State Tested Nursing Aides’ Provision of End-of-Life Care in Nursing Homes Implications for Quality Improvement Emma Nochomovitz, MPH Maryjo Prince-Paul, PhD, APRN, AHPCN, FPCN Mary Dolansky, PhD, RN Mendel E. Singer, PhD Peter DeGolia, MD, CMD Scott H. Frank, MD, MS v An increasing prevalence in deaths occurring within nursing homes has led to a growing concern surrounding quality issues in end-of-life (EOL) nursing home care. In addition, prior research has failed to emphasize the importance of state tested nursing aides (STNAs) in providing this type of care. The purpose of this study was to examine quality issues in EOL nursing home care within the context of STNAs’ comfort in providing this care
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. A convenience sample of 108 STNAs from four nursing homes in the Cleveland, Ohio area used PDAs to provide answers to an audio questionnaire. Questions included emergent themes from the literature pertaining to EOL care in nursing homes, as well as materials from a national education initiative to improve palliative care. Findings demonstrated lack of comfort in discussing death with nursing home residents and their families and insufficient knowledge surrounding EOL decisions and certain types of EOL care. Overall, the level of comfort providing EOL care was found to be associated with STNAs’ perceived importance of EOL care, understanding of hospice, and spiritual well-being. JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 4, July/August 2010 255 Author Affiliations: Emma Nochomovitz, MPH, is Research Analyst, National Quality Forum, Washington, DC and Case Western Reserve University, Cleveland, OH. Maryjo Prince-Paul, PhD, APRN, AHPCN, FPCN, is Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. Mary Dolansky, PhD, RN, is Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. Mendel E. Singer, PhD, is Associate Professor, Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH. Peter DeGolia, MD, CMD, is Director, Center for Geriatric Medicine, University Hospitals Case Medical Center and Associate Professor, Family Medicine, Case Western Reserve University School of Medicine, Cleveland, OH. Scott H. Frank, MD, MS, is Director, Master of Public Health Program, Department of Epidemiology and Biostatistics, Department of Family Medicine, Case Western Reserve University, Cleveland, OH. Address correspondence to Emma Nochomovitz, MPH, National Quality Forum, 601 13th St NW, Suite 500 North Washington, DC 20005 (email@example.com). KEY WORDS end-of-life care hospice nursing aides nursing home I n recent years, the growth of the older segment of the population and the prevalence of chronic illness have led to increased institutionalization of the frail and elderly prior to their deaths. In particular, nursing homes have been identified as a place in which end-oflife (EOL) care is occurring with increasing prevalence, as 20% to 25% of deaths now occur in the nursing home setting.1 Given the increasing significance of EOL care within the nursing home setting, nursing homes are under increased scrutiny to provide quality care. This has led to the creation of nursing home specific measures of quality and outcomes. As a result, a growing body of literature highlights several concerns surrounding quality issues in EOL nursing home care. The purpose of this study was to examine quality issues in EOL care as they relate to the role of state tested nursing aides (STNAs), with a particular focus on the degree to which STNAs feel comfortable providing EOL care. v BACKGROUND Despite the significance of EOL care in nursing homes in the context of the growing elderly population likely to utilize EOL health services, there is evidence to suggest that it is not a topic that is widely understood or addressed by nursing home staff. According to Hanson et al,2 a focus group approach may have important implications for understanding the beliefs and practices among nursing home staff caring for dying residents. The study by Hanson and colleagues2 was conducted in two nursing home facilities. Participants included all nursing aides, nurses, or physicians working in either of these facilities, who were willing to volunteer their time to participate in 90-minute focus group sessions that focused on the care of dying nursing home residents.2 Focus group participants’ resulting recommendations for improved quality care at the end of life included four main categories, including changes in delivery of care, improved staff education and skills, addition of new services, and improved support of staff.2 These findings suggest that open discussion about death and dying can improve the quality of care at the end of life and offer several specific contributions to future efforts to improve quality of care in EOL nursing home care.