Browsing by Subject "Long-term care"

Behavioral symptoms of dementia cause considerable distress for persons with dementia and their caregivers and are related to adverse outcomes that have significant social and economic impact. Thus, behavioral symptoms represent one of the most challenging aspects of dementia care. Over the past three decades, research on behavioral symptoms of dementia has laid the foundation for development of non-pharmacological interventions by identifying underlying mechanisms of symptom development. However, the research has largely overlooked how the needs of military veterans may influence development and treatment of behavioral symptoms of dementia, including those needs associated with co-occurring dementia and posttraumatic stress disorder (PTSD). This dissertation aimed to develop knowledge related to behavioral symptoms of dementia among older veterans with and without PTSD by synthesizing current understanding of neurocognitive and psychiatric comorbidities of PTSD among veterans as well as explicating relationships among background factors, proximal factors, and behavioral symptoms of dementia among veterans living in residential care using the need-driven, dementia-compromised behavior (NDB) model.

This dissertation includes a systematic review in Chapter 2 that synthesized the patterns of neurocognitive and psychiatric comorbidities of PTSD in older veterans and revealed a substantial gap in the literature with regards to understanding manifestations and treatment of behavioral symptoms of dementia among older veterans with co-occurring dementia and PTSD. The primary study of this dissertation that encompasses Chapters 3 and 4 utilized an exploratory sequential mixed methods design using secondary data derived from the evaluation dataset of the STAR-VA training program. In Chapter 3, a qualitative study, as the first phase of the mixed methods study, analyzed text data that captured the interdisciplinary care team’s observation of behavioral symptoms of dementia and their circumstances for the subsample of 33 veterans from the STAR-VA dataset. This qualitative study described how behavioral symptoms of dementia are manifested among veterans with and without PTSD in the context of personal, interpersonal/social, and environmental factors that trigger the symptoms. Findings demonstrated that behavioral symptoms of dementia are heterogeneous, with distinct clusters of triggers that are multi-level, thereby warranting an interdisciplinary, multi-level approach to developing person-centered interventions. In addition, findings from this qualitative study informed the development of the second phase of the sequential mixed methods study in Chapter 4 that aimed to test hypothesized pathways between background factors, interpersonal triggers (proximal factors), and behavioral symptoms of rejection of care and aggression and to explore the moderating effect of PTSD on the hypothesized pathways. The mixed methods approach integrated quantitative data measured by standardized scales and text data for 315 veterans derived from the STAR-VA dataset. After converting text data into categorical variables, structural equation modeling (SEM) was performed to compare the patterns of relationships among background factors, interpersonal triggers, and behavioral symptoms of rejection of care and aggression between veterans with and without PTSD. The direct effect of interpersonal triggers and the indirect effect of background factors through interpersonal triggers on rejection of care and aggression emphasizes the importance of developing and implementing psychosocial interventions that improve interpersonal relationships. The multi-group SEM revealed that the full model was not moderated by PTSD. However, the differential direct and indirect effect of background factors and interpersonal triggers as a proximal factor on the behavioral outcomes between veterans with and without PTSD suggest potential different mechanisms of behavioral outcomes between veterans depending upon whether or not PTSD is present. Evidence for the PTSD-moderated mediating effect of interpersonal triggers on the relationship between depression and rejection of care was demonstrated, suggesting the need to develop targeted interventions for veterans with dementia and PTSD who have greater depressive symptoms.

The new knowledge generated from this dissertation helps to clarify complex patterns of associations among background factors such as PTSD and proximal factors and behavioral symptoms of dementia consistent with the NDB model, strengthening the foundation for development of novel approaches to designing and implementing person-centered care for veterans with co-occurring dementia and PTSD.

