System-Level Interventions: Long-Term Changes for Long-Term Care
By Ashley Opp Hofmann
“I have been drawn to working with older adults for a long, long time,” says Wendy Wood, PhD, OTR/L, FAOTA, research associate professor at the University of New Mexico in Albuquerque. A noted researcher and occupational therapist, Wood’s current research project centers on developing staff education programs to promote person-centered and ability-focused care in long-term care facilities.
Wood’s latest study has its roots in her dissertation, for which she studied zoo chimpanzees. “Part of my reason was to look at a captive primate model of the relationship of activity engagement to psychological well-being,” she says. “I had always wanted to bring this [topic] back to older adults, and I’ve been captivated by the experiences of older adults in institutional facilities. This project is where I am today with that.” Previously, Wood had done direct behavioral observations to understand older adults’ time use within the context of everyday activity situations in long-term care.
With graduate students Jennifer Strand and Sara Metheny, Wood is now aiming her research at the level of the entire long-term-care institutional system and will deliver a set of educational recommendations targeted at improving residents’ quality of life. To do this, Wood is drawing on the research of Rosalie Kane, who identifies 11 domains of quality of life in long-term care: (1) sense of safety, security, and order; (2) enjoyment; (3) meaningful activity; (4) relationships; (5) functional competence; (6) physical comfort; (7) dignity; (8) privacy; (9) individuality; (10) autonomy and choice; and (11) spiritual well-being (Kane, 2001).
Occupational Science and Transforming Cultures of Nursing Homes
The 1-year study, funded by the Good Samaritan Society, is based in a Good Samaritan long-term-care facility in Albuquerque. Beginning in April 2007, phase one centered on developing and implementing a 10-week curriculum. Concurrently, Wood’s team conducted homogenous focus groups made up of stakeholders, such as certified nursing assistants (CNAs), registered nurses, licensed practical nurses, managers, family members, and rehabilitation therapists and aides.
“People in the same social group were brought together to talk about what is broadly called ‘culture change reforms’ in nursing homes,” Wood says. “Culture change reforms, as interpreted in this study, boil down to person-centered, ability-focused care.” Wood and her team asked questions such as: How do you understand this type of care? What educational approaches and topics do you think are essential for promoting it? What are the barriers to promoting it in the facility? What enables such care?
“If you’re in a complex system such as a nursing home where there are about 240 employees and 117 beds, then you need to have a shared process of decision-making among key stakeholders,” Wood says. “The education interventions that you develop have to both mirror and teach strategies for deliberate, open dialogue.”
The Next Phases
Wood and her team are now in the second phase of the study, which began in October. It has involved completing an analysis of the initial data and developing an interim report. Wood is currently disseminating the report by presenting it to the executive director, facility employees, family members, residents, and the regional director and national office of the umbrella organization.
The last part of phase two is to recruit participants for deliberative forums. “Deliberative forums are designed to bring people from different groups together in a forum where there’s great attention to balancing the power in order to say, ‘Here’s what everyone said and here are the findings. Now, let’s hash out how we’re going to proceed with doing staff education in this facility in order to promote culture change reforms,” explains Wood.
For phase three, Wood will complete the deliberative forums and continue analyzing the qualitative data the forums produce. Finally, Wood will develop and disseminate a final report that includes a set of educational recommendations that are informed by data, responsive to contemporary adult learning theory and research, and inclusive of both instructional processes and content.
The Results—So Far
The team’s first research question was, how did participants evaluate the implemented curriculum? Feedback indicated that they found the educational program useful. The second question, which was Strand’s main project, examined what stakeholders believe is conducive or inhibitive to maximizing the impact of a staff education program. “We found that training suggestions or programs are not helpful if systems issues are not addressed,” Wood says, citing such issues as problems with communication, turnover, and teamwork, and inconsistencies in staff accountability.
Metheny took on the third research question, which explored the nature of common ethical dilemmas. “Ethical dilemmas that occur within the context of everyday activities like getting dressed or dining can wear the caregiver down over time,” Wood says. For example, a caregiver might be trying to respect a resident’s wishes and autonomy to eat what he or she wants even thought the person is diabetic. According to Wood, “We also found that those ethical dilemmas are really helped when there are strong bonds between the caregiver and care recipients, which happened in the Alzheimer’s Special Care Unit.”
The final research question, addressing what content and instructional processes are essential for promoting person-centered and ability-focused care of residents through staff education, “is the big question of the study,” says Wood. Although the study is only at its halfway point, one recommendation Wood is prepared to make is moving to a three-dimensional education model centered on everyday experience, skill competence, and process competence. At the end of March 2008, the study will have a final report with complete recommendations.
The Rewards of Research
Thus far, Wood’s favorite part of the research study has been getting to know the people at the facility—residents and staff alike. “I am truly in awe of some of these CNAs and their level of caring and commitment. They can be very extraordinary,” she says. “It’s also been really rewarding to engage in this process and to realize that there is quite a bit of consensus about the strengths and challenges of the facility.”
As Wood sees it, occupational therapy practitioners can benefit both long-term-care residents and the profession by going beyond their traditional roles in nursing homes. “I see this study as a whole new way of being an occupational therapist in long-term care,” says Wood. “This is a systems-level intervention to promote person-centered, ability-focused care, positioning a concern with everyday occupation at the very center of that care. I think that is very consistent with AOTA’s Centennial Vision.”
Kane, R. A. (2001). Long-term care and a good quality of life: Bringing them closer together. The Gerontologist, 41, 293–304.
Ashley Opp Hofmann is AOTA’s senior staff writer.