Small-scale, homelike facilities in dementia care: A process evaluation into the experiences of family caregivers and nursing staff

https://doi.org/10.1016/j.ijnurstu.2011.07.008Get rights and content

Abstract

Background

Current developments in institutional dementia care aim at the downsizing of facilities and increasing their homelike appearance. Small-scale living facilities are an example of this movement, in which a small group of residents (usually six to eight) live together in a homelike environment. Residents are encouraged to participate in normal daily activities and nursing staff is part of the household with integrated tasks. Despite the increase of these facilities, little is known about experiences of family caregivers of residents and nursing staff.

Objective

To gain an in-depth insight into the experiences of family caregivers and nursing staff with small-scale living facilities.

Design

A process evaluation was conducted alongside the final measurement of an effectiveness study, using a cross-sectional, descriptive design.

Settings

Two types of institutional dementia care in the Netherlands: small-scale living facilities and regular wards in nursing homes.

Participants

In total, 130 family caregivers and 309 nursing staff workers in both care settings participated in a survey questionnaire. Additional in-depth interviews were conducted with a random selection of 24 participants in small-scale living facilities: 13 family caregivers and 11 nursing staff workers.

Methods

Survey questions for family caregivers focused on care service delivery; questions for nursing staff were related to skills. The interviews especially related to positive and negative aspects of small-scale living facilities and skills for nursing staff.

Results

Both family caregivers and staff mainly reported positive experiences with small-scale living facilities, especially the personal attention that nursing staff provides to residents, their involvement with residents and the emphasis on autonomy in daily life. Barriers mainly related to nursing staff working alone during a large part of the day. Family caregivers in small-scale living facilities were more satisfied with the care facility and nursing staff than those in regular wards.

Conclusion

The findings of the study revealed several positive aspects of small-scale living facilities related to physical, social and organizational aspects that could be used as tools to implement changes in institutional dementia care settings.

Introduction

Due to the progressive nature of dementia, admission to a long-term care facility is usually inevitable when homecare becomes insufficient. Currently, a common policy in long-term institutional care is to create small-scale and homelike care environments (Verbeek et al., 2009b). Worldwide this concept has been implemented in various settings (Annerstedt et al., 1996, Kane et al., 2007, Onishi et al., 2006). Similarities among care concepts reflect person-centred care with normalisation of daily life by focusing on meaningful activities centred on daily household chores. Nursing staff is often part of the household. All concepts emphasise values such as quality of life, well-being, preserving autonomy and enabling residents to maintain their own lifestyle as much as possible (Verbeek et al., 2009b).

Studies investigating small-scale living facilities are scarce and have mainly focused on its effects, showing contrasting results. Promising results were reported for residents (e.g. increased quality of life and less use of physical restraints) and nursing staff (e.g. higher job satisfaction and fewer burn-out symptoms) compared with traditional care (Kane et al., 2007, Te Boekhorst et al., 2009, Te Boekhorst et al., 2008). However, other studies found no convincing effects (Onishi et al., 2006, Verbeek et al., 2010).

Hardly any research has been conducted into experiences with daily care processes in small-scale living facilities. This is important though, since insight these experiences could help future care planning. The role of nursing staff is changing in small-scale living facilities, and they have integrated tasks, not only focusing on nursing care but also organization of activities, preparing meals and other household work (Rabig et al., 2006). Furthermore, the hierarchy in small-scale living facilities is often flattened (White-Chu et al., 2009). This may require other skills and competencies than working at a regular ward, although evidence for this is lacking.

Moreover, evidence shows that small-scale living facilities may be considered as an efficient way to reduce informal caregiver burden (Colvez et al., 2002, Moise et al., 2004, Verbeek et al., 2010). The decision for family caregivers to house their relative in a long-term care facility is very challenging and they often experience feelings of guilt and distress (Bramble et al., 2009). More knowledge and understanding of family caregivers’ experiences with these types of facilities is highly warranted to improve service delivery.

This study therefore aims to provide an in-depth insight into the experiences of family caregivers and nursing staff with daily care processes in small-scale living facilities in the Netherlands. For family caregivers, it specifically addresses experiences with care service delivery, description of the facility and positive and negative aspects of the caregiving process in small-scale living facilities. For nursing staff, the study focuses on skills and positive and negative experiences with working in a small-scale living facility. The study was conducted as a process evaluation as part of a quasi-experimental, longitudinal study into effects of small-scale living facilities on residents, their family caregivers and nursing staff (Verbeek et al., 2009a, Verbeek et al., 2010).

Section snippets

Methods

A cross-sectional study was conducted during April 2009–January 2010, alongside the last measurement of the effectiveness study in long-term institutional nursing care settings for people with dementia (Verbeek et al., 2009a). Questionnaires were sent to family caregivers and nursing staff in small-scale living facilities and traditional nursing homes to obtain an overall understanding of differences in experiences between both institutional nursing care settings. Furthermore, in-depth

Results

Participants’ characteristics are presented in Table 1. No significant differences were found between groups on background variables. Although relatively more women worked in small-scale living facilities compared with regular wards, this difference did not reach significance (p = .06).

Discussion

This study shows that family caregivers and nursing staff have mainly positive experiences with small-scale living facilities in dementia care and their experiences show many similarities with each other. Both family caregivers and staff highly appreciate the personal attention that nursing staff spends on residents, their involvement with residents and the emphasis on autonomy in daily life. Barriers are also experienced, though, mainly related to nursing staff working alone during a large

Conclusion

The current study shows that many aspects of small-scale living facilities related to the physical, social and organizational climate are appreciated by family caregivers and nursing staff. These aspects, such as personal contact and autonomy in day structure, could provide tools to implement change in all institutional dementia care settings.
Conflict of interest: None declared.
Funding: This study was funded by Maastricht University, the Province of Limburg and 5 health care organisations, all

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