EMPIRICAL STUDIES
doi: 10.1111/scs.12117
Applying a palliative care approach in residential care: effects on nurse assistants’ experiences of care provision and caring climate Ingela Beck RN, PhD (Senior Lecturer)1,2, Ulf Jakobsson RN, PhD (Associate Professor)3 and Anna-Karin Edberg RN, PhD (Professor)1,2 1
Department of Health and Society, Kristianstad University, Kristianstad, Sweden, 2The Swedish Institute for Health Sciences, Lund University, Lund, Sweden and 3Center for Primary Health Care Research, Lund University, Lund, Sweden
Scand J Caring Sci; 2014; 28; 830–841 Applying a palliative care approach in residential care: effects on nurse assistants’ experiences of care provision and caring climate
Background: A palliative care approach aims to integrate psychosocial and existential as well as relationship aspects in the care and is an approach that can be used in residential care. Nurse assistants are the ones who are closest to the residents but have limited prerequisites for working in accordance with the palliative care approach. We aimed to investigate the effects on nurse assistants’ experiences of care provision and the caring climate of an intervention applying a palliative care approach in residential care. Methods: An intervention involving nurse assistants (n = 75) and their leaders (n = 9), in comparison with controls (n = 110), was evaluated using a questionnaire at three points in time. Results: In the intervention group, positive effects were seen concerning the nurse assistants’ reports of the care provision in that they focused more on the residents’
Introduction Palliative care is a holistic approach that integrates psychosocial and existential aspects in the care and highlights the importance of communication between all those involved in addressing the needs of patients and their families (1). The WHO (2) states that palliative care is appropriate for frail older people living in residential care facilities and that palliative care should be offered early in the illness phase. Although caring consists of both relationship and task aspects, a study by Beck et al. Correspondence to: Ingela Beck, Department of Health and Society, Kristianstad University, SE-291 88 Kristianstad, Sweden. E-mail: [email protected]
830
stories about their lives and on communicating with the residents about what gave meaning to their lives. Also, negative effects were seen when the nurse assistants rated that the residents’ needs for medical and nursing care had not been met at the facility directly after the intervention. No effects were seen concerning the caring climate or the prerequisites of providing more personcentred care. Conclusion: The intervention seemed to have encouraged the nurse assistants to focus on relationship aspects with the residents. So as not to jeopardise the NAs’ well-being and to support NAs in keeping themselves involved in existential issues, their support most certainly needs to be continuous and ongoing. However, in spite of the leaders’ involvement, the intervention was not sufficient for changing the organisational prerequisites for more person-centred care. Keywords: intervention, palliative care, caring, longterm care, nurse assistants, quality of care, person-centred care, caring climate. Submitted 23 July 2013, Accepted 28 December 2013
(3) showed that nurse assistants (NAs) working in residential care facilities mainly focused on the tasks. The study also showed that the NAs experienced that a palliative care approach was to be used only during the very last days in the resident’s life. Previous studies have shown that NAs working with older people in residential care express difficulties in focusing on emotional, existential, and relationship aspects in the care provision (3, 4), and there is, therefore, a need for the development of supportive measures for this group. The populations of residential care facilities mainly consist of very old and frail people (5). Living in a residential care facility means safety for many older people because they are able to receive help at any time (6), but entering residential care also means that they have to adapt their lives to the routines in the facility (7). A © 2014 Nordic College of Caring Science
Applying a palliative care approach in residential care recent inspection of residential care facilities found that residents expressed a loss of individual activities, namely that the residents wished they had someone to talk to (8). A research study (3) reported that NAs in residential care facilities feel insecure with regard to talking about existential and emotional problems or needs with the residents and their relatives. Furthermore, a study by Dwyer reported that staff members working in residential care express a conflict between their ideals of how care should be provided and the reality of care provision (4). The Swedish National Guidelines concerning palliative care recommends that staff who meet people in their end-oflife are offered education and supervision in palliative care in order to improve their ability to meet the person’s needs (9). Thus, there seems to be an urgent need for supporting NAs in being able to approach existential, psychosocial and relationship issues as well as the unique needs of the residents and their relatives. According to Brooker (10), it is important to have a supportive care environment in order to meet the unique individual needs and rights of the persons and to support the person’s personhood. Important components in a supportive environment are the inclusion of the person in conversations and supporting the person in relating to others, as well as communicating that the person is respected, accepted, validated, and enabled and can take an active part in the community (10). McCormack and McCance (11) stated that we need a person-centred