supporting the successful management of care homes fileexpectations down on a flipchart, which can...
TRANSCRIPT
SUPPORTING THE SUCCESSFUL MANAGEMENT OF CARE HOMES
nursing & residential careThe only clinical journal for professionals
working in long-term care
Bene� ts of walking for people with dementia
Improving life for people with Parkinson’s 309Selecting heel-o� oading devices: evaluation 317Falls: things to consider before dialling 999 330Providing meaningful activities for residents 354
www.nursingresidentialcare.com
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nursing & residential careThe only clinical journal for professionals
working in long-term care
Life routines and sundown syndrome
Causes of chronic traumatic encephalopathy 249Essentials of venous leg ulcer management 252Rediscovering personal histories in dementia 272Challenging a negative CQC review 288
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Nursing & Residential Care (NRC) was launched in 1999 to give care teams a professional voice and a specialist resource to meet their educational needs. Since then we have remained dedicated to supporting the successful management of care homes, sharing insight, analysis and advice to inform high-quality care.
Every issue contains a wide selection of content for the home manager, covering all the issues that affect the home behind the scenes. We also provide essential information to share with staff, focused on training and the intricacies of care provision.
All articles are written and reviewed by leading authorities in long-term care. This is to guarantee quality, and to ensure everything we publish contains relevant, practical information that can be applied to the care home setting.
Pauline van Roijen, Editor
l MANAGEMENT Expert insight on managing a care home, covering everything from finance and staffing to legal responsibilities and CQC inspections.
l CLINICAL The latest evidence-based expertise, focused on the clinical issues common to long-term care.
l CARE ANALYSIS Focus on best practice and new developments in both the clinical and non-clinical aspects of care provision.
l TRAINING A series of practical articles that share tips and strategies for training staff on a variety of topics.
ESSENTIAL FEATURES©
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COMMENT
‘The way health professionals approach intimate tasks has a significant effect’
Continence is an essential part of the human life cycle; we all expect to
achieve control of our bladder and bowels at a young age. Incontinence
is a common occurrence that affects many individuals in all areas of
health and social care. It is a challenge to accurately identify, assess
and manage effectively. The adverse effects it has on the psychological, social and
physical health and wellbeing of those who experience it is well documented. The
global population is increasing and we are all living longer with more health-
related issues than ever before. More individuals need care provision as they
age. Incontinence is one of the great fears of many people as they age. Although
continence issues can affect anyone at any age from any background or culture, it
is recognised that the risk factors increase with age. The prevalence of dementia-
related conditions are increasing, with 70% of people with a cognitive function
impairment reported to be living with bladder or bowel incontinence (Bladder and
Bowel Community, 2019).
Losing independenceOlder people may find themselves in a position of needing assistance with personal
care, as functional, physical and cognitive ability reduces over time. This may be in
hospital, at home or in residential or nursing care. Allowing someone to assist with
personal tasks such as toileting can challenge someone’s dignity and cross the
boundaries of socially acceptable interventions. Continence is intimate; we spend
our whole lives managing it in a private and personal way, behind a closed, locked
door. It can feel undignified for an older person having someone stood over them
while they are using the toilet if they are at risk of falling or are unable to dress and
undress in a timely manner to manage their own toilet needs.
For health professionals, assisting people to manage the most intimate tasks
when illness reduces their independence is a normal part of the working day.
The way we approach these tasks can, however, have a significant and possibly
demeaning effect on the individual. Feelings of vulnerability, exposure, lack
of control, and dependence on others have been widely recognised as negative
elements associated with incontinence.