Developing nations in Asia are posed to experience a significant increase in the population of older adults living in their respective societies. Over the coming decades, India, the second most populous country in the entire world, is poised to experience a significant increase in its elder population. India's population of adults 60 years of age or older is projected to increase from 8% to 19% of the countries total population by the year 2050. Figures predict that by mid-century, 323 million people in India will be aged 60 years or older, more than the total current U.S. population. As the demographic structure of India is making a dramatic shift, concerns regarding the health and wellbeing of the growing Indian elder population are emerging, as is the growing concern for social policy. In addition, Sri Lanka is the fastest aging nation in South Asia. Multiple factors, including an increase in the number of people considered to be the "oldest old" (80+ years of age), a decrease in the number of working age adults, and increases in disability amongst the elderly, could necessitate an increased need for institutionalization of elderly Sri Lankans into long-term care facilities.

This project aims to study aging in south Asia from two different perspectives. An analysis of existing data from Southern India was done to examine the attitudes and beliefs of Indian elders towards aging and support systems for the elderly. Mental health of Indian elders was assessed and logistic regression analysis was conducted to examine possible correlations between attitudes and beliefs of the elderly and elder mental health. In addition, a qualitative descriptive study of Sri Lankan elder homes was carried out in the southern district of Galle, Sri Lanka. A convenience sampling method was used to identify six elder homes located in the area, and visits were made to each of the homes. During the visits, elder home mangers were interviewed in order to gain general information on the functioning and history of the elder homes, as well as general information on the residents living at the facilities.

Results from the Kerala Aging Survey revealed that psychological distress was present for over one third of elders in Kerala. Rates of psychological distress were higher for women, the poor, and those with advanced age. Elder women appear to be especially vulnerable to psychological distress in old age. Elders believe that children are responsible for supporting parents in their old age; lack of satisfaction with support received from children was associated with the presence of psychological distress amongst elders. For the qualitative study on Sri Lankan elders homes, it was found that both familial and community support are significant factors in the long-term care of elderly Sri Lankans. Though many elder home residents had been diagnosed with a chronic NCD or disability, lack of familial support was consistently identified as the driving force necessitating the elderly to reside at the long-term care facilities. With little or no financial assistance from the government, the facilities themselves all relied heavily on donations from the community to function on a daily basis.

Globally there is a rapid growth in the population of older adults ≥65 years. In the United States similar trends are evident and the increasing number of older adults is driving demands for Long-term Care (LTC); however, there is a shortage of registered nurses (RNs) to provide skilled care. Older adults experience higher rates of multiple chronic illnesses that require skilled care and recruiting Foreign Educated Nurses (FENs) is one strategy used in the United States. FEN migration increases racial and ethnic, cultural, and linguistic diversity, and the proportion of baccalaureate prepared RNs in the US. However, research on FENs in LTC is limited, yet most studies focus on acute care settings. The acute care-based research indicates FENs are vulnerable to inequitable compensation, racism, communication challenges and exploitation. If FENs in LTC have similar experiences, this may contribute to burnout and turnover which may further destabilize the RN workforce. To maintain workforce stability, improve inclusive work environments and advance person-centered care for older adults, more research is needed to deepen our understanding of employment outcomes and professional experiences of FENs in LTC. Therefore, the goals of this dissertation are: 1) to generate knowledge to inform culturally appropriate interventions for creating an inclusive environment for all RNs to provide quality person-centered care, and to inform health policies to improve workforce planning for FEN retention in LTC. Chapter 2 presents an integrative review that synthesized peer-reviewed studies and grey literature on RN migration and the impact on LTC in the US. Findings indicated FENs mainly migrated from Low and Middle Income Countries (LMICs) due to socio-economic factors, workplace characteristics, and contextual factors. Increased FEN staffing was mainly associated with significantly improved health outcomes. Further, FENs had higher qualifications, and typically earned higher income relative to US educated nurses (USENs); however, FENs experience multiple forms of discrimination. Chapter 3 presents a secondary analysis of the National Sample Survey of Registered Nurses (NSSRN) 2017 data which compared employment-outcomes (annual salaries, hourly wages, annual RN work hours, job satisfaction) and human capital among FENs and USENs. Findings showed that most FENs belong to racial and ethnic minority groups and have significantly higher human capital, make significantly higher hourly wages and worked significantly fewer annual hours relative to USENs. While FENs and USENs had similar annual salaries and job satisfaction, human capital partially accounted for differences in hourly wages only. Chapter 4 presents findings qualitative study that explored barriers and facilitators for FENs from racial and ethnic minority groups to provide quality care. Cultural barriers, discrimination, ineffective workplace integration, and negative facility characteristics (eg. poor staffing and lack of preceptorship and orientation programs) are major barriers for FENs to provide quality care. However, facilitators to providing quality care identified were positive support, effective workplace integration, acculturation, and positive facility characteristics (eg. having preceptorship and mentorship programs, adequate staffing). The knowledge generated from this dissertation filled critical gaps in the LTC literature. Our mixed methods review was the first to evaluate the state of the science on FENs’ impact on LTC. The state of the science is underdeveloped, however, the integrative review highlighted the very complex experiences of FENs and their unique contributions to LTC. The COVID 19 pandemic highlighted how essential FENs are in supporting the LTC workforce and the health system struggle to maintain adequate staffing levels. Our innovative statistical method of developing the human capital variable holds promise for informing future research to get more accurate measures of its impact on employment outcomes. Examining employment outcomes allowed us to determine that FENs are paid equitable; however, the existence of pay disparity among males and females indicate policies need to be implemented to ensure clinical ladders are free of bias and discrimination. Qualitative findings indicate FENs have mixed professional experiences, however, the knowledge generated could inform potential interventions like structured mentorship and preceptorship programs to improve onboarding practices. Further, this dissertation confirmed the need for policies and interventions that help with language support and cultural sensitivity training for the workforce since LTC is a multicultural environment.

