A widespread movement to reduce the use of both physical and chemical restraints in long-term care has evolved over the past decade. One impetus for this change was the Omnibus Budget Reconciliation Act of 1987 (OBRA '87, Public Law No. 100-203) which included regulations intended to protect nursing home residents from inappropriate use of physical and chemical restraints. As a consequence of federal mandates, as well as compelling advocacy efforts, long-term care providers began to explore alternative approaches to caring for residents, particularly those suffering from behavioral symptoms of dementia who were at risk to themselves or others.
The practice of individualized care has emerged as one such alternative. Practitioners, advocates, and researchers concerned with restraint reduction have urged the adoption of individualized care models to reduce or negate the need for use of restraints (Dunbar, Neufeld, White, & Libow, 1996; Rader, Lavelle, Hoeffer, & McKenzie, 1996; Werner, Koroknay, Braun, & CohenMansfield, 1994). Individualized care refers to those approaches that support and care for the specific needs of the individual, treating each resident as an autonomous adult. These practices encourage an individual's independence, freedom of movement, and right to make decisions regarding one's daily life (Williams, 1989). This method of care has been described as resident-directed care, in which caregivers are encouraged to seek to understand situations from a resident's perspective (Boyd, 1994; Rader, 1995). Individualized care provides a framework for responding to needs that arise in the process of reducing restraints, and approaches are as varied as the needs of each resident (Werner et al., 1994).
The development and implementation of individualized care and reduction of restraints has been impeded by a number of obstacles, both perceived and real. Reported barriers include cost, insufficient staff, safety and regulatory concerns, lack of team cooperation, and staff and family attitudes (Brandriet, 1995; Hill & Schirm, 1996; Janelli, Kanski, & Neary, 1994). Successful integration of individualized care approaches into the nursing home culture requires that potential impediments be examined thoroughly and addressed fully.
Although as primary caregivers, nurses and certified nurse aides (CNAs) are in a unique position to offer insights regarding residents' care needs, few studies have explored their perceptions of using individualized care. Much of the literature focuses on elimination or reduction of restraints, without fully examining any individualized care techniques employed as alternatives (Hill & Schirm, 1996; Nêary, Kanski, Janelli, Scherer, & North, 1991; Sundel, Garrett, & Horn, 1994). A few studies have examined specific strategies and obstacles to their implementation, but the generalizability of such findings is limited by relatively small sample sizes (Brandriet, 1995; Feldt & Ryden, 1992; Wagner & Colling, 1993).
Another significant limitation of many current studies is the failure to study CNAs as a distinct type of caregiver (Janelli et al., 1994). Because individualized care plans are implemented primarily by CNAs, understanding their perspective is critical to improving care of residents as well as ensuring compliance with federal regulations. This article contributes to the literature on the use of individualized care in nursing homes by exploring the views of nurses and CNAs, with a particular focus on perceived obstacles to implementing change.
Connecticut nursing homes have made measurable strides in embracing the principles and practices of restraint reduction and, more broadly, individualized care over the past several years. Through the efforts of a coalition known as the "Breaking the Bonds" Committee, an ongoing series of educational conferences have addressed issues of physical and chemical restraints, mental health of residents, and concepts of individualized care. Formed in 1994, the committee is a statewide consortium of service providers, federal and state regulators, resident advocates, trade associations, and geriatric researchers. Conference participants have included nurses, administrators, physical therapists, recreational therapists, CNAs, pharmacists, social workers, physicians, home health providers, ombudsmen, state regulators, and other employees from the Departments of Public Health, Social Services, and Protection and Advocacy.
This descriptive study used data collected from these statewide educational forums. Surveys contained both program-specific evaluation content and broader questions pertaining to current practices, barriers to change, and supports needed for adopting alternative approaches to care. A linked database was developed from four conferences between December 1995 and March 1997, yielding a total of 245 nurse and 289 CNA respondents. Nurses include directors of nursing, unit nurses, and nurse managers. A series of common items were included in all conference surveys; the data analyzed in this article are from a subset of 13 forcedchoice items and 2 open-ended questions. Standard descriptive statistics as well as chi-square tests for significant differences between the two groups were computed.
There were a number of highly significant differences among CNAs and nurses regarding obstacles to individualizing care (Figure). For CNAs, inadequate staffing was identified as the greatest barrier to individualized care (66% CNAs versus 51% nurses, ? < .001). The CNAs reported lack of interdisciplinary teams more often than nurses (19% CNAs versus 8% nurses, p < .001).
