Mental Illness in Assisted Living: Challenges for Quality of Life and Care

ABSTRACT

An unknown number of mentally ill elders in the United States receive care in assisted living, along with persons facing physical or cognitive challenges. While dementia is familiar in assisted living, our data indicate that neither staff nor residents are prepared to work or live with the mentally ill. Challenges are created for professionals, since these residents bring diverse needs. Daily interresident interactions are also disrupted or stressful. Qualitative data describe the impacts on quality of resident life as well as care and management dilemmas identified within five assisted-living settings having varying presence of mental illness among residents.     

The ties that bind? Social networks of nursing staff and staff's behaviour towards residents with dementia

This study investigated social networks of nursing staff and staff's behaviour towards residents with dementia. We focused on two types of networks: communication networks among staff, and networks between nursing staff and relatives/acquaintances of residents. Data was collected in 37 long-term care units in nursing- and residential homes in the Netherlands.     

Does Self-Neglect Occur Among Older Adults With Dementia When Unsupervised in Assisted Living? An Exploratory,Observational Study

The phenomenon of older adults with dementia who develop behavioral expressions when they are unsupervised in assisted living residences is understudied. This qualitative study aimed to bridge this gap in the literature by focusing on 12 residents in various stages of dementia. Grounded Theory was followed to guide data collection and analysis. Data were collected in two special care units of an assisted living residence for 10 months. Participant observation was the primary data collection strategy. Semistructured interviews with staff and managers and review of clinical records augmented the observation data. While unsupervised, residents exhibited a wide spectrum of negative emotional states, behavioral expressions, functional difficulties, wayfinding difficulties, serious hygiene problems, and safety risks. More than half of the identified incidents represented self-neglectful behaviors. The study highlights the need for enhanced supervision and targeted interventions for residents with dementia who are susceptible to self-neglect.     

The circumstances surrounding the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes

Resident-to-resident incidents in dementia in long-term care homes resulting in deaths represent a growing concern among residents, family members, care providers, care advocacy organizations, and policy makers. Despite these concerns and experts’ predictions by which injurious and fatal incidents will increase in the coming years due to the projected growth in the number of people with dementia, no studies have been conducted in North America on these fatal incidents. This exploratory pilot study makes first steps towards bridging this major gap in research and practice. Using publicly available information (primarily newspaper articles and death review reports), practically useful patterns were identified pertaining to the circumstances surrounding the death of 105 elders as a result of these incidents. The findings could inform various efforts to prevent future deaths in similar circumstances, keep vulnerable and frail residents safe, and encourage researchers to examine risk and protective factors for these incidents.     

Preservation of self in the nursing home: Contradictory practices within two models of care

Researchers have identified several aspects of nursing home care that interfere with residents' preservation of self. This paper examines how different models of care shape residents' opportunities for preserving a sense of self, adult identity, and agency. Using ethnographic data, I analyze staff practices in two facilities that reflect the contrast between the home and hospital models of long-term care. Previous research on long-term care suggests that an informal, “home-like” approach to care creates more opportunities for residents to preserve a sense of self-identity, whereas a formal, “institutional” approach fosters depersonalizing practices that interfere with residents' psychosocial well-being. My research suggests, however, that both approaches can have contradictory effects on residents' preservation of self. I analyzed patterns of objectification and infantilization that emerged in the social interactions between residents and staff members, as well as practices that mitigated these patterns. This study highlights how a larger culture of ageism and stigma surrounding dependency can become embedded in micro-level practices and underscores the challenges of defining and implementing “good” care.     

The Music Engagement Program for people with Alzheimer’s disease and dementia: Pilot feasibility trial outcomes

Alzheimer’s disease and dementia are common, highly disabling conditions frequently requiring residential care. This exploratory proof-of-concept study aimed to determine if the specialised Music Engagement Program (MEP) was sustainable, acceptable, and effective in improving quality of life, emotional wellbeing, and depression symptoms in this population. Sixteen residents, six staff members, and three family and community members took part in the evaluation of the MEP for people living with dementia in a residential aged-care nursing home in Canberra, Australia. Multiple methods were used. Quantitative evaluation assessed residents’ depression symptoms (Cornell scale) at pre- and post-intervention, and emotional wellbeing pre- and post-session. Qualitative interviews with staff, and family and community members addressed the MEP’s acceptability and potential sustainability. Results showed residents’ mean depression scores were reduced from pre- to post-intervention (p = .039; d_z = 0.72). Interviews established multiple benefits for residents including improved mood, calmness, and reduced aggression. However, staff did not believe it was feasible to continue the MEP sessions beyond the trial period without an external facilitator, citing potential difficulties in adhering to internal activities due to time constraints. This pilot study provides encouraging preliminary evidence for the MEP’s acceptability and potential effectiveness for improving depression and wellbeing in this group.     

