Recent research has highlighted the need for better quality care at night. Alison Petch reports
Title: Supporting older people in care homes at night
Authors: Diana Kerr, Heather Wilkinson and Colm Cunningham
Affiliations: Diana Kerr and Heather Wilkinson are researchers at the Centre for Research on Families and Relationships at the University of Edinburgh Colm Cunningham is director of operations at the Dementia Services Development Centre, University of Stirling.
This report of a study funded by the Joseph Rowntree Foundation looks at an area neglected in much research in care homes, the nature and quality of night-time support provided to care home residents. The twin objectives of the study were, firstly, to ascertain the perspectives of different stakeholders, including residents, staff and regulators, and, secondly, to identify, implement and evaluate practice changes that might improve the night-time experience of residents.
Three care homes in central Scotland were used as case study sites for observation and for the staff, resident and relative interviews. Interviews were completed with 22 direct care staff, six managers, eight residents, and 10 relatives. The care homes varied in size, in provider and in built environment. Interviews were also conducted with staff from the Care Commission, the Scottish regulatory agency. Observations extended over several night shifts at each location.
For the second, “action research” phase, a site-specific action plan designed to improve night-time practices was developed for each of the care homes. This was discussed with management and with night staff and a small number of interventions were agreed for each site and put in place for a period of up to twelve weeks. These interventions included the development and delivery of dementia training training on continence management changes to the physical environment in terms of light and noise changes to staff practices and increased night-time involvement of managers. Both managers and night staff were asked to keep written records of any changes they implemented or observed, and they were interviewed at the end of the implementation phase.
The study found that night-time care generally received less attention – from managers, from care inspections, and in terms of training for night staff. Staff numbers were often “cut to the bone”, and staff were often less experienced and had received little training.
This could lead to staff feeling vulnerable and isolated and to problems with communication and knowledge. Recruitment difficulties led to regular use of agency and bank staff, with consequent lack of familiarity and the need for permanent staff to spend time providing basic information. Residents expressed concerns if there was no choice in the gender of staff for intimate care.
There was little or no training in responding to people with dementia, supporting continence, recognising and managing pain, or supporting good hydration and nutrition. Routine checking for breathing, for falls and for incontinence was intrusive – “I am fast asleep and then they open the door and out on the light and I jump awake, my heart jumps and then I cannot get back to sleep”.
Sleep could be further disrupted by unacceptable levels of light and noise. The night-time physical environment was often disabling rather then enabling, especially for people with dementia. Night-time disruption could be doubly confusing for those with dementia who might wake in the night to find strangers in their room, or be disoriented by mirrors or poor design features. Relatives of those in care homes felt they knew little about night-time care – “there was another world that their relative entered at night, to which they were not party”.
The research identified a number of areas of practice that it was considered required attention. These included management involvement in night-time supervision and practice the frequency and nature of “checking” noise levels light levels staff understanding and response to people with dementia staff understanding and response to issues around incontinence the physical environment and relationships between day and night staff.
The experimentation period showed that small changes could lead to considerable improvements in the night-time care experience. For example the involvement of managers reduced the feelings of isolation and increased communication, with managers able to encourage the implementation of change. The practice of checking was changed from being routine for all to one tuned to the needs of the individual, reducing unnecessary intrusion and disturbed sleep. Efforts were made to reduce noise levels, for example jangling keys and washing machines, and light modification included the use of torches.
A night-time key worker system and night-time care plans were introduced at one home, with promising results. Two of the homes developed new handover arrangements between day and night staff, leading to better communication of residents’ needs.
The experiences of these experimental changes were incorporated into a series of recommendations. These included greater management involvement with night staff and the development of night-time key worker systems which allow for a more individualised approach to care. Risk for example should be assessed for each individual, with the development of an individual night-time care plan which keeps intrusive practices to the minimum. The details of such plans should be communicated to other staff and to relatives. Training should be introduced for night-time care staff. This should include training on dementia awareness and, where required, training on communication with residents in English.
There should be clear expectations as to night-time practices, with regular communication and supervision. The use of agency and bank staff should be kept to a minimum, and managers should address environmental and technological initiatives which could minimise disruption and intrusion. Regulatory bodies should include night-time inspections as routine, with inspectors appropriately trained in dementia awareness and providing home-specific guidance on night-time staffing levels.
The case study nature of this research was designed to identify key practice issues and to explore potential changes rather than to quantify the extent to which the practices found at these sites were representative. The value of the study is in highlighting the impact that practices such as routine checking may have if carried out indiscriminately. Much recent debate has focused on the contrasts between different models of support rather than on the detail of provision within a specific model.
Yet whether an individual receives support within a care home or an alternative such as extracare housing, it is the detail of the daily routine, the extent to which this is tailored to the individual and delivered with dignity and respect that has a major impact on quality of life.
The My Home Life initiative led by Help the Aged, the National Care Homes Research and Development Forum and City University is an extensive programme “aimed at improving the quality of life of those who are living, dying, visiting and working in care homes for older people”. It has identified eight key themes: managing transitions, maintaining identity, creating community, sharing decision-making, improving health and healthcare, supporting good end-of-life, keeping the workforce fit for purpose, and promoting a positive culture. Most of these themes are relevant to the delivery of night-time care the study outlined here offers a valuable starting point for consideration of how good practice can be implemented in this area of crucial importance.
Alison Petch is director of Research in Practice for Adults. Ripfa promotes the use of evidence informed practice in the delivery of adult social care services
LINKS AND RESOURCES
● Supporting Older People in Care Homes at Night by Diana Kerr, Heather Wilkinson and Colm Cunningham, is published by the Joseph Rowntree Foundation.
● As the authors of this report discuss, night-time care has rarely been researched. More general discussion of the context and general principles can be found in the following reports.
● Alzheimer’s Society (2007) Home from Home: A Report Highlighting Opportunities for Improving Standards of Dementia Care in Care Homes
● Help the Aged (2007) My Home Life: Quality of Life in Care Homes
● Help the Aged (2007) My Home Life: Quality of Life in Care Homes – A Review of the Literature