpreted inductively using content analysis, code building, theme development, and synthesis of findings. All data sources confirmed that, when adopted, the person-centered model increased the number and variety of opportunities for resident interaction, improved flexibility in care regimens, enhanced staff's attention to resident needs, reduced resident agitation, and improved their well-being. Barriers and enablers for the person-centered model related to leadership, manager, staff and family appreciation of the model, staff's capacity, effective communication and team work among direct care staff, care service flexibility, and staff education on how to focus care on the person's well-being. Successful knowledge translation of the person-centered model starts with managerial leadership and support; it is sustained when staff are educated and assisted to apply the model, and, along with families, come to appreciate the benefits of flexible care services and teamwork in achieving resident well-being. The Australian New Zealand Clinical Trials Registry number is ACTRN 12608000095369.
Older Australians experience health disparities in pain management compared to other groups. This... more Older Australians experience health disparities in pain management compared to other groups. This article is focused on understanding the emergency nurses' perceptions of pain and pain management for older persons with cognitive impairment and presenting with a long bone fracture. This article is part of a larger study focusing on emergency nurses' pain management practices for older Australians with cognitive impairment. The aim of the study was to understand emergency nurses' perceptions of the management of pain for older persons with cognitive impairment and presenting with a long bone fracture. This is part of a larger multicentre programme of research exploring pain management in older persons with cognitive impairment and who are experiencing pain from a long bone fracture. This study had a qualitative research design, with data collected through focus group interviews and a thematic method of analysis. The study is framed by a constructivist's paradigm, which...
Although older people frequently present to the emergency department (ED), little is known about ... more Although older people frequently present to the emergency department (ED), little is known about their experiences in this setting, despite increasing attendance rates reported in this population internationally. This study explores the experiences of older people and their carers leading to and during ED care in a metropolitan university hospital in Sydney, Australia. The study forms part of a larger prospective exploratory study on this topic. Individual in-depth interviews were conducted with 10 people over 65 years of age who had a chronic illness and their carers one month after they presented to the ED. Interviews were transcribed verbatim and analyzed using general interpretive methods. The results revealed that the participants presented to the ED as a result of escalating symptoms and on their general practitioner's advice. Participants felt uninformed about ED procedures, therefore, families/carers felt the need to advocate for information and basic services. Participa...
Journal of the American Medical Directors Association, 2015
Clinical leadership long-term care work environment leadership styles care quality a b s t r a c ... more Clinical leadership long-term care work environment leadership styles care quality a b s t r a c t Objective: To evaluate the effectiveness of a leadership and management program in aged care. Design: Double-blind cluster randomized controlled trial. Setting: Twelve residential and community-aged care sites in Australia. Participants: All care staff employed for 6 months or longer at the aged care sites were invited to participate in the surveys at 3 time points: baseline (time 1), 9 months from baseline (time 2), and 9 months after completion of time 2 (time 3) from 2011 to 2013. At each time point, at least 500 care staff completed a survey. At baseline (N ¼ 503) the largest age group was 45 to 54 years (37%), and the majority of care staff were born in Australia (70%), spoke English (94%), and had at least completed secondary education (57%). Intervention: A 12-month Clinical Leadership in Aged Care (CLiAC) program for middle managers, which aimed to further develop their leadership and management skills in creating positive workplace relationships and in enabling person-centered, evidence-based care. Main outcome measures: The primary outcomes were care staff ratings of the work environment, care quality and safety, and staff turnover rates. Secondary outcomes were care staff's intention to leave their employer and profession, workplace stress, job satisfaction, and cost-effectiveness of implementing the program. Absenteeism was excluded due to difficulty in obtaining reliable data. Managers' self-rated knowledge and skills in leadership and management are not included in this article, which focuses on care staff perceptions only. Results: At 6 months after its completion, the CLiAC program was effective in improving care staff's perception of management support [mean difference 0.61, 95% confidence interval (CI) 0.04e1.18; P ¼ .04]. Compared with the control sites, care staff at the intervention sites perceived their managers' leadership styles as more transformational (mean difference 0.30, 95% CI 0.09e0.51; P ¼.005), transactional (mean difference 0.22, 95% CI 0.05e0.39; P ¼ .01), and less passive avoidant (mean difference 0.30, 95% CI 0.07e0.52; P ¼ .01); and were rated higher on the overall leadership outcomes (mean difference 0.35, 95% CI 0.13e0.56; P ¼ .001) as well as individual manager outcomes: extra effort (P ¼ .004), effectiveness (P ¼ .001), and satisfaction (P ¼ .01). There was no evidence that CLiAC was effective in reducing staff turnover, or improving patient care quality and safety.