environment in order to be able to provide person-centred care. The environment needs to consist of a supportive organisational system that facilitates shared decisionmaking and power as well as person-centred activities (i.e. using biographical information to facilitate patients’ participation). Research further describes that a supportive care setting is experienced as an atmosphere of ease (12). A tentative framework by Rasmussen and Edvardsson (13) described such an atmosphere as that of a feeling of athomeness emerging from the three integral dimensions of atmospheres (hospitality, safety and everydayness) and the needs and expectations of the person in the palliative care setting. Furthermore, Norbergh et al. (14) investigated the climate in residential care facilities regarding the work situation. They found that older people living in facilities where the staff rated the climate as more creative (challenges, freedom, idea support and idea time) spent more time with the staff than older people living in facilities where the staff rated the climate as less creative. Thus, the climate of the setting seems to be important for the care provision. Findings in reviews reveal that studies concerning palliative care in long-term care settings are mostly descriptive (15, 16) and that empirical research mainly reports poor-quality end-of-life care (16). The review by Froggatt and Payne (15) reported that only four of 82 © 2014 Nordic College of Caring Science
831
studies addressed education in palliative care for staff in long-term care. Bolmsj€ o (17) reviewed the literature concerning intervention studies in palliative care for older people and found only four studies with a focus on education and support to the staff. Two of these (18, 19) concerned residential care facilities. The study by Stillman et al. (18) reported that staff training in the principles of palliative care, corporate support and consultation with an expert nurse increased the staff’s ability to identify problems in providing palliative care as well as ways of improving care for dying people. Hanson et al. (19) found that recruitment and training of palliative care leadership teams and educational sessions from hospice providers to the staff in nursing homes increased the number of residents that received palliative care, pain assessment, pain treatment, end-of-life care discussions and hospice enrolment. A recent descriptive research study by Philips and colleagues (20) reported that registered nurses (RN) and NAs, as a result of participating in a multifaceted palliative intervention, experienced increased understanding and competence and a desire to adopt multidisciplinary approaches to care planning. Beck et al. (21) reported qualitative results from an intervention focusing on a palliative care approach in the form of study circles and workshops for NAs and their leaders. The results showed that NAs experienced the intervention as positive and that it encouraged them to provide more person-centred care and that it also supported openness and understanding in the workgroup. However, they also experienced obstacles in the form of lack of resources and lack of supportive leadership. Only a few interventions concerning education and support in palliative care have been evaluated, and more knowledge is needed regarding the effectiveness of these. Hence, the aim of this study is to investigate the effects of an intervention applying a palliative care approach in residential care on NAs’ experiences of care provision and of the caring climate.
Research questions Does an intervention applying a palliative care approach in residential care have effects on NAs’ experiences of palliative care provision, the quality of care and personcentred care at the facility? Does an intervention applying a palliative care approach in residential care have effects on NAs’ experiences of the caring climate and the work climate at the facility?
Methods Design This study had a quasi-experimental design that included an intervention group and a control group (22).
832
I. Beck et al.
Assessments were performed in each group at baseline, postintervention, and at a 6-month follow-up. The intervention group also received a 12-month follow-up assessment.
Settings and participants This study was conducted in nine facilities in three of 10 districts in a city (~300 000 inhabitants) in the south of Sweden. All 10 districts in the city had previously provided staff training in basic end-of-life care, and the three districts selected were those that completed it first. Thus, staff in both the intervention and the control groups had previously received training in basic end-of-life care. A power analysis for the main study was performed with the Creative Climate Questionnaire (23) showing that at least 63 participants were required in each group. The calculation was based on the ability to detect a mean difference of 0.2 points with a SD of 0.4 using a two-way significance test at a level of 5% with a power of 80%. Because we anticipated a higher dropout rate in the control group, twice as many participants were selected as controls. The inclusion criteria for the facilities were that they were required to be stable (i.e. no planned leadership or organisational changes) and provide longterm care not only for people with dementia. The control facilities were required to be free from influence from the intervention. The care manager in the respective district was involved in the selection of suitable intervention and control units based on the above-described inclusion criteria. All regularly employed NAs at the selected units were asked to participate in the study. One coordinator and one study-circle leader in each district were employed to administrate the data collection and facilitate the study-circle groups, respectively.