Problem: The demand for residential care facilities is high and still increasing in China. However, the quality of care in these facilities is concerning due to lack of quality control and regulations and insufficient funding. To achieve high-quality care in these facilities, knowledge is needed about residents’ care needs and current efforts to address residents’ care needs in these facilities. Studies from other countries have reported the high prevalence of functional limitations and pain among residents in residential care facilities. This suggested that residents’ care needs relating to functional limitations and pain are potentially substantial in residential care facilities. Therefore, this dissertation aimed to: (1) synthesize existing literature on residents’ care needs and current care, and (2) describe residents’ care needs related to functional limitations and pain.

Methods: Chapter 2 describes a systematic literature review that synthesized evidence on resident characteristics and care needs and staff characteristics and care, and defines areas where research is needed. Chapter 3 describes a qualitative exploratory study that described residents’ challenges with daily life in Chinese residential care facilities. Chapter 4 describes a mixed-method, observational study that explored residents’ descriptions of challenges with pain and functional limitations.

Results: The systematic review revealed that frontline workers received little systematic training for resident care. Chinese residential care facilities had few qualification standards for staff preparation for their roles in these facilities. Also, chronic conditions were prevalent among residents in Chinese residential care facilities. The two observational studies provided three major findings: (1) residents reported significant care needs with functional limitations and pain; (2) residents adopted a substantial number of self-management strategies to address these care needs; (3) residents faced significant barriers when adopting these self-management strategies, including inaccessibility of health care, unsupportive facility policies and administrators, and lacking staff care.

Summary: Knowledge from this dissertation enhances understanding of residents’ care needs with physical limitations and pain in Chinese residential care facilities. This knowledge informs changes to achieve high-quality care in these facilities. This dissertation provides important implications for practice and policy, including: (1) building a resident assessment system with valid tools to comprehensively capture residents’ care needs with functional limitations and pain; (2) incorporating into staff training programs knowledge and skills about how to manage functional limitations and pain;( 3) developing facility policies to support residents’ self-management and frontline workers’ strategies; (4) integrating health care into residential care facilities; (5) modifying physical environment to be resident-centered.