Ersek et al3 echo the findings of Hanson and colleagues2 in their analysis of focus group interviews among licensed nursing staff and certified nursing aides (CNAs) at two nursing homes in the Pacific Northwest.

Ersek et al3 echo the findings of Hanson and colleagues2 in their analysis of focus group interviews among licensed nursing staff and certified nursing aides (CNAs) at two nursing homes in the Pacific Northwest. This study addressed participants’ concerns and educational needs surrounding nursing home care at the end of life. Interviews were administered by three different investigators to a group of 15 licensed staff and 39 CNAs.3 Participants revealed major concerns surrounding symptom management, communication and interaction with patients, uncertainty and stress related to their role as a provider, discrepancies between different involved parties’ goals of care, time constraints, attachment to residents, and self-care needs as the most significant challenges to providing care to dying nursing home residents. Similarly, focus group participants from Wilson and Daley’s4 study of 155 members of nursing home staff and administrators and their perspectives on dying in long-term-care facilities also highlight improvement goals related to the individual role of providers (ie, communication), internal aspects of the nursing home environment (ie, private space), and factors external to the nursing home, such as regulatory requirements and reimbursement.4 A recurrent theme throughout the literature on EOL care in nursing homes identifies nursing assistant job stress as an inevitable characteristic of EOL care. Both Hanson et al2 and Wilson and Daley4 utilized focus groups to assess quality of care within nursing homes at the end of life, while simultaneously unveiling some of the emotional burdens placed on those caring for nursing home residents near the end of life. Hanson et al discovered that there were several factors unique to the type of care they provide that increased their experience of stress at work. For instance, lack of communication and coordination with hospitals, pressure to minimize staffing while maximizing profit, and the fact that they are caring for an increasingly frail and impoverished population were identified as particular barriers to providing the ideal setting for dying residents.2 Included in the body of knowledge pertaining to EOL nursing home care is the potential for research surrounding the use of hospice services to improve quality of care and reduce healthcare expenditures. According to the National Quality Forum, hospice care is defined as ‘‘a service delivery system that provides 256 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 4, July/August 2010 palliative care for patients who have a limited life expectancy and require comprehensive biomedical, psychosocial, and spiritual support as they enter the terminal stage of an illness or condition.’’5 Miller et al6 reported on hospice care within nursing homes in five different states. The study compared the experience of hospice and nonhospice nursing home patients based on Minimum Data Set data, drug prescriptions, and Medicare claims.6 The authors cite several advantages experienced by hospice versus nonhospice nursing home residents. For instance, hospice patients were found to be significantly less likely to be hospitalized in the last 30 or 90 days of life, as well as within the last 6 months of life.6 Miller et al6 also conclude that more frequent pain detection among hospice patients was an indication of more thorough pain assessment among hospice patients compared with their nonhospice counterparts. Miller et al7 found further support for the benefits of hospice in their comparison of analgesic pain management among hospice and nonhospice nursing home patients. In this retrospective cohort study of more than 800 nursing homes in five different states, hospice residents were found to be twice as likely as nonhospice residents to receive regular treatment for daily pain.7 Findings surrounding the potential benefits of hospice utilization highlight the need to integrate EOL principles, such as those promoted in hospice, into the nursing home setting. Given the degree to which STNAs interact at a personal level with nursing home residents and their families, it follows that awareness among STNAs surrounding the principles of hospice and the mechanisms by which hospice may be accessed have the potential to benefit patients’ experience of nursing home care. v PROBLEM AND PURPOSE OF STUDY Research demonstrates that there is a need for increased attention to STNAs, as they play an integral role in EOL care in a nursing home setting and provide up to 90% of direct care to nursing home residents.8,9 Current research fails to provide quantitative data on the needs of STNAs responsible for EOL care, as well as their perceptions surrounding quality issues in EOL nursing home care. Thus, the purpose of this study was to describe the experience of STNAs in providing EOL nursing home care through a survey-based quantitative study. More specifically, this study addresses a gap in the relevant literature on EOL nursing home care focused on STNAs’ perceived level of comfort with providing EOL care. The primary aim of this study was to examine the degree to which STNAs perceive themselves to possess the necessary training, skills, and knowledge to feel comfortable providing quality care at the end of life. A secondary aim was to examine STNAs’ comfort with the provision of EOL care in nursing homes as it relates to job satisfaction, spiritual well-being, and the degree to which STNAs feel supported by their working environment. v METHODS The present study included a convenience sample of STNAs from four nursing homes in Cleveland, Ohio. The STNAs who worked for a hospice were excluded from participation. Institutional review board approval was obtained from Case Western Reserve University. A sample of 380 STNAs from four nursing homes was approached to participate. Following informed consent and face-to-face enrollment, 108 participants (28%) completed the investigator-developed questionnaire consisting of 62 questions. Data were collected pertaining to demographic information, personal characteristics, and several variables pertaining to STNAs’ overall experience with and perceived understanding of EOL care. Demographic information included age, education, and work-related information, including how many years STNAs had been working with older adults in a nursing home and the number of classes they had taken related specifically to EOL care. The collection of more detailed demographic information was limited in an effort to preserve the anonymity of survey respondents. Information pertaining to personal characteristics was collected surrounding individuals’ job satisfaction, spiritual well-being, and the degree to which STNAs felt they were supported by their coworkers. Job satisfaction was measured using a 4-component scale created by the author, after review of existing job satisfaction literature. The internal reliability for this instrument was adequate (Cronbach’s ! = .84). Spiritual well-being was evaluated with the Brief Assessment of Spiritual Insight and Commitment questionnaire.10 This instrument included 14 items measuring the domains of faith, community, control, meaning, peace, and love and has demonstrated a high degree of internal reliability (Cronbach’s ! = .83) when utilized to evaluate spirituality and religiosity within the primary care setting.10 Support from coworkers was measured by a single question asking STNAs whether they felt ❖ ❖ ❖ ❖ ❖ JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 4, July/August 2010 257 they worked in an atmosphere where they were supported by their coworkers. The STNAs’ experience with EOL care was measured primarily by an investigator-developed instrument, which included several components of EOL care, as identified by the geriatric End-of-Life Nursing Education Consortium (ELNEC) curriculum.9 The geriatric ELNEC curriculum is focused on long-term-care settings with detailed sections pertaining to the role of STNAs in EOL care.9 In conjunction with material from the ELNEC curriculum, the investigator conducted a review of scientific literature pertaining to EOL nursing home care from the perspective of STNAs and other nursing home providers. As a result, the investigator developed the ‘‘Comfort Scale’’ in which STNAs were asked to respond to whether they felt comfortable with their role in providing 12 specific types of care. The STNAs’ perspectives on the importance of EOL care were measured according to how important they felt each of the 12 components of the Comfort Scale was in their provision of care. Reliability for these investigator-developed scales ranged from 0.88 to 0.89. The STNAs’ experience with EOL care was also measured using a dichotomous variable that assessed STNAs’ perceived understanding of hospice and palliative care as different models of EOL care delivery. Statistical Analyses SPSS, version 15.0 (SPSS Inc, Chicago, IL), was used to analyze the data. Descriptive statistics were analyzed as either dichotomous variables or as part of individual scales. In addition to the descriptive statistics, potential associations with the outcome variable, comfort providing EOL care, were explored. It was hypothesized that the following study variables might be associated: perceived importance of EOL care skills, understanding of hospice, understanding of palliative care, job satisfaction, spiritual well-being, and support from coworkers. These associations were tested using a multivariable linear regression model. The model was adjusted for age, education, experience with older adults, EOL education, and EOL care experience as potential confounders. A significant statistical test was considered if P G .05.


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