Intervention The intervention was based on the study circles (cf. 21) in combination with interactive workshops to increase knowledge and understanding and to change practices (cf. 24). Seven 2-hour study-circle sessions with three 6-hour workshop meetings in between were carried out at the NAs’ workplaces (Fig. 1). Each study-circle session consisted of discussions and reflections based on researchbased texts or practical tasks focusing on relational, emotional and existential issues in the palliative care approach. In total, there were 13 study-circle groups (n = 82 NAs) consisting of four to eight NAs participating in each group. Eighty-nine percentage of the NAs participated in at least five of the seven sessions. To help the managers and the RNs support the NAs, they had a similar study-circle group as the NAs consisting of all managers (n = 4) and all RNs (n = 5) at the three intervention facilities. The content followed the NAs’ study-circle sessions
but was focused on how to support and guide the NAs. Fifty-five percentage of the leaders participated in at least five of the seven sessions (the results concerning the leaders will be published elsewhere). The in-between workshops were cross-professional where one or two NA representatives from each study-circle group and the manager and/or the RN from the facility participated. During the workshops, the participants discussed how to change practice based on what had been discussed during the study-circle meetings. The intervention has been previously described elsewhere (21).
Data collection A questionnaire was used to collect data at three points in time: before the intervention started, directly after the completion of the intervention and after an additional 6 months (the 6-month follow-up). The NAs in the intervention group also answered the questionnaire after an additional 6 months (the 12-month follow-up) to evaluate whether or not possible effects remained (Fig. 1). The data collection was organised and administered by the coordinator, who was available for clarification of questions. Participants answered the questionnaire during working hours. To ensure confidentiality, they returned the questionnaire in a sealed envelope to the coordinator. Before the data collection, all NAs had received information about the study by the coordinator at workplace meetings, and the NAs had given written informed consent to participate in the study. The number of participants who answered the questionnaire at the three points in time was n = 75 (85.2%) in the intervention group and n = 110 (78.6%) in the control group. The number who answered the questionnaire at four points in time (intervention group only) was n = 65 (73.9%). The most commonly stated reason for not answering the questionnaire was that of being on leave or of having left the position. An attrition analysis in the intervention group showed that those who dropped out in the intervention group experienced the work climate as worse than those who answered the questionnaire at four points in time (p = 0.038). In the control group, the dropouts more often worked part-time than those who answered the questionnaire at the three points in time (p = 0.047). No other differences were seen when comparing those who dropped out and those who remained throughout the study.
Measurements In this study, data concerning demographics, single questions and instruments measuring care provision (palliative care, quality of care and person-centred care) and caring climate (caring climate and work climate) were used. Two additional questions about the benefit of © 2014 Nordic College of Caring Science
Applying a palliative care approach in residential care
833
A convenience sampling of NAs at nine faciliƟes
INTERVENTION n = 100 NAs at 3 facilities
CONTROL n = 212 NAs at 6 facilities
n = 88
n = 137
Baseline, Nov. 2009
Non responders n=1
Non responders n=3
SC-session 1. Palliative care philosophy 2. Older persons experiences 3. Roles as staff/fellow human Workshop 1. How to change practice SC-session 4. Autonomy in palliative care 5. e.g. Social coherence Workshop 2. How to change practice SC-session 6. Relatives situation and needs 7. Support for relatives Workshop 3. How to change practice Dropouts n = 15
Dropouts n = 9
n = 79
Postintervention, May 2010
n = 119
Non responders n=1
Non responders n=6
Dropouts n = 10
Dropouts n = 4
n = 76
Figure 1 An overview of the study design, timing for data collection and the intervention study-circle sessions (SC-session) and workshops.