Reducing negative feelingsThere are some simple measures we can engage to help reduce the negative
connotations associated with older people who experience continence issues. A
Reducing negative feelings around continence care
Sharon HolroydLead Calderdale Bladder & Bowel Service
Beechwood Community Health Centre,
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RECENT HIGHLIGHTSl Improving care home life for people
with Parkinson's
l Autophagy: a treatment option in neurodegenerative disease
l Changes in employment law: mitigating the gig economy
l Complying with the accessible information standard
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CLINICAL REVIEW
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PROOF Influenza (flu) is one of the main causes of hospitalisation, morbidity and death among the elderly population in the winter months (Walsh et al, 2013). The incubation period of the influenza virus is just 1–4 days, allowing it to spread rapidly. This makes influenza a potentially dangerous disease in the care home setting, where there is a high concentration of vulnerable older people (Lessler et al, 2009). As a seasonal disease, the peak time for the rise in influenza activity occurs between December and April, and is dependent on the strain and subtype of the most common strain of the influenza virus present in the population (Public Health England (PHE), 2016a). Influenza outbreaks in care homes may, however, occur early in the autumn before seasonal immunisation campaigns have been fully started. This is because people over the age of 65 have an immune system that is weaker than that of younger adults (Bakhshi and While, 2014). Although the vaccine is less effective in those over 65 years, it has been shown to reduce the incidence of hospitalisation (Vu et al, 2002).
The pathophysiology of influnza Influenza is caused by a number of viruses of the Orthomyxovirade family (Taubenberger et al, 2008). The World Health Organization (WHO) has classified these into three categories: A, B and C; based on their genomic differences (WHO, 2016). Influenzas A and B have a
similar structure containing eight discrete gene segments, and cause an acute respiratory disease characterised by the sudden onset of high fever, coryza (stuffy nose), cough, headache, prostration, malaise, and inflammation of the upper respiratory tree and trachea (Taubenberger et al, 2008). The acute symptoms and fever can persist for 7–10 days, but the resultant weakness and fatigue may linger for weeks. Further to this, influenza can cause an acute respiratory illness in the older population, leading to complications and morbidity (Pebody et al, 2010). Influenza can be transmitted via droplets or through direct contact (PHE, 2015).
WHO campaignThe 2016–2017 influenza campaign mirrors the WHO target for of 75% flu vaccine uptake for those who are aged 65 years and over (PHE, 2016a). PHE (2016a) also recommends that staff are vaccinated to reduce spread of the virus, as health care workers have a duty of care for their patients. This refers to all public health workers who are defined as frontline health and social care workers providing face-to-face care to patients. The recommendations for the influenza season from the WHO (2016) and the Department of Health (DH) (2013) are the trivalent vaccines (vaccines with three strains of the inactivated virus), which contain the following combination:zz An A/California/7/2009 (H1N1)pdm09-like viruszz An A/Hong Kong/4801/2014 (H3N2)-like viruszz A B/Brisbane/60/2008-like virus. There is also a quadrivalent vaccine, recommended by WHO (2016), that contains the strains above and B/Phuket/3073/2013-like virus (WHO, 2016).
Vaccine administrationThe administration of intradermal inactivated influenza vaccine (Intanza) has now been included in the 2016/2017 influenza campaign for individuals aged 60 years and over, in accordance with the national immunisation programme for active immunisation against influenza, (PHE, 2016b).
Influenza, or the flu, can have a significant effect on the health and wellbeing of older people living in care. In this article Debbie Duncan explains how care home staff can be involved in preventing and reducing the impact of the virus
Identifying and managing influenza in the care home
Deborah Louise DuncanSenior Nurse lecturerBuckinghamshire New [email protected]
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Although the public health measures such as influenza vaccination are effective in limiting influenza transmission in closed environments such as nursing and care homes, it is does not offer 100% effectiveness against the disease (Lee et al, 2009). Simple measures, such as enhanced surveillance (including taking daily temperature if patients appear symptomatic) can help identify early cases. Residents can then be started on the appropriate antiviral medication and segregated from larger groups in the home. Segregation should last 7 days from start of the disease presentation or 24 hours post fever even with antivirals. These measures have been shown to decrease the spread of influenza by 12%, (Lee et al, 2009). It is worth noting, however, that while the normal infectious period is 5 days from presentation of symptoms, this can be longer in the older population due to prolonged viral shedding (Lee et al, 2009).
Identifying influenzaIt is clear that nursing staff need to be able to identify what is a case of influenza and what is a case of the common cold. The PHE definition of what constitutes as a case of influenza is outlined in Box 1; the signs and symptoms of which, are listed in Box 2. It is worth noting, however, that older people do not always present with fever when they have influenza (PHE, 2016c). The reason for this is not yet fully understood.