Surprise in Social Work Education

Training is commonly seen as the most viable way of ensuring good quality care in residential homes for elderly people. The literature on training has focused on a shift in emphasis from traditional 'professional' social work training for staff at a senior level to training which is to be provided for junior level staff. To this end, Scottish/National Vocational Qualifications have been introduced which, through workplace assessment of competence, have been proclaimed to be the means by which to raise the status and career prospects of a social care workforce. This article argues that task-based competence is increasingly being seen as relevant for a 'para-professional' social care workforce such as that found in the residential care sector. In the light of this, research was undertaken to establish whether residents preferred 'trained' staff, holding formal qualifications and/or NVQs, to 'untrained' staff with no recognised qualifications. The research concluded that residents want kind, understanding and experienced staff, and when length of time in post was taken into account, the effect of training was negligible. The study concluded that homes need to select staff for their good personal qualities and encourage them to stay. Staff need training that integrates skill with understanding and above all, assessment should reflect this perspective. Moreover, residents need to be involved in the assessment process.     

Communication in assisted living

This study of communication in an Assisted Living Facility (ALF) focuses on staff's interpretive frameworks and situational tactics for managing elderly residents. It is based on interviews with staff and residents in an ALF together with ethnographic fieldwork. As in other quasi-total institutions, staff members engage in control as well as care, monitoring residents for compliance with rules and directives. Residents, aware of the threat of being moved to a nursing home, also monitor their own behavior and cognition in comparison to other residents. Other communication issues include the infantilization of the elderly by staff, and the race, class, and ethnic prejudices of residents.     

Improving Australian Residential Aged Care Facilities: A Review of Minor Refurbishment Elements

The objective of this study is to identify elements pertaining to minor refurbishments of residential aged care facilities. A narrative review of relevant publications was conducted. Inductive content analysis was used to categorize coded data into major or minor refurbishment or staff practices. Further analysis identified minor refurbishment domains. There were 14 major refurbishment, seven minor refurbishment and two staff practices domains established. The minor refurbishment elements (n?=?7) identified were lighting, furniture, color and contrast, wayfinding, noise, signage, and flooring. Assessing these elements would assist residential aged care providers to prioritize the provision of minor improvements to the environment for residents.     

Mom and Pop Versus the Big Boys: Adult Family Homes as Providers of Medicaid-Funded Residential Care

This paper compares assisted living apartments (ALs), adult residential care facilities (ARCs), and small adult family homes (AFHs) for Medicaid residents in Washington State, with particular emphasis on the settings, staffing, services, and policies of AFHs. We targeted for enrollment all residents entering an AFH, ARC, or AL setting on Medicaid/state funding in a three-county area of Washington State. We obtained information on 199 settings, interviewing administrative and direct care providers. AFHs are smaller than ARCs and ALs and less likely to be part of a chain, with no significant difference in staffing ratios of registered nurses and licensed practical nurses. Sixty-four percent of AFH residents were receiving public funds compared to 32% of AL residents. AFHs report admitting residents with more activities of daily living needs, health conditions, and behavior problems. They are less likely to have autonomy-related policies, and they provide more services and fewer activities. While attention should continue to be paid to staff supports, policy and practice should support the continued role of AFHs, which are of special interest because of their potential to provide more homelike, less costly care but with possible trade-offs compared to larger facilities.     