This paper reports on a participatory action research study which arose out of the initiatives of... more This paper reports on a participatory action research study which arose out of the initiatives of people caring for clients attending a multicultural dementia day-care program. Through a democratic decision making process, the daycare staff and family carers consulted with clients to design, implement and evaluate a new therapy program. The researchers acted as facilitators in this process, with a view to empowering participants at each stage in the action research cycles. What started out as a negative situation for the majority of study participants, evolved to become a satisfying group process and positive outcomes resulted from the therapy program itself. For clients there was the renewal of close personal relationships with family carers, increased alertness and a reduction in some of their distressing symptoms. For the family carers, there arose an awareness of new purposes in the caring role and therefore less distress in their daily lives, for day-care staff there emerged a re-conceptualisation of purpose of dementia care programs and the benefits to be gained from community collaboration in program design. The focus of this paper is to describe the action research process, which resulted in positive outcomes for the study participants.
Nurses provide the majority of care in the ED, so increases in the number of older people (≥60 ye... more Nurses provide the majority of care in the ED, so increases in the number of older people (≥60 years) may impact nursing workload and provision of care. To determine whom, of older people, emergency nurses perceive as using the most nursing resources and to profile this subgroup from the ED dataset, including illustrative cases. A mixed-methods design study in a metropolitan hospital. Data were collected from focus group interviews with emergency nursing staff (n = 27), from the patient dataset for the corresponding year, and an audit of 13 patients' medical records. Emergency nurses perceived that the highest demand for their resources came from the older persons representing multiple times in short timeframes (cluster presenter). Cluster presenters had a longer length of stay and required intensive nursing time and vigilance because they had one or more chronic illnesses and comorbid conditions such as limited mobility and dementia. Cluster presenters had to have a full assessment each presentation, were usually admitted to the hospital and admitting specialists were reluctant to assume care. Emergency nurses associate a high workload with cluster presenters for reasons including ED processes and availability of expertise. Further research should examine more objectively and precisely nursing workload in this area.
International psychogeriatrics / IPA, Jan 22, 2015
Dementia is a chronic illness without cure or effective treatment, which results in declining men... more Dementia is a chronic illness without cure or effective treatment, which results in declining mental and physical function and assistance from others to manage activities of daily living. Many people with dementia live in long term care facilities, yet research into their quality of life (QoL) was rare until the last decade. Previous studies failed to incorporate important variables related to the facility and care provision or to look closely at the daily lives of residents. This paper presents a protocol for a comprehensive, multi-perspective assessment of QoL of residents with dementia living in long term care in Australia. A secondary aim is investigating the effectiveness of self-report instruments for measuring QoL. The study utilizes a descriptive, mixed methods design to examine how facility, care staff, and resident factors impact QoL. Over 500 residents with dementia from a stratified, random sample of 53 facilities are being recruited. A sub-sample of 12 residents is also...
To examine the literature on the impact of the discharge experience of patients with dementia and... more To examine the literature on the impact of the discharge experience of patients with dementia and their continuity of care. Peer-reviewed and grey literature published in the English language between 1995 and 2014 were systematically searched using Medline, CINAHL, PubMed, PsycINFO and Cochrane library databases, using a combination of the search terms Dementia, Caregivers, Integrated Health Care Systems, Managed Care, Patient Discharge. Also reviewed were Department of Health and Ageing and Alzheimer's Australia research reports between 2000 and 2014. The review found a wide range of studies that raise concerns in relation to the quality of care provided to people with dementia during hospital discharge and in transitional care. Discharge planning and transitional care for patients with dementia are not adequate and are likely to lead to readmission and other poor health outcomes.
This study was conducted in one multicultural dementia day-care centre over a period of 18 months... more This study was conducted in one multicultural dementia day-care centre over a period of 18 months. It introduced a gentle hand treatment for clients using three essential oils. The study evolved out of the process of action research where the family carers and day-care staff participated with the researchers to choose, design, develop and evaluate a hand treatment programme. Data was collected through in-depth interviews pre-and post-treatment, focus group discussions, client observation logbooks and a disability scale. The findings indicate a positive strengthening of the relationship between the person with dementia and their family carer, and an improvement in feelings of health and well-being for both. The specific improvements for clients include increased alertness, self-hygiene, contentment, initiation of toileting, sleeping at night and reduced levels of agitation, withdrawal and wandering. Family carers have reported less distress, improved sleeping patterns and feelings of calm. They also found the treatment useful in helping them manage the difficult behaviours exhibited by their relative with dementia. The benefits of this treatment for nursing practice are that it is safe, effective and easily administered by staff in any setting. a multicultural dementia day-care service in the south-Technology,
The American Journal of Geriatric Psychiatry, 2014
To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing... more To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. 14 nursing homes in Sydney and Brisbane, Australia. 92 residents with a mean age of 85 years. Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.