An outbreak is considered when there are two or more cases within a 48-hour period. When an outbreak occurs, the local health protection team will need to be contacted with relevant information, such as the size of the home and the residents’ details. Local NHS laboratories can then send virology samples to their local PHE public health laboratory for diagnosis of influenza A and B infection, influenza A subtyping and the detection of H275Y-mediated oseltamivir resistance in A (H1N1) pdm09 viruses (PHE, 2016d).
Antiviral medicationAntiviral medicines (known as neuraminidase (NA) inhibitors) are also part of the wider package of public health measures to prevent influenza and its complications (PHE, 2016e). Antivirals may be prescribed at any time in the secondary care setting for patients with suspected seasonal influenza infection. In primary care, they may only prescribed when the chief medical officer has announced that there is influenza within the community (PHE, 2016e). The prescribing guidelines for the influenza virus NA inhibitors zanamivir (Relenza) and oseltamivir (Tamiflu) are available from the National Institute for Health and Care Excellence (NICE) (2008; 2009). Oseltamivir appears to be safe and effective when used both as a treatment or prophylaxis for influenza in the older population (Bowles et al, 2002). Those age 65 and over are considered at risk and are recommended to start their treatment of oral oseltamivir within 48 hours of onset, (Harper et al, 2009).
Box 1: Public Health England definition of influenza in care homes
Influenza is defined as an oral or tympanic temperature ≥37.8 oC and acute onset of at least one of the following respiratory symptoms: zz Cough (with or without sputum)zz Hoarsenesszz Nasal discharge or congestionzz Shortness of breathzz Sore throatzz Wheezingzz Sneezing zz Acute deterioration in physical or mental ability without other known cause.Influenza can also be a confirmed on laboratory detection.
Adapted from Public Health England, 2016a
Box 2. Signs, symptoms and complications of influenzaCommon signs and symptoms of influenza include:zz Sudden onset of feverzz Temperature ≥37.8 oC zz Chillszz Headachezz Myalgia (muscle pain)zz Extreme fatiguezz Dry coughzz Sore throat and stuffy nose.
It can also lead to secondary infections such as: zz Bacterial pneumonia zz Otitis mediazz Meningitiszz Encephalitis zz Meningoencephalitis.
Adapted from Public Health England, 2015
Infection preventionAlthough vaccination has been shown to be a cost-effective intervention for the prevention of influenza in nursing homes, a combination model of vaccination and antiviral medication appears to be associated with significantly fewer cases than use of vaccination alone, particularly in years with vaccine–strain mismatches (Monto et al, 2001; Dharan et al, 2009). Vaccination should also be offered by all health care workers, as there is low herd immunity within the older population. This additional vaccination of health care workers ultimately protects an additional fraction of patients within the care facility (van den Dool et al, 2008). Perry et al (2016) showed that influenza can remain virulent for up to 7 days. Infection prevention and control measures therefore need to include: limiting and avoiding
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TRAINING
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One of the most important aspects of training is to establish what the participants can actually expect from the face-to-face training session they are attending. I find it useful to write these
expectations down on a flipchart, which can be referred to at any time during and at the end of the course.
If the size of the group is between 12–15 people, it is a good idea to ask them to introduce themselves by stating their name and their specific role and how long they have been working in their job. If there are new starters with the company, it is useful to know what their last post was, as some people may enter the care sector without any previous work experience in supporting and caring for older people.
While this exercise may take a few minutes to complete, I believe it is worth referring to everyone’s personal expectations at the end of the session, to seek feedback and establish if I have met or maybe even exceeded people’s expectations.
Equal opportunitiesI begin the session by discussing the law concerning equal opportunities. This law states that is unlawful to discriminate directly or indirectly in recruitment or employment because of age, disability, sex, gender reassignment, pregnancy, maternity, race (which includes colour, nationality and ethnic or national origins), sexual orientation, religion or belief, or because someone is married or in a civil partnership. These are known as protected characteristics.
I remind the people present that it may also be unlawful to refuse to provide a reference for a reason related to one of the protected characteristics.