n = 115
Dropouts n = 11
the intervention were used in the intervention group at the 12-month follow-up. Demographics. Demographics concerning age, gender, education and working unit (general or dementia unit) were used. Palliative care questions. Four questions about the experience of the palliative care provision were used. Two of them concerned the residents, and two concerned the relatives. The response alternatives ranged from 1 (No, not at all) to 3 (Yes, to a large extent). Quality of care aspect questionnaire. The quality of care was measured using the Quality of Care Aspect Questionnaire (25) that consists of 24 items measuring four factors. The response alternatives ranged from 0 (Never happens) to 4 (Happens very often) or 0 (Very bad) to 4 (Very good). High scores represent a desirable state. Factor scores are © 2014 Nordic College of Caring Science
6-month follow-up, Nov. 2010
n = 65
12-month follow-up, May 2011
---
transformed into values that can vary from 0 to 100. Previous studies in similar contexts have reported values of Cronbach’s alpha between 0.80 and 0.86 for the factors and of 0.84 for the total score (25). In this study, corresponding values were 0.76–0.89 for the factors and 0.86 for the total score. Person-centred care assessment tool. The organisational prerequisite for providing person-centred care was measured using the Person-Centered Care Assessment Tool (26). The scale consists of 13 items measuring two factors (27). The response alternatives ranged from 1 (Completely disagree) to 5 (Completely agree), and high scores indicated a high degree of person–centredness. Mean scores were calculated for each factor and for the whole instrument with a possible range from 1 to 5. A previous study in a similar context reported r = 0.75 for test–retest reliability and r = 0.75 for scale agreement reliability (intraclass correlation [ICC]) and an internal consistency with
834
I. Beck et al.
Cronbach’s alpha between 0.72 and 0.73 for the factors and 0.75 for the total score (27). In this study, Cronbach’s alpha values were 0.74–0.79 for the factors and 0.78 for the total score. Person-centred climate questionnaire. The caring climate was measured using the Person-Centered Climate Questionnaire, staff version (28). The scale consists of 14 items measuring three factors. To adjust to the residential context, the term ‘patients’ was replaced with ‘residents’. The response alternatives ranged from 1 (No, completely disagree) to 6 (Yes, totally agree). Mean scores were calculated for each factor and for the whole instrument with a possible range from 1 to 6 for the factors and for the total scale. A higher score corresponds to a more person-centred unit climate. The study within a Swedish nursing care context reported r = 0.51 (ICC) for the scale agreement reliability and internal consistency with Cronbach’s alpha values between 0.77 and 0.84 for the factors and 0.88 for the total score (28). In this study, the corresponding values were 0.80–0.84 for the factors and 0.90 for the total score. Creative climate questionnaire. The work climate was measured using the Creative Climate Questionnaire (29). The scale consists of 50 items measuring 10 factors. The response alternatives ranged from 0 (No, not at all) to 3 (To a high degree). Mean scores were calculated for each factor and for the whole instrument, with a possible range from zero to 3. High scores correspond to a creative organisation. A previous study in a similar context reported Cronbach’s alpha values between 0.77 and 0.91 for the factors (30). In this study, the corresponding values were 0.62–0.88 for the factors and 0.96 for the total score. Questions about the benefit of the study circles. Two additional questions about the benefit of the study circles were used with the intervention group at the 12-month follow-up. The questions asked whether they had been able to use what had been learned during the study circle and whether they had been able to implement changes at the workplace. The response alternatives ranged from 1 (yes) to 3 (No).