Background: Depression is a common psychiatric disorder in older people. The study aimed to exami... more Background: Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting.
The American Journal of Geriatric Psychiatry, 2014
To test the hypothesis that individual and institutional-level factors influence the effects of a... more To test the hypothesis that individual and institutional-level factors influence the effects of a humor therapy intervention on aged care residents. Data were from the humor therapy group of the Sydney Multisite Intervention of LaughterBosses and ElderClowns, or SMILE, study, a single-blind cluster randomized controlled trial of humor therapy conducted over 12 weeks; assessments were performed at baseline, week 13, and week 26. One hundred eighty-nine individuals from 17 Sydney residential aged care facilities were randomly allocated to the humor therapy intervention. Professional performers called "ElderClowns" provided 9-12 weekly humor therapy 2-hour sessions, augmented by trained staff, called "LaughterBosses." Outcome measures were as follows: Cornell Scale for Depression in Dementia, Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and proxy-rated quality of life in dementia population scale. Facility-level measures were as follows: support of the management for the intervention, commitment levels of LaughterBosses, Environmental Audit Tool scores, and facility level of care provided (high/low). Resident-level measures were engagement, functional ability, disease severity, and time-in-care. Multilevel path analyses simultaneously modeled resident engagement at the individual level (repeated measures) and the effects of management support and staff commitment to humor therapy at the cluster level. Models indicated flow-on effects, whereby management support had positive effects on LaughterBoss commitment, and LaughterBoss commitment increased resident engagement. Higher resident engagement was associated with reduced depression, agitation, and neuropsychiatric scores. Effectiveness of psychosocial programs in residential aged care can be enhanced by management support, staff commitment, and active resident engagement.
The study aimed to explore the practice of care among emergency nurses caring for older persons w... more The study aimed to explore the practice of care among emergency nurses caring for older persons with cognitive impairment and who presented in pain from a long bone fracture, to highlight nurse confidence and self-efficacy in practice. Cognitive impairment is an issue increasingly facing emergency departments. Older persons with cognitive impairment have complex care needs, requiring effective clinical decision-making and provision of care. Nurse confidence and self-efficacy are critical to meeting the necessary standards of care for this vulnerable patient group. A multi-centre study. The study was undertaken across four emergency departments in Sydney, Australia. Sixteen focus group discussions were conducted with 80 emergency departments of nurses. Four main themes emerged: confidence and self-efficacy through experience; confidence and self-efficacy as a balancing act; confidence and self-efficacy as practice; and confidence and self-efficacy and interpersonal relations. Our findings demonstrate that confidence, self-efficacy and reflexivity enabled the delivery of appropriate, timely and compassionate care. Further, confidence and self-efficacy within nursing praxis relied on clinical experience and reflective learning and was crucial to skill and knowledge acquisition. Our research suggests that confidence, self-efficacy and reflexivity need to be developed and valued in nurses' careers to better meet the needs of complex older persons encountered within everyday practice.
This article reports on a study designed to determine whether demographic characteristics of pati... more This article reports on a study designed to determine whether demographic characteristics of patients such as age, gender and cultural background were associated with different perceptions of the importance of and satisfaction with various aspects of nursing care. In addition, patients, their family/carer and nurses from wards specializing in aged care were compared with general medical wards to determine if there were differences in these perceptions. Results demonstrated that
Background: Dementia care mapping and person centred care are well-accepted as processes for impr... more Background: Dementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched. Objectives: The impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions. Design: A cluster-randomised, controlled trial. Settings: The study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care. Participants: 194 consenting managers, nurses, therapists and nurse assistants working in the participating sites. Methods: Intervention care sites received training and support in either person centred care (n = 5) or dementia care mapping (n = 5); control sites continued with usual dementia care (n = 5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias. Results: The Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Posthoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p = 0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (r s = 0.26, p = 0.004, n = 122) and less depersonalisation (r s = 0.21, p = 0.023, n = 122), but not for any of the other outcome measures.