Avoiding prejudiceI split the group into two smaller groups consisting of six people in each team and I ask them to elect a leader and spokesperson and a scribe. The scribe makes notes on a large piece of paper to be placed on a flipchart for the presentation feedback delivered by the spokesperson to the rest of the group. This discussion is timed to last 15 minutes and addresses the issues surrounding gender and sexual orientation. This is followed by discussions on other protected characteristics.
Both teams give their feedback, and this is followed by a general discussion with the full group. After the discussion, everyone agrees on the need to treat all their colleagues and residents with respect and dignity and to be aware of how they can be affected by prejudice surrounding any of the protected characteristics.
Sometimes people who do not conform to the majority may become a target for discrimination or abuse. I have highlighted some key points raised in the group discussions.
AgeWe discussed the impact of age discrimination on older staff members and how these issues may be resolved locally.zz Older people at work may find it difficult to work 12-hour shifts, and the manager may discuss a time-share with another member of staff to reduce the older person’s workloadzz Some older people may find the physical part of the role difficult, and if there are any issues that arise from this, these should be addressed in a sensitive manner.
DisabilityThe point has been raised by delegates that some staff may have mobility, visual and or hearing difficulties and steps should be taken to address these issues for staff working in administration roles. Sometimes changes may be required to provide specialist seating or a larger computer screen.Access to the main care home building and facilities must be taken into consideration and actioned on prior to a new member of staff with a disability being appointed.
With the recent Government campaign against discrimination, everyone is aware of the impact being targeted for being part of a minority can have on people. Adrian Ashurst tells how he trains nurses on equality, so that an inclusive care environment can be created.
Equality and diversity training for care staff
Adrian AshurstConsultant EditorNRC
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Sexual orientationCompared with heterosexual people, older LGBT people are 2.5 times more likely to live alone, two times more likely to be single, and four and a half times more likely to have no children to call upon in times of need (Renate, 2011). The participants agreed that it was essential to make older gay people feel at ease. Unfortunately, many gay individuals still face discrimination in society. Therefore, it is important that employers are aware of the issues around discrimination in the workplace.
Sex and gender reassignmentIndividuals have the right to dress in accordance with the local dresscode for the care home. However, if a male chooses to dress as a female, this should be made possible with minimum disruption to that person’s life. It is also important for colleagues to be informed how a person undertaking gender reassignment or with a different gender identity would like to be addressed.
Ethnic origin and religionThe group members discuss some of the real issues that they have encountered during previous work experiences. Some of them explain that certain nurses struggle if and when they are spoken to rudely by older people: this can have serious effects on their wellbeing. Nurses who hear others being treated in this manner should have the courage to speak up and defend the victims. Staff all have a duty of care to ensure that all their colleagues are treated with respect and dignity around their cultural and religious beliefs. It is good practice for care homes to provide a multi-
faith room, where residents and staff have the opportunity to reflect and pray at any time.
Any reports of racial abuse must be reported and acted upon immediately, as there should be zero tolerance for this in any care home environment.
Achieving diversityThe group was reminded that it is illegal to discriminate against someone based upon them being part of a minority group, but some companies and employers actually go one step further and promote their ‘commitment to diversity’ in their recruitment advertising campaigns.
It is important that large and small independent care providers be able to illustrate true diversity, where all ethnic groups are represented naturally, rather than being forced into making appointments based upon ethnicity instead of ability. There is the danger of tokenism, where individuals are appointed just to represent a certain group, which can lead to resentment. Personally, I enjoy working in a multicultural environment, as we can all benefit from learning about different cultures from each other.
Managing discussionsThis face-to-face training session can sometimes prove to be very thought-provoking and in some case people can become visibly upset by the topics being discussed. Therefore, it is essential for me to support those individuals who find the subject matter difficult to discuss openly in a large group.
Group discussions need to have a leader to ensure everyone in the group has a chance to speak. A dominant
True diversity is achieved when all groups are represented naturally in a working environment
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adrian.indd 55 03/12/2018 16:02
nursing & residential careThe only clinical journal for professionals
working in long-term care
Bene� ts of walking for people with dementia
Improving life for people with Parkinson’s 309Selecting heel-o� oading devices: evaluation 317Falls: things to consider before dialling 999 330Providing meaningful activities for residents 354
www.nursingresidentialcare.com
cover.indd 1
03/05/2019 15:52
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