Participants and Data Collection Process Audio technology was used to create a spoken version of the questionnaire that could be administered using a PDA. The process of transforming the original questionnaire into a version that was accessible to PDAs involved pairing the audio recording of each question from the investigator-developed questionnaire with its appropriate answer using SEDCA software (Don’t Pa..Panic Software, Lyndhurst, OH). PDAs served to overcome several limitations of paper-based questionnaires, such as reliance on respondents’ reading comprehension and understanding of the English language.11 In addition, PDAs have been demonstrated to increase respondents’ perception of privacy in their answers, which was useful in addressing potentially sensitive information regarding STNAs’ perceptions of EOL care.11,12 Table 1 Demographic and Job Characteristics Variable Percentage n Age, y 18-25 21.6 22 26-35 24.5 25 36-45 24.5 25 46-55 20.6 21 56+ 8.8 9 Education Less than high school 2.8 3 Graduated high school or GED 43.9 47 Some college or technical school 46.7 50 Graduated college 6.5 7 Years working with older adults in nursing home G1 10.2 11 1-3 20.4 22 4-7 24.1 26 8-11 11.1 12 12+ 34.3 37 Times worked with dying residents within last 3 y 0 9.3 10 1-4 31.5 34 5-8 19.4 21 9+ 39.8 43 EOL care continuing education classes within last 3 y 0 16.8 18 1 13.1 14 2 15.0 16 3 15.9 17 4+ 39.3 42 Abbreviations: EOL, end-of-life; GED, general equivalency diploma. 258 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 4, July/August 2010 v RESULTS Demographics Demographic information is reported in Table 1. The sample’s age range was 18 to 25 years, and 46% of respondents reported some college or technical school training. More than one-third of the sample (34.3%) has at least 12 years of job experience in nursing homes; 39.8% of STNAs expressed having cared for a dying resident during recent work experience at least nine times. Similarly, nearly 40% of participants noted having attended at least four continuing education classes related to EOL care in recent years. STNA Comfort With EOL Care Table 2 displays each item from the Comfort Scale. Each item lists the degree to which STNAs agreed that they felt comfortable with their role in terms of a particular skill or aspect of care. Each individual component of this scale was examined based on two groups of responses, including ‘‘strongly agree’’ and ‘‘did not strongly agree.’’ This analysis strategy was based on the assumption that respondents who did not strongly agree still had some doubt about their understanding of the service in question. The items in which fewer respondents strongly agreed represent aspects of care in which STNAs expressed less comfort or confidence. In particular, only 14% strongly agreed that they felt comfortable talking about death. While the majority of STNAs did express strong agreement with their comfort in providing assistance with activities of daily living, observing symptoms that may occur near the end of life, and providing care at the time of death, less than half of STNAs expressed as much comfort with the nine other aspects of care about which they were questioned. Only a third of STNAs strongly agreed that they felt comfortable in their knowledge of EOL decisions about care, working with a the body of a deceased resident, or supporting a resident experiencing nausea or vomiting. In a further effort to describe STNAs’ level of comfort with the provision of EOL care, the Comfort Scale was used as the dependent variable in a multivariable linear regression model (Table 3). The model showed that several of the study variables were significantly associated with comfort giving EOL care. Greater perceived importance of EOL care skills (B = .161, P = .015), understanding of hospice (B = .365, P = .006), and spiritual well-being (B = .359, P = .005) were all associated with increased comfort providing EOL care. Understanding of palliative care, job satisfaction, and support from coworkers were not associated with comfort providing EOL care. These analyses were adjusted for age, education, experience working Table 2 Comfort Scale Components: ‘‘I Am Comfortable With My Role inI’’ Variable Percentage n Talking about death Do not SA 86.1 93 SA 13.9 15 Being present at time of death Do not SA 62 67 SA 38 41 Working with body of deceased Do not SA 65.7 71 SA 34.3 37 Supporting resident with delirium Do not SA 54.6 59 SA 45.4 49 Supporting resident with noisy respirations Do not SA 59.3 64 SA 40.7 44 Supporting resident with nausea/vomiting Do not SA 69.4 75 SA 30.6 33 Supporting resident with emotional discomfort Do not SA 61.1 66 SA 38.9 42 Providing assistance at EOL Do not SA 39.8 43 SA 60.2 65 Observing EOL symptoms Do not SA 46.3 50 SA 53.7 58 Observing EOL treatment response Do not SA 57.4 62 SA 42.6 46 Providing care at time of death Do not SA 45.4 49 SA 54.6 59 Being aware of treatment decisions at EOL Do not SA 68.5 74 SA 31.5 34 Abbreviations: ADLs, activities of daily living; EOL, end-of-life; SA, strongly agree. ❖ ❖ ❖ ❖ ❖ JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 4, July/August 2010 259 with older adults, EOL education, and EOL care experience. These findings are strengthened by R2 = 0.471, which suggests that nearly 50% of total variance in STNAs’ comfort with EOL care was explained by this model. Additional Findings The findings pertaining to each of the variables included in the linear regression model shown in Table 3 are outlined in this section. The STNAs’ overall job satisfaction, spiritual well-being, and perceived importance of EOL care were analyzed according to three categorical responses, including low, moderate, and high. The boundaries for the low and high response categories were established using the following formula: mean T [(1/2)] SD. Based on these categories, approximately 19% of STNAs rated themselves having low job satisfaction, whereas 42% identified themselves as highly satisfied with their job. Less than half of STNAs rated themselves as having high spiritual wellness (41.3%). Forty-two percent of STNAs demonstrated a high level of agreement with the importance of specific aspects of EOL care as identified