International Journal of Older People Nursing, 2008
Aim.  To identify the factors associated with better self-management in people with moderate to h... more Aim.  To identify the factors associated with better self-management in people with moderate to high levels of Parkinson's disease following an acute illness event. Design and methods.  A prospective, descriptive study conducted with 75 persons with Parkinson's disease over the age of 55, collected twice: within a week of an acute event and 1 month later, after resuming usual life at home. Participants completed a questionnaire on self-rated health status, self-efficacy, sense of coherence, symptom monitoring and medication and general self-management. Background.  Parkinson's disease is a chronic neurological condition that affects many dimensions of life, including threats to self-identity and confidence in self-management. Self-management has the potential to reduce costs through decreased hospital admissions, disease progression and avoidance of complications. While evidence for the relationships between self-management and self-efficacy and sense of coherence has been demonstrated in some chronic illness groups, this has not previously been demonstrated in Parkinson's disease. Results.  The independent predictors of better self-management were not being hospitalized in the last 6 months, more frequent symptom checking and better self-efficacy for self-management. The influence of other factors on self-management, such as sense of coherence, was mediated through self-efficacy. Support of family and others was associated with better self-efficacy both directly and through an improved sense of coherence. Conclusions and relevance to nursing practice.  The presence of informal support plays an important role in sustaining self-efficacy and sense of coherence and hence self-management in persons with Parkinson's disease. Since these attributes are amenable to change, nurses are in a good position to encourage participation in Parkinson's support groups, teach self-management skills through regular symptom monitoring and to assess and promote self-efficacy and sense of coherence.
Chronic illness causes the majority of disease burden and health costs in developed countries; ho... more Chronic illness causes the majority of disease burden and health costs in developed countries; however, this could be substantially reduced by optimal patient self-management. This study examined the levels of self-management in patients (n = 300) with chronic illness (chronic heart failure, chronic respiratory disease, Parkinson's disease and chronic schizophrenia) of moderate severity who had experienced an illness exacerbation in the last month. Patient's perceptions of self-efficacy in relation to their self-management and their sense of coherence were also assessed at baseline and 1 month later. No changes occurred in self-perceptions or self-management from baseline to follow-up. Patients at risk of poor self-management included people with low self-efficacy, poor sense of coherence, older age and a primary diagnosis of chronic schizophrenia. As self-efficacy is the only predictor known to be amenable to intervention, self-efficacy enhancing support should be promoted.
ABSTRACT Background: Older people who present to the emergency department (ED) often experience a... more ABSTRACT Background: Older people who present to the emergency department (ED) often experience a significant delay to analgesia. This study compares the time to analgesia for cognitively impaired and cognitively intact older people diagnosed with a long bone fracture. Methods: The aim of the study was to determine if cognitive impairment is associated with a delayed analgesic response. A 12-month exploratory study, using patient data, was conducted across four EDs. Medical records of 264 patients with long bone fractures were randomly selected. Results: The majority of patients waited longer than 60 minutes for analgesia. The median time to analgesia was longer for the cognitively impaired (149 minutes) compared with cognitively intact (72 minutes; Mann-Whitney U test: p < 0.001). Conclusions: This study suggests that cognitive impairment is a significant risk factor for delayed analgesia response in the ED.
Literature suggests that quality of life (QOL), quality of care (QOC) and Behavioural and Psychol... more Literature suggests that quality of life (QOL), quality of care (QOC) and Behavioural and Psychological Symptoms of Dementia (BPSD) can be improved by relatively simple and inexpensive person-centred approaches to nursing care practices (PCC) and modifications to physical environment (PCE). Most research on this topic is observational and few randomised controlled trials have included an economic evaluation of PCC and PCE together. The PerCEN study aims to confirm the value of evidence-based nursing by evaluating the efficacy and cost effectiveness of implementing PCC and PCE in residential dementia care services. This article describes the PerCEN study protocol (ANZCTR 12608000095369). The 3-year study commenced in 2009 in 38 eligible government-accredited residential dementia care homes in New South Wales, Australia. Study participants include 605 consented residents over 60 years of age with dementia and 380 consenting permanent direct-care staff. The study employs a factorial, group-randomised, cohort design with stratification to evaluate the main effects of PCC and PCE and their joint effects (PCC + PCE), compared with Usual Care (UC) and Usual Environment (UE) on QOL, QOC and BPSD in dementia. The primary outcomes analysis will use a mixed-model analysis of covariance to determine the effects of PCC and PCE on resident QOL and BPSD, and QOC, adjusting for stratification and other potential confounders. The incremental cost of providing PCE and PCC over UC and UE will be calculated; costs and outcomes will be presented as a cost-consequence analysis and cost-effectiveness ratios will be estimated as a cost per unit change in resident QOL and BPSD. This cluster-randomised trial will rigorously test Kitwood's Social-Psychological Theory of Personhood in Dementia (Kitwood & Bredin 1992). The results will provide timely and solid evidence that can inform policy and nursing practice development in improving the person's QOL and QOC, and reducing BPSD.