Data analysis In cases of missing data (≤10%) in an instrument, imputation of the items’ mean values was used (cf. 31). For descriptive statistics, the mean value, percentage and SD were calculated, as the data were normally distributed. For comparison between independent groups, Student’s t-test, the chi-squared test and the Mann–Whitney U-test were used. Because the intervention and control group differed at baseline on outcome measures, comparison within groups was performed. Friedman’s tests were used
for comparison over time within groups, and Wilcoxon’s signed-rank tests were used for post hoc analyses and for the 12-month follow-up. The alpha level was set at p < 0.05, and to avoid mass significance in post hoc tests, the Bonferroni-adjusted alpha value (
doi: 10.1111/scs.12117
Applying a palliative care approach in residential care: effects on nurse assistants’ experiences of care provision and caring climate Ingela Beck RN, PhD (Senior Lecturer)1,2, Ulf Jakobsson RN, PhD (Associate Professor)3 and Anna-Karin Edberg RN, PhD (Professor)1,2 1
Department of Health and Society, Kristianstad University, Kristianstad, Sweden, 2The Swedish Institute for Health Sciences, Lund University, Lund, Sweden and 3Center for Primary Health Care Research, Lund University, Lund, Sweden
Scand J Caring Sci; 2014; 28; 830–841 Applying a palliative care approach in residential care: effects on nurse assistants’ experiences of care provision and caring climate
Background: A palliative care approach aims to integrate psychosocial and existential as well as relationship aspects in the care and is an approach that can be used in residential care. Nurse assistants are the ones who are closest to the residents but have limited prerequisites for working in accordance with the palliative care approach. We aimed to investigate the effects on nurse assistants’ experiences of care provision and the caring climate of an intervention applying a palliative care approach in residential care. Methods: An intervention involving nurse assistants (n = 75) and their leaders (n = 9), in comparison with controls (n = 110), was evaluated using a questionnaire at three points in time. Results: In the intervention group, positive effects were seen concerning the nurse assistants’ reports of the care provision in that they focused more on the residents’
Introduction Palliative care is a holistic approach that integrates psychosocial and existential aspects in the care and highlights the importance of communication between all those involved in addressing the needs of patients and their families (1). The WHO (2) states that palliative care is appropriate for frail older people living in residential care facilities and that palliative care should be offered early in the illness phase. Although caring consists of both relationship and task aspects, a study by Beck et al. Correspondence to: Ingela Beck, Department of Health and Society, Kristianstad University, SE-291 88 Kristianstad, Sweden. E-mail: [email protected]
830
stories about their lives and on communicating with the residents about what gave meaning to their lives. Also, negative effects were seen when the nurse assistants rated that the residents’ needs for medical and nursing care had not been met at the facility directly after the intervention. No effects were seen concerning the caring climate or the prerequisites of providing more personcentred care. Conclusion: The intervention seemed to have encouraged the nurse assistants to focus on relationship aspects with the residents. So as not to jeopardise the NAs’ well-being and to support NAs in keeping themselves involved in existential issues, their support most certainly needs to be continuous and ongoing. However, in spite of the leaders’ involvement, the intervention was not sufficient for changing the organisational prerequisites for more person-centred care. Keywords: intervention, palliative care, caring, longterm care, nurse assistants, quality of care, person-centred care, caring climate. Submitted 23 July 2013, Accepted 28 December 2013
(3) showed that nurse assistants (NAs) working in residential care facilities mainly focused on the tasks. The study also showed that the NAs experienced that a palliative care approach was to be used only during the very last days in the resident’s life. Previous studies have shown that NAs working with older people in residential care express difficulties in focusing on emotional, existential, and relationship aspects in the care provision (3, 4), and there is, therefore, a need for the development of supportive measures for this group. The populations of residential care facilities mainly consist of very old and frail people (5). Living in a residential care facility means safety for many older people because they are able to receive help at any time (6), but entering residential care also means that they have to adapt their lives to the routines in the facility (7). A © 2014 Nordic College of Caring Science
Applying a palliative care approach in residential care recent inspection of residential care facilities found that residents expressed a loss of individual activities, namely that the residents wished they had someone to talk to (8). A research study (3) reported that NAs in residential care facilities feel insecure with regard to talking about existential and emotional problems or needs with the residents and their relatives. Furthermore, a study by Dwyer reported that staff members working in residential care express a conflict between their ideals of how care should be provided and the reality of care provision (4). The Swedish National Guidelines concerning palliative care recommends that staff who meet people in their end-oflife are offered education and supervision in palliative care in order to improve their ability to meet the person’s needs (9). Thus, there seems to be an urgent need for supporting NAs in being able to approach existential, psychosocial and relationship issues as well as the unique needs of the residents and their relatives. According to Brooker (10), it is important to have a supportive care environment in order to meet the unique individual needs and rights of the persons and to support