Pioneering partnerships: Resident involvement from multiple perspectives

Resident involvement in residential care homes is a challenge due to shortcomings of consumerist and formal approaches such as resident councils. The PARTNER approach aims to involve residents through collective action to improve their community life and wellbeing. The purpose of this article is to provide insights into the process of resident involvement by the PARTNER approach from the perspectives of multiple stakeholders, including residents, volunteers and staff members. A responsive evaluation was conducted, using participant observations, semi-structured interviews with residents, volunteers and professionals (n = 16), and three focus groups. The findings show that critical elements in this process of resident involvement were the agenda-setting by residents, the formation of a cohesive resident group, the sharing of experiences and stories, the development of collective action, and the development of partnerships between residents and professionals and other stakeholder groups. Residents developed actions (gallery parties and a buddy project) to strengthen social interactions and realized these with the help of volunteers and professionals. We conclude that bringing residents together around a shared topic creates room for activism and leads to empowerment, feelings of social belonging and learning processes. We argue that it is a worthwhile enterprise to further develop structural partnership relations between residents, volunteers and staff in residential care homes.     

Enhancing Critical Reflection amongst Social Work Students: The Contribution of an Experiential Learning Group in Care Homes for Older People

As part of a Practice Learning Centre, representing a partnership between an English University social work department and a non-governmental organisation, 12 students were placed in care homes for older people for their first period of assessed practice. The aims of this initiative were to facilitate: development of critical reflection; deployment of social work skills in a care home setting; and opportunities for social work students to work with care home residents. The learning was captured via four Experiential Groups facilitated by the Practice Educator with responsibility for assessing the students' practice. On-site supervisors also participated. Key learning included understanding of: the importance of critical reflection as a key social work skill; the influence of organisational norms and care home culture on the quality of care practice; the complexity and emotion-rich nature of person-centred care; and the pivotal role of relationships in work with people with dementia. Links made in the Groups—between the experiential and theoretical, the emotional and cognitive, and the structural and personal—demonstrate their value as learning platforms. Placements in care homes have considerable potential to enrich practice education; this is especially important in the context of an ageing population.     

Factors Influencing Family-Member Perception of “Homelikeness” in Long-Term Care Homes

Background: A number of long-term care homes in Nova Scotia, Canada, have been built or redesigned with new models of care with expanded care aide scope of practice and neighborhood-style layouts. Our objective was to examine what physical characteristics (bed size, owner-operator), model of care, and relational (family–staff relationship, perceived staff–resident relationship) factors were associated with increased family-member perception of homelikeness in long-term care homes.

Methods: We analyzed surveys collected from 273 family members from 23 long-term care homes in Nova Scotia, Canada. We conducted a multivariate linear regression to assess variables associated with increased family-member perception of homelikeness.

Results: We found that relationships between family and staff, perceived resident-to-resident relationships, and family involvement in decision making were positively associated with increased family perception of homelikeness. We found no significant associations between model of care or physical characteristics and increased family perception of homelikeness.

Conclusion: Relationships among family members, residents, and staff are integral to family members feeling at home in their loved one's long-term care home. Feeling at home in long-term care is largely related to family-member perception of meaningful social interactions between family and staff, and between residents.     

Staff and youth views on autonomy and emancipation from residential care: A participatory research study

The use of participatory approaches in designing services is still relatively uncommon. In this study, we helped design a service to support the transition of youth from residential care to independent living by exploring the perspectives of staff and of youth regarding: (a) the concept and development of autonomy; and (b) key factors in developing this type of service. We gathered the data through 10 interviews with staff (n = 10) and 4 focus groups with youth (n = 21), and subjected the data to a thematic content analysis. Staff defined autonomy as self-regulation and self-care, and identified three paths to foster autonomy – a sense of normality, meaningful relationships, and planning for emancipation. The staff and youth identified the following important aspects in designing the service: achieving normality (e.g. limited number of residents), promoting youth capacity (e.g. skill-building activities), providing social support (e.g. trust and respect between residents), and assuring guidance and boundaries (e.g. supervision of youth).     

Coming together and pulling apart: Exploring the influence of functional status on co-resident relationships in assisted living

Social relationships can have considerable influence on physical and mental well-being in later life, particularly for those in long-term care settings such as assisted living (AL). Research set in AL suggests that other residents are among the most available social contacts and that co-resident relationships can affect life satisfaction, quality of life, and well-being. Functional status is a major factor influencing relationships, yet AL research has not studied in-depth or systematically considered the role it plays in residents' relationships. This study examines the influences of physical and mental function on co-resident relationships in AL and identifies the factors shaping the influence of functional status. We present an analysis of qualitative data collected over a one-year period in two distinct AL settings. Data collection included: participant observation, informal interviews, and formal in-depth interviews with staff, residents, administrators and visitors, as well as surveys with residents. Grounded theory methods guided our data collection and analysis. Our analysis identified the core category, “coming together and pulling apart”, which signifies that functional status is multi-directional, fluid, and operates in different ways in various situations and across time. Key facility- (e.g., admission and retention practices, staff intervention) and resident-level (e.g., personal and situational characteristics) factors shape the influence of functional status on co-resident relationships. Based on our findings, we suggest strategies for promoting positive relationships among residents in AL, including the need to educate staff, families, and residents.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