Well-being and various forms of agitation in people with dementia can be improved in a person-cen... more Well-being and various forms of agitation in people with dementia can be improved in a person-centered long-term care setting. Data obtained during the Person-Centered Dementia Care and Environment (PerCEN) randomized controlled trial shed light on the factors that influenced the adoption and outcomes of person-centered interventions in long-term care from the perspective of study participants. Data were obtained from PerCEN participants: individual semi-structured interviews with care managers (29), nurses and care staff (70); telephone surveys with family members (73); staff reports of care approaches; and 131 field note entries recorded by the person-centered care and environment facilitators. Data were interpreted inductively using content analysis, code building, theme development, and synthesis of findings. All data sources confirmed that, when adopted, the person-centered model increased the number and variety of opportunities for resident interaction, improved flexibility in care regimens, enhanced staff's attention to resident needs, reduced resident agitation, and improved their well-being. Barriers and enablers for the person-centered model related to leadership, manager, staff and family appreciation of the model, staff's capacity, effective communication and team work among direct care staff, care service flexibility, and staff education on how to focus care on the person's well-being. Successful knowledge translation of the person-centered model starts with managerial leadership and support; it is sustained when staff are educated and assisted to apply the model, and, along with families, come to appreciate the benefits of flexible care services and teamwork in achieving resident well-being. The Australian New Zealand Clinical Trials Registry number is ACTRN 12608000095369.
Older Australians experience health disparities in pain management compared to other groups. This... more Older Australians experience health disparities in pain management compared to other groups. This article is focused on understanding the emergency nurses' perceptions of pain and pain management for older persons with cognitive impairment and presenting with a long bone fracture. This article is part of a larger study focusing on emergency nurses' pain management practices for older Australians with cognitive impairment. The aim of the study was to understand emergency nurses' perceptions of the management of pain for older persons with cognitive impairment and presenting with a long bone fracture. This is part of a larger multicentre programme of research exploring pain management in older persons with cognitive impairment and who are experiencing pain from a long bone fracture. This study had a qualitative research design, with data collected through focus group interviews and a thematic method of analysis. The study is framed by a constructivist's paradigm, which...
Although older people frequently present to the emergency department (ED), little is known about ... more Although older people frequently present to the emergency department (ED), little is known about their experiences in this setting, despite increasing attendance rates reported in this population internationally. This study explores the experiences of older people and their carers leading to and during ED care in a metropolitan university hospital in Sydney, Australia. The study forms part of a larger prospective exploratory study on this topic. Individual in-depth interviews were conducted with 10 people over 65 years of age who had a chronic illness and their carers one month after they presented to the ED. Interviews were transcribed verbatim and analyzed using general interpretive methods. The results revealed that the participants presented to the ED as a result of escalating symptoms and on their general practitioner's advice. Participants felt uninformed about ED procedures, therefore, families/carers felt the need to advocate for information and basic services. Participa...
Journal of the American Medical Directors Association, 2015
Clinical leadership long-term care work environment leadership styles care quality a b s t r a c ... more Clinical leadership long-term care work environment leadership styles care quality a b s t r a c t Objective: To evaluate the effectiveness of a leadership and management program in aged care. Design: Double-blind cluster randomized controlled trial. Setting: Twelve residential and community-aged care sites in Australia. Participants: All care staff employed for 6 months or longer at the aged care sites were invited to participate in the surveys at 3 time points: baseline (time 1), 9 months from baseline (time 2), and 9 months after completion of time 2 (time 3) from 2011 to 2013. At each time point, at least 500 care staff completed a survey. At baseline (N ¼ 503) the largest age group was 45 to 54 years (37%), and the majority of care staff were born in Australia (70%), spoke English (94%), and had at least completed secondary education (57%). Intervention: A 12-month Clinical Leadership in Aged Care (CLiAC) program for middle managers, which aimed to further develop their leadership and management skills in creating positive workplace relationships and in enabling person-centered, evidence-based care. Main outcome measures: The primary outcomes were care staff ratings of the work environment, care quality and safety, and staff turnover rates. Secondary outcomes were care staff's intention to leave their employer and profession, workplace stress, job satisfaction, and cost-effectiveness of implementing the program. Absenteeism was excluded due to difficulty in obtaining reliable data. Managers' self-rated knowledge and skills in leadership and management are not included in this article, which focuses on care staff perceptions only. Results: At 6 months after its completion, the CLiAC program was effective in improving care staff's perception of management support [mean difference 0.61, 95% confidence interval (CI) 0.04e1.18; P ¼ .04]. Compared with the control sites, care staff at the intervention sites perceived their managers' leadership styles as more transformational (mean difference 0.30, 95% CI 0.09e0.51; P ¼.005), transactional (mean difference 0.22, 95% CI 0.05e0.39; P ¼ .01), and less passive avoidant (mean difference 0.30, 95% CI 0.07e0.52; P ¼ .01); and were rated higher on the overall leadership outcomes (mean difference 0.35, 95% CI 0.13e0.56; P ¼ .001) as well as individual manager outcomes: extra effort (P ¼ .004), effectiveness (P ¼ .001), and satisfaction (P ¼ .01). There was no evidence that CLiAC was effective in reducing staff turnover, or improving patient care quality and safety.