the person’s personhood. Important components in a supportive environment are the inclusion of the person in conversations and supporting the person in relating to others, as well as communicating that the person is respected, accepted, validated, and enabled and can take an active part in the community (10). McCormack and McCance (11) stated that we need a person-centred environment in order to be able to provide person-centred care. The environment needs to consist of a supportive organisational system that facilitates shared decisionmaking and power as well as person-centred activities (i.e. using biographical information to facilitate patients’ participation). Research further describes that a supportive care setting is experienced as an atmosphere of ease (12). A tentative framework by Rasmussen and Edvardsson (13) described such an atmosphere as that of a feeling of athomeness emerging from the three integral dimensions of atmospheres (hospitality, safety and everydayness) and the needs and expectations of the person in the palliative care setting. Furthermore, Norbergh et al. (14) investigated the climate in residential care facilities regarding the work situation. They found that older people living in facilities where the staff rated the climate as more creative (challenges, freedom, idea support and idea time) spent more time with the staff than older people living in facilities where the staff rated the climate as less creative. Thus, the climate of the setting seems to be important for the care provision. Findings in reviews reveal that studies concerning palliative care in long-term care settings are mostly descriptive (15, 16) and that empirical research mainly reports poor-quality end-of-life care (16). The review by Froggatt and Payne (15) reported that only four of 82 © 2014 Nordic College of Caring Science
831
studies addressed education in palliative care for staff in long-term care. Bolmsj€ o (17) reviewed the literature concerning intervention studies in palliative care for older people and found only four studies with a focus on education and support to the staff. Two of these (18, 19) concerned residential care facilities. The study by Stillman et al. (18) reported that staff training in the principles of palliative care, corporate support and consultation with an expert nurse increased the staff’s ability to identify problems in providing palliative care as well as ways of improving care for dying people. Hanson et al. (19) found that recruitment and training of palliative care leadership teams and educational sessions from hospice providers to the staff in nursing homes increased the number of residents that received palliative care, pain assessment, pain treatment, end-of-life care discussions and hospice enrolment. A recent descriptive research study by Philips and colleagues (20) reported that registered nurses (RN) and NAs, as a result of participating in a multifaceted palliative intervention, experienced increased understanding and competence and a desire to adopt multidisciplinary approaches to care planning. Beck et al. (21) reported qualitative results from an intervention focusing on a palliative care approach in the form of study circles and workshops for NAs and their leaders. The results showed that NAs experienced the intervention as positive and that it encouraged them to provide more person-centred care and that it also supported openness and understanding in the workgroup. However, they also experienced obstacles in the form of lack of resources and lack of supportive leadership. Only a few interventions concerning education and support in palliative care have been evaluated, and more knowledge is needed regarding the effectiveness of these. Hence, the aim of this study is to investigate the effects of an intervention applying a palliative care approach in residential care on NAs’ experiences of care provision and of the caring climate.
Research questions Does an intervention applying a palliative care approach in residential care have effects on NAs’ experiences of palliative care provision, the quality of care and personcentred care at the facility? Does an intervention applying a palliative care approach in residential care have effects on NAs’ experiences of the caring climate and the work climate at the facility?
Methods Design This study had a quasi-experimental design that included an intervention group and a control group (22).
832
I. Beck et al.
Assessments were performed in each group at baseline, postintervention, and at a 6-month follow-up. The intervention group also received a 12-month follow-up assessment.
Settings and participants This study was conducted in nine facilities in three of 10 districts in a city (~300 000 inhabitants) in the south of Sweden. All 10 districts in the city had previously provided staff training in basic end-of-life care, and the three districts selected were those that completed it first. Thus, staff in both the intervention and the control groups had previously received training in basic end-of-life care. A power analysis for the main study was performed with the Creative Climate Questionnaire (23) showing that at least 63 participants were required in each group. The calculation was based on the ability to detect a mean difference of 0.2 points with a SD of 0.4 using a two-way significance test at a level of 5% with a power of 80%. Because we anticipated a higher dropout rate in the control group, twice as many participants were selected as controls. The inclusion criteria for the facilities were that they were required to be stable (i.e. no planned leadership or organisational changes) and provide longterm care not only for people with dementia. The control facilities were required to be free from influence from the intervention. The care manager in the respective district was involved in the selection of suitable intervention and control units based on the above-described inclusion criteria. All regularly employed NAs at the selected units were asked to participate in the study. One coordinator and one study-circle leader in each district were employed to administrate the data collection and facilitate the study-circle groups, respectively.