Social work in the development of institutional care for older people in Slovenia

Social work in homes for older people in Slovenia has a special role since we have extremely institutionally-oriented care for older people. Characteristic of the development of Slovenian homes for older people is a shift in the dynamics of the orientation of the homes from a medical to a social one. Different factors influenced the shift towards a social orientation, i.e. the policy of establishing homes, the influence of sociogerontological principles, the development of social work and, recently, by their engagement with residents with dementia. In socially-oriented homes a different model of social work is used than in medically-oriented ones. The difference lies in social work methods as well as in the roles of the social worker in different areas of work with the residents, relatives and staff. By defining a model of social work in a socially-oriented home, a special field of social work with older people in the field of institutional care in Slovenia has been developed.     

Staff responses to age‐related health changes in people with an intellectual disability in group homes

The purpose of this study was to explore how supervisors in group homes caring for people with intellectual disability responded to the development of age‐related health changes in their residents. Ten group home supervisors working in the disability sector were interviewed once. Data were analysed using Dimensional Analysis. The study identified several factors related to whether a resident could stay ‘at home’ or would need to be moved to residential aged care (nursing home) including: nature and extent of group home resources, group home staff comfort with residents’ health changes, staff skill at navigating the intersection between the disability and ageing sectors, and the supervisor’s philosophy of care. The ability of older people with an intellectual disability to ‘age in place’ is affected by staff knowledge about and comfort with age‐related illnesses, staff skills at navigating formal services, staffing flexibility, and the philosophy of group home supervisors. Despite the growing international concern for the rights of people with disability, particularly in relation to decision making, questions about the older person’s choice of residence and participation in decision making about what was best for them, were almost nonexistent. Rather, decisions were made based on what was considered to be in ‘the best interest’.     

Meeting communication needs: topics of talk in the nursing home

Nursing home residents primarily rely on staff for communication and interpersonal relationships. Challenged by staffing shortages and increasingly complex care, staff who provide the most communication with residents lack awareness and skills to effectively communicate with older adults. This study, a secondary analysis of staff-resident interactions from one nursing home, explores communication topics and the effects of an intervention. Staff from one unit were recorded during 2 hours of caregiving to provide a representative sample of their communication with residents. Staff then attended an educational program targeting improved awareness of communication needs and reducing "elderspeak". Recording was repeated post-intervention. Baseline conversations focused on activities of daily living (ADLs), personal-social, technical care, and health assessment. Post-intervention ADL talk decreased in staff-resident interactions, while personal-social topics increased. These findings suggest that residents' limited opportunities for communication with staff are primarily focused on care tasks. With increased communication awareness, staff can learn to modify conversational topics to better meet older adults' psychosocial needs.     

Facility Ownership and Resident Satisfaction with Assisted Living

Abstract

Although the majority of assisted living facilities operate as for-profit organizations and serve increasingly frail elderly populations, little is known about the impact of ownership on the quality of care in assisted living. This study examines the relationship between facility ownership and the quality of care in assisted living, using resident satisfaction as a quality indicator. The assessed aspects of satisfaction include health care, housekeeping, physical environment, relationships with staff, and social life/activities. The relationship of facility ownership to resident satisfaction is examined controlling for resident psychological well-being, functional ability, facility size, and staff resources. Data were collected in personal interviews with 156 residents, including 96 residents in eight for-profit facilities and 60 residents in five nonprofit facilities in Maryland. Residents in the sampled nonprofit facilities were more satisfied with assisted living than were residents in the for-profit facilities. In particular, residents in nonprofit facilities were more satisfied with health care, physical environment, and social life/activities in the facility. Better understanding of the relationship between facility ownership and resident satisfaction can help administrators create environments that maximize resident satisfaction in both nonprofit and for-profit facilities.