This paper reports on a participatory action research study which arose out of the initiatives of... more This paper reports on a participatory action research study which arose out of the initiatives of people caring for clients attending a multicultural dementia day-care program. Through a democratic decision making process, the daycare staff and family carers consulted with clients to design, implement and evaluate a new therapy program. The researchers acted as facilitators in this process, with a view to empowering participants at each stage in the action research cycles. What started out as a negative situation for the majority of study participants, evolved to become a satisfying group process and positive outcomes resulted from the therapy program itself. For clients there was the renewal of close personal relationships with family carers, increased alertness and a reduction in some of their distressing symptoms. For the family carers, there arose an awareness of new purposes in the caring role and therefore less distress in their daily lives, for day-care staff there emerged a re-conceptualisation of purpose of dementia care programs and the benefits to be gained from community collaboration in program design. The focus of this paper is to describe the action research process, which resulted in positive outcomes for the study participants.
Nurses provide the majority of care in the ED, so increases in the number of older people (≥60 ye... more Nurses provide the majority of care in the ED, so increases in the number of older people (≥60 years) may impact nursing workload and provision of care. To determine whom, of older people, emergency nurses perceive as using the most nursing resources and to profile this subgroup from the ED dataset, including illustrative cases. A mixed-methods design study in a metropolitan hospital. Data were collected from focus group interviews with emergency nursing staff (n = 27), from the patient dataset for the corresponding year, and an audit of 13 patients' medical records. Emergency nurses perceived that the highest demand for their resources came from the older persons representing multiple times in short timeframes (cluster presenter). Cluster presenters had a longer length of stay and required intensive nursing time and vigilance because they had one or more chronic illnesses and comorbid conditions such as limited mobility and dementia. Cluster presenters had to have a full assessment each presentation, were usually admitted to the hospital and admitting specialists were reluctant to assume care. Emergency nurses associate a high workload with cluster presenters for reasons including ED processes and availability of expertise. Further research should examine more objectively and precisely nursing workload in this area.
International psychogeriatrics / IPA, Jan 22, 2015
Dementia is a chronic illness without cure or effective treatment, which results in declining men... more Dementia is a chronic illness without cure or effective treatment, which results in declining mental and physical function and assistance from others to manage activities of daily living. Many people with dementia live in long term care facilities, yet research into their quality of life (QoL) was rare until the last decade. Previous studies failed to incorporate important variables related to the facility and care provision or to look closely at the daily lives of residents. This paper presents a protocol for a comprehensive, multi-perspective assessment of QoL of residents with dementia living in long term care in Australia. A secondary aim is investigating the effectiveness of self-report instruments for measuring QoL. The study utilizes a descriptive, mixed methods design to examine how facility, care staff, and resident factors impact QoL. Over 500 residents with dementia from a stratified, random sample of 53 facilities are being recruited. A sub-sample of 12 residents is also...
To examine the literature on the impact of the discharge experience of patients with dementia and... more To examine the literature on the impact of the discharge experience of patients with dementia and their continuity of care. Peer-reviewed and grey literature published in the English language between 1995 and 2014 were systematically searched using Medline, CINAHL, PubMed, PsycINFO and Cochrane library databases, using a combination of the search terms Dementia, Caregivers, Integrated Health Care Systems, Managed Care, Patient Discharge. Also reviewed were Department of Health and Ageing and Alzheimer's Australia research reports between 2000 and 2014. The review found a wide range of studies that raise concerns in relation to the quality of care provided to people with dementia during hospital discharge and in transitional care. Discharge planning and transitional care for patients with dementia are not adequate and are likely to lead to readmission and other poor health outcomes.
This study was conducted in one multicultural dementia day-care centre over a period of 18 months... more This study was conducted in one multicultural dementia day-care centre over a period of 18 months. It introduced a gentle hand treatment for clients using three essential oils. The study evolved out of the process of action research where the family carers and day-care staff participated with the researchers to choose, design, develop and evaluate a hand treatment programme. Data was collected through in-depth interviews pre-and post-treatment, focus group discussions, client observation logbooks and a disability scale. The findings indicate a positive strengthening of the relationship between the person with dementia and their family carer, and an improvement in feelings of health and well-being for both. The specific improvements for clients include increased alertness, self-hygiene, contentment, initiation of toileting, sleeping at night and reduced levels of agitation, withdrawal and wandering. Family carers have reported less distress, improved sleeping patterns and feelings of calm. They also found the treatment useful in helping them manage the difficult behaviours exhibited by their relative with dementia. The benefits of this treatment for nursing practice are that it is safe, effective and easily administered by staff in any setting. a multicultural dementia day-care service in the south-Technology,
The American Journal of Geriatric Psychiatry, 2014
To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing... more To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. 14 nursing homes in Sydney and Brisbane, Australia. 92 residents with a mean age of 85 years. Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.