Intervention The intervention was based on the study circles (cf. 21) in combination with interactive workshops to increase knowledge and understanding and to change practices (cf. 24). Seven 2-hour study-circle sessions with three 6-hour workshop meetings in between were carried out at the NAs’ workplaces (Fig. 1). Each study-circle session consisted of discussions and reflections based on researchbased texts or practical tasks focusing on relational, emotional and existential issues in the palliative care approach. In total, there were 13 study-circle groups (n = 82 NAs) consisting of four to eight NAs participating in each group. Eighty-nine percentage of the NAs participated in at least five of the seven sessions. To help the managers and the RNs support the NAs, they had a similar study-circle group as the NAs consisting of all managers (n = 4) and all RNs (n = 5) at the three intervention facilities. The content followed the NAs’ study-circle sessions
but was focused on how to support and guide the NAs. Fifty-five percentage of the leaders participated in at least five of the seven sessions (the results concerning the leaders will be published elsewhere). The in-between workshops were cross-professional where one or two NA representatives from each study-circle group and the manager and/or the RN from the facility participated. During the workshops, the participants discussed how to change practice based on what had been discussed during the study-circle meetings. The intervention has been previously described elsewhere (21).
Data collection A questionnaire was used to collect data at three points in time: before the intervention started, directly after the completion of the intervention and after an additional 6 months (the 6-month follow-up). The NAs in the intervention group also answered the questionnaire after an additional 6 months (the 12-month follow-up) to evaluate whether or not possible effects remained (Fig. 1). The data collection was organised and administered by the coordinator, who was available for clarification of questions. Participants answered the questionnaire during working hours. To ensure confidentiality, they returned the questionnaire in a sealed envelope to the coordinator. Before the data collection, all NAs had received information about the study by the coordinator at workplace meetings, and the NAs had given written informed consent to participate in the study. The number of participants who answered the questionnaire at the three points in time was n = 75 (85.2%) in the intervention group and n = 110 (78.6%) in the control group. The number who answered the questionnaire at four points in time (intervention group only) was n = 65 (73.9%). The most commonly stated reason for not answering the questionnaire was that of being on leave or of having left the position. An attrition analysis in the intervention group showed that those who dropped out in the intervention group experienced the work climate as worse than those who answered the questionnaire at four points in time (p = 0.038). In the control group, the dropouts more often worked part-time than those who answered the questionnaire at the three points in time (p = 0.047). No other differences were seen when comparing those who dropped out and those who remained throughout the study.
Measurements In this study, data concerning demographics, single questions and instruments measuring care provision (palliative care, quality of care and person-centred care) and caring climate (caring climate and work climate) were used. Two additional questions about the benefit of © 2014 Nordic College of Caring Science
Applying a palliative care approach in residential care
833
A convenience sampling of NAs at nine faciliƟes
INTERVENTION n = 100 NAs at 3 facilities
CONTROL n = 212 NAs at 6 facilities
n = 88
n = 137
Baseline, Nov. 2009
Non responders n=1
Non responders n=3
SC-session 1. Palliative care philosophy 2. Older persons experiences 3. Roles as staff/fellow human Workshop 1. How to change practice SC-session 4. Autonomy in palliative care 5. e.g. Social coherence Workshop 2. How to change practice SC-session 6. Relatives situation and needs 7. Support for relatives Workshop 3. How to change practice Dropouts n = 15
Dropouts n = 9
n = 79
Postintervention, May 2010
n = 119
Non responders n=1
Non responders n=6
Dropouts n = 10
Dropouts n = 4
n = 76
Figure 1 An overview of the study design, timing for data collection and the intervention study-circle sessions (SC-session) and workshops.