by the ELNEC curriculum. Among the most important were the abilities to observe and report EOL symptoms, provide care at the time of death, and provide support for residents with emotional discomfort. Understanding of hospice and palliative care was analyzed as dichotomous variables, in which 66 respondents (61.1%) strongly agreed that they understood the meaning of hospice and when hospice may be needed, while only 26 respondents (24.3%) strongly agreed that they understand the meaning of palliative care and when it may be needed. Similarly, support from coworkers was analyzed as a dichotomous variable and demonstrated that 88% of STNAs strongly agreed that they worked in an atmosphere in which they were well supported by their peers. v DISCUSSION The STNAs’ comfort with providing EOL care varied widely. In terms of the skills and knowledge outlined by the ELNEC curriculum as important to the role of nursing aides in the provision of EOL care, 40% of STNAs rate themselves as having a high level of comfort, and approximately 30% rate themselves as experiencing a low level of comfort with these aspects of EOL care. The results indicate that there is opportunity for improvement in STNAs’ overall level of comfort with EOL care. There is evidence to suggest that STNAs’ comfort providing certain aspects of EOL care may translate into the quality of care provided. For instance, the fact that less than 14% of STNAs strongly agreed that they feel comfortable talking about death has important implications based on findings from existing literature that difficulty talking about death hinders the ability of nursing home providers, residents, and families to communicate openly and honestly about death.13 This finding and others pertaining to areas in which STNAs are less comfortable providing EOL care are important for targeting areas in which improved nursing assistant training or education is necessary. In addition to talking about death, the fact that only 42.6% respondents feel particularly comfortable observing and reporting symptoms that may occur at the end of life suggests that this is another area of care requiring more careful consideration in efforts to improve the quality of EOL nursing home care. Moreover, this study provides evidence to suggest that efforts to improve STNA comfort with EOL care may find success in independently targeting STNA understanding of hospice care or spiritual well-being. There are both strengths and limitations within this study that may serve as lessons for future research. The strengths of this study include its attention to a relevant and timely topic, as well as an underrecognized member of the interdisciplinary care team: the Table 3 Linear Regression Model for Comfort Providing EOL Carea Study Variable Coefficient (B) P Comfort providing EOL care (dependent variable) 1.564 .000 Perceived importance of EOL care skills .161 .015 Understanding of hospice .365 .006 Understanding of palliative care .187 .162 Job satisfaction j.078 .734 Spiritual well-being .359 .005 Support from coworkers .082 .687 a Controlled for age, education, experience working with older adults, EOL education and EOL care experience. Abbreviation: EOL, end-of-life. 260 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 4, July/August 2010 STNA. This research also provides a promising foundation for future research about EOL nursing home care and nursing aides. In particular, it serves as a potential resource for building targeted educational curricula to improve STNA education about specific aspects of EOL care. Another strength of the study is the use of audio PDA for data collection as this segment of the workforce population has potential difficulty with reading comprehension. The reading comprehension issue may be why current literature on STNAs tends to focus on qualitative methods. The investigator reported that the PDA mode of data collection was well received by STNAs, which suggests that this method may be useful in future research. This study is limited by the representativeness of its sample. The study participants’ level of education and job experience were not consistent with national data. Data from the 2006 Annual Social and Economic Supplement to the Current Population Survey, which indicate that 65% of nursing aides working in nursing homes have less than a high-school degree, provide evidence of the level of education within this representative of STNAs at the national level.14 Furthermore, the four nursing homes chosen for this study included administration that embraced the hospice philosophy and were more likely to educate their STNAs about comprehensive EOL care. Despite these limitations, the study has important clinical implications as there is a dearth of quantitative analysis of the experience of STNAs in providing EOL care. This study demonstrated the need for more education directed toward increasing STNAs knowledge and skill in providing EOL care. Nursing homes can use the instruments from the current study to assess STNAs’ knowledge, comfort, skill, spiritual well-being, understanding of models of EOL care, and perceived importance of EOL care to measure the needs of their current staff. Nursing homes can then individualize education and support of their STNA staff in this important area. The study also indicated a need for emotional support. Hospice programs can collaborate with nursing home staff and provide support group sessions for STNAs who provide 90% of the direct care. Interdisciplinary teams need to include STNAs in the planning of care for patients at the end of life. More research pertaining to this subject is necessary. Research that includes larger samples from different states will help define the needs of STNAs to empower them to provide quality EOL care. The National Nursing Assistant Survey, the first study of STNAs at the national level, represents an example of a large-scale resource that may have the potential to provide insight to the experience of STNAs working in nursing homes.15 In its current form, this survey does not aim to collect information about nursing aides’ experience providing care for dying nursing home
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