Background: Depression is a common psychiatric disorder in older people. The study aimed to exami... more Background: Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting.
The American Journal of Geriatric Psychiatry, 2014
To test the hypothesis that individual and institutional-level factors influence the effects of a... more To test the hypothesis that individual and institutional-level factors influence the effects of a humor therapy intervention on aged care residents. Data were from the humor therapy group of the Sydney Multisite Intervention of LaughterBosses and ElderClowns, or SMILE, study, a single-blind cluster randomized controlled trial of humor therapy conducted over 12 weeks; assessments were performed at baseline, week 13, and week 26. One hundred eighty-nine individuals from 17 Sydney residential aged care facilities were randomly allocated to the humor therapy intervention. Professional performers called "ElderClowns" provided 9-12 weekly humor therapy 2-hour sessions, augmented by trained staff, called "LaughterBosses." Outcome measures were as follows: Cornell Scale for Depression in Dementia, Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and proxy-rated quality of life in dementia population scale. Facility-level measures were as follows: support of the management for the intervention, commitment levels of LaughterBosses, Environmental Audit Tool scores, and facility level of care provided (high/low). Resident-level measures were engagement, functional ability, disease severity, and time-in-care. Multilevel path analyses simultaneously modeled resident engagement at the individual level (repeated measures) and the effects of management support and staff commitment to humor therapy at the cluster level. Models indicated flow-on effects, whereby management support had positive effects on LaughterBoss commitment, and LaughterBoss commitment increased resident engagement. Higher resident engagement was associated with reduced depression, agitation, and neuropsychiatric scores. Effectiveness of psychosocial programs in residential aged care can be enhanced by management support, staff commitment, and active resident engagement.
The study aimed to explore the practice of care among emergency nurses caring for older persons w... more The study aimed to explore the practice of care among emergency nurses caring for older persons with cognitive impairment and who presented in pain from a long bone fracture, to highlight nurse confidence and self-efficacy in practice. Cognitive impairment is an issue increasingly facing emergency departments. Older persons with cognitive impairment have complex care needs, requiring effective clinical decision-making and provision of care. Nurse confidence and self-efficacy are critical to meeting the necessary standards of care for this vulnerable patient group. A multi-centre study. The study was undertaken across four emergency departments in Sydney, Australia. Sixteen focus group discussions were conducted with 80 emergency departments of nurses. Four main themes emerged: confidence and self-efficacy through experience; confidence and self-efficacy as a balancing act; confidence and self-efficacy as practice; and confidence and self-efficacy and interpersonal relations. Our findings demonstrate that confidence, self-efficacy and reflexivity enabled the delivery of appropriate, timely and compassionate care. Further, confidence and self-efficacy within nursing praxis relied on clinical experience and reflective learning and was crucial to skill and knowledge acquisition. Our research suggests that confidence, self-efficacy and reflexivity need to be developed and valued in nurses' careers to better meet the needs of complex older persons encountered within everyday practice.
This article reports on a study designed to determine whether demographic characteristics of pati... more This article reports on a study designed to determine whether demographic characteristics of patients such as age, gender and cultural background were associated with different perceptions of the importance of and satisfaction with various aspects of nursing care. In addition, patients, their family/carer and nurses from wards specializing in aged care were compared with general medical wards to determine if there were differences in these perceptions. Results demonstrated that
Background: Dementia care mapping and person centred care are well-accepted as processes for impr... more Background: Dementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched. Objectives: The impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions. Design: A cluster-randomised, controlled trial. Settings: The study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care. Participants: 194 consenting managers, nurses, therapists and nurse assistants working in the participating sites. Methods: Intervention care sites received training and support in either person centred care (n = 5) or dementia care mapping (n = 5); control sites continued with usual dementia care (n = 5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias. Results: The Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Posthoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p = 0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (r s = 0.26, p = 0.004, n = 122) and less depersonalisation (r s = 0.21, p = 0.023, n = 122), but not for any of the other outcome measures.