n = 115
Dropouts n = 11
the intervention were used in the intervention group at the 12-month follow-up. Demographics. Demographics concerning age, gender, education and working unit (general or dementia unit) were used. Palliative care questions. Four questions about the experience of the palliative care provision were used. Two of them concerned the residents, and two concerned the relatives. The response alternatives ranged from 1 (No, not at all) to 3 (Yes, to a large extent). Quality of care aspect questionnaire. The quality of care was measured using the Quality of Care Aspect Questionnaire (25) that consists of 24 items measuring four factors. The response alternatives ranged from 0 (Never happens) to 4 (Happens very often) or 0 (Very bad) to 4 (Very good). High scores represent a desirable state. Factor scores are © 2014 Nordic College of Caring Science
6-month follow-up, Nov. 2010
n = 65
12-month follow-up, May 2011
---
transformed into values that can vary from 0 to 100. Previous studies in similar contexts have reported values of Cronbach’s alpha between 0.80 and 0.86 for the factors and of 0.84 for the total score (25). In this study, corresponding values were 0.76–0.89 for the factors and 0.86 for the total score. Person-centred care assessment tool. The organisational prerequisite for providing person-centred care was measured using the Person-Centered Care Assessment Tool (26). The scale consists of 13 items measuring two factors (27). The response alternatives ranged from 1 (Completely disagree) to 5 (Completely agree), and high scores indicated a high degree of person–centredness. Mean scores were calculated for each factor and for the whole instrument with a possible range from 1 to 5. A previous study in a similar context reported r = 0.75 for test–retest reliability and r = 0.75 for scale agreement reliability (intraclass correlation [ICC]) and an internal consistency with
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I. Beck et al.
Cronbach’s alpha between 0.72 and 0.73 for the factors and 0.75 for the total score (27). In this study, Cronbach’s alpha values were 0.74–0.79 for the factors and 0.78 for the total score. Person-centred climate questionnaire. The caring climate was measured using the Person-Centered Climate Questionnaire, staff version (28). The scale consists of 14 items measuring three factors. To adjust to the residential context, the term ‘patients’ was replaced with ‘residents’. The response alternatives ranged from 1 (No, completely disagree) to 6 (Yes, totally agree). Mean scores were calculated for each factor and for the whole instrument with a possible range from 1 to 6 for the factors and for the total scale. A higher score corresponds to a more person-centred unit climate. The study within a Swedish nursing care context reported r = 0.51 (ICC) for the scale agreement reliability and internal consistency with Cronbach’s alpha values between 0.77 and 0.84 for the factors and 0.88 for the total score (28). In this study, the corresponding values were 0.80–0.84 for the factors and 0.90 for the total score. Creative climate questionnaire. The work climate was measured using the Creative Climate Questionnaire (29). The scale consists of 50 items measuring 10 factors. The response alternatives ranged from 0 (No, not at all) to 3 (To a high degree). Mean scores were calculated for each factor and for the whole instrument, with a possible range from zero to 3. High scores correspond to a creative organisation. A previous study in a similar context reported Cronbach’s alpha values between 0.77 and 0.91 for the factors (30). In this study, the corresponding values were 0.62–0.88 for the factors and 0.96 for the total score. Questions about the benefit of the study circles. Two additional questions about the benefit of the study circles were used with the intervention group at the 12-month follow-up. The questions asked whether they had been able to use what had been learned during the study circle and whether they had been able to implement changes at the workplace. The response alternatives ranged from 1 (yes) to 3 (No).
Data analysis In cases of missing data (≤10%) in an instrument, imputation of the items’ mean values was used (cf. 31). For descriptive statistics, the mean value, percentage and SD were calculated, as the data were normally distributed. For comparison between independent groups, Student’s t-test, the chi-squared test and the Mann–Whitney U-test were used. Because the intervention and control group differed at baseline on outcome measures, comparison within groups was performed. Friedman’s tests were used
for comparison over time within groups, and Wilcoxon’s signed-rank tests were used for post hoc analyses and for the 12-month follow-up. The alpha level was set at p < 0.05, and to avoid mass significance in post hoc tests, the Bonferroni-adjusted alpha value (