International Journal of Older People Nursing, 2008
Aim.  To identify the factors associated with better self-management in people with moderate to h... more Aim.  To identify the factors associated with better self-management in people with moderate to high levels of Parkinson's disease following an acute illness event. Design and methods.  A prospective, descriptive study conducted with 75 persons with Parkinson's disease over the age of 55, collected twice: within a week of an acute event and 1 month later, after resuming usual life at home. Participants completed a questionnaire on self-rated health status, self-efficacy, sense of coherence, symptom monitoring and medication and general self-management. Background.  Parkinson's disease is a chronic neurological condition that affects many dimensions of life, including threats to self-identity and confidence in self-management. Self-management has the potential to reduce costs through decreased hospital admissions, disease progression and avoidance of complications. While evidence for the relationships between self-management and self-efficacy and sense of coherence has been demonstrated in some chronic illness groups, this has not previously been demonstrated in Parkinson's disease. Results.  The independent predictors of better self-management were not being hospitalized in the last 6 months, more frequent symptom checking and better self-efficacy for self-management. The influence of other factors on self-management, such as sense of coherence, was mediated through self-efficacy. Support of family and others was associated with better self-efficacy both directly and through an improved sense of coherence. Conclusions and relevance to nursing practice.  The presence of informal support plays an important role in sustaining self-efficacy and sense of coherence and hence self-management in persons with Parkinson's disease. Since these attributes are amenable to change, nurses are in a good position to encourage participation in Parkinson's support groups, teach self-management skills through regular symptom monitoring and to assess and promote self-efficacy and sense of coherence.
Chronic illness causes the majority of disease burden and health costs in developed countries; ho... more Chronic illness causes the majority of disease burden and health costs in developed countries; however, this could be substantially reduced by optimal patient self-management. This study examined the levels of self-management in patients (n = 300) with chronic illness (chronic heart failure, chronic respiratory disease, Parkinson's disease and chronic schizophrenia) of moderate severity who had experienced an illness exacerbation in the last month. Patient's perceptions of self-efficacy in relation to their self-management and their sense of coherence were also assessed at baseline and 1 month later. No changes occurred in self-perceptions or self-management from baseline to follow-up. Patients at risk of poor self-management included people with low self-efficacy, poor sense of coherence, older age and a primary diagnosis of chronic schizophrenia. As self-efficacy is the only predictor known to be amenable to intervention, self-efficacy enhancing support should be promoted.
ABSTRACT Background: Older people who present to the emergency department (ED) often experience a... more ABSTRACT Background: Older people who present to the emergency department (ED) often experience a significant delay to analgesia. This study compares the time to analgesia for cognitively impaired and cognitively intact older people diagnosed with a long bone fracture. Methods: The aim of the study was to determine if cognitive impairment is associated with a delayed analgesic response. A 12-month exploratory study, using patient data, was conducted across four EDs. Medical records of 264 patients with long bone fractures were randomly selected. Results: The majority of patients waited longer than 60 minutes for analgesia. The median time to analgesia was longer for the cognitively impaired (149 minutes) compared with cognitively intact (72 minutes; Mann-Whitney U test: p < 0.001). Conclusions: This study suggests that cognitive impairment is a significant risk factor for delayed analgesia response in the ED.
Literature suggests that quality of life (QOL), quality of care (QOC) and Behavioural and Psychol... more Literature suggests that quality of life (QOL), quality of care (QOC) and Behavioural and Psychological Symptoms of Dementia (BPSD) can be improved by relatively simple and inexpensive person-centred approaches to nursing care practices (PCC) and modifications to physical environment (PCE). Most research on this topic is observational and few randomised controlled trials have included an economic evaluation of PCC and PCE together. The PerCEN study aims to confirm the value of evidence-based nursing by evaluating the efficacy and cost effectiveness of implementing PCC and PCE in residential dementia care services. This article describes the PerCEN study protocol (ANZCTR 12608000095369). The 3-year study commenced in 2009 in 38 eligible government-accredited residential dementia care homes in New South Wales, Australia. Study participants include 605 consented residents over 60 years of age with dementia and 380 consenting permanent direct-care staff. The study employs a factorial, group-randomised, cohort design with stratification to evaluate the main effects of PCC and PCE and their joint effects (PCC + PCE), compared with Usual Care (UC) and Usual Environment (UE) on QOL, QOC and BPSD in dementia. The primary outcomes analysis will use a mixed-model analysis of covariance to determine the effects of PCC and PCE on resident QOL and BPSD, and QOC, adjusting for stratification and other potential confounders. The incremental cost of providing PCE and PCC over UC and UE will be calculated; costs and outcomes will be presented as a cost-consequence analysis and cost-effectiveness ratios will be estimated as a cost per unit change in resident QOL and BPSD. This cluster-randomised trial will rigorously test Kitwood's Social-Psychological Theory of Personhood in Dementia (Kitwood & Bredin 1992). The results will provide timely and solid evidence that can inform policy and nursing practice development in improving the person's QOL and QOC, and reducing BPSD.
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Papers by Lynn Chenoweth