BARRIERS TO INDIVIDUALIZED CARE
Attitudes of residents and families also were perceived as an impediment more frequently by CNAs than nurses (36% CNAs versus 25% nurses,/» < .01).
Nurses were significantly more likely to report cost of alternative approaches as an obstacle (19% nurses versus 5% CNAs, p < .0001). Similarly, nurses believed more often that concepts are not integrated into daily work (38% nurses versus 15% CNAs, p < .0001). Lack of administrative support was more likely to be noted by nurses (22% nurses versus 16% CNAs, p < .10). Finally, staff attitudes were seen as a greater barrier to providing individualized care by nurses (59% nurses versus 51% CNAs, p < .10).
Despite these significant differences, three issues consistendy were identified most frequently by both nurses and CNAs as obstacles to providing individualized care: inadequate staffing, staff attitudes, and poor communication among team members. However, there was variability in perceptions of their relative importance between the groups. For nurses, staff attitudes was perceived as the greatest barrier (59% nurses, 51% CNAs), while CNAs identified inadequate staffing as the primary impediment to individualized care (66% CNAs, 51% nurses). Poor communication among team members was selected by CNAs as the second greatest obstacle, while for nurses, it was the third most frequently chosen obstacle (54% CNAs, 48% nurses).
The qualitative data were obtained from an open-ended question at the conclusion of each survey. Comments from nurses were taken from responses to the question, "What do you see as the next steps for you or for your facility?" The concluding question on the CNA survey was, "What further training or supports would help you to provide better care for residents in your workplace?".
The qualitative responses from both nurses and CNAs focused primarily on the three most commonly perceived barriers to individualized care expressed in the quantitative data: inadequate staffing, staff attitudes, and poor communication among team members. As was the case in the quantitative findings, CNAs were significantly more likely to identify staffing constraints and lack of interdisciplinary teams as obstacles than were nurses (Table 1). A number of CNA responses expressed concerns regarding insufficient staff to allow the time for individualized care. Responses from nurses echoed some of the CNAs' concerns (Table 2). As reflected in these comments, nurses also view staff constraints as a substantial obstacle to implementing change, although not to the extent CNAs do.
Another theme which emerged from the CNA responses was acknowledgment of their contribution by other facility staff, including respect for CNAs' knowledge and care of residents. The majority of comments suggested CNAs feel undervalued for their expertise and are excluded from substantive participation in interdisciplinary team discussions. Significantly, responses from nurses acknowledged that CNAs are not fully appreciated for their role in caring for residents and are perhaps not perceived as equal members of the team.
Both nurses and CNAs requested further education for all staff, including administrators, recreation therapists, nurses, and CNAs. Suggestions from CNAs included greater awareness from administrators and nurses of the critical role of CNAs and their work in caring for residents. Responses from nurses suggested that educational programs designed for CNAs should focus on specific care approaches for residents, especially those with behavioral symptoms resulting from dementia or mental illness.
IMPLICATIONS FOR NURSING PRACTICE
Since the inception of the "Breaking the Bonds" initiative, a comprehensive database has been developed with the cooperation of the nursing home provider community to plan effective training programs and assess changes in individualized care practices. Surveys have been completed at six time points by conference attendees who represented a variety of professional disciplines, including nurses, social workers, nurse aides, therapists, and administrators, and at two time points by facility directors of nursing.
The generalizability of the data is constrained by two factors. First, surveys were conducted among nursing home professionals only in Connecticut. Given the great variation in nursing home care across states, the observations of CNAs and nurses in Connecticut may not represent the experiences of colleagues in other states. Second, surveys used in this analysis were completed only by individuals who attended one of the "Breaking the Bonds" educational forums and, therefore, may be working in a facility that is more receptive to professional development and committed to implementing individualized care approaches.
This article highlights a number of significant differences in the perceptions of nurses and CNAs in effecting changes in care practices in Connecticut nursing homes. Such disparate views have important implications for nursing practice. Nurses expressed significantly different perceptions of the degree to which individualized care practices are integrated into daily work. Nurses may be more familiar with the movement toward individualized care at a conceptual level, suggesting a need for enhanced training and support of CNAs in the practical application of theories of care, including further education on working with residents who have dementia or a mental illness. Nurses also were more likely to identify staff attitudes as an obstacle to individualized care, which is consistent with previous studies reporting that CNAs recommend use of restraints more often than licensed nursing staff (Hill & Schirm, 1996). Rigid staff attitudes also may indicate CNAs' comfort with familiar practices, facility routine, or facility policy, thereby creating some resistance to change (Wagner & Colling, 1993).
The CNAs were more likely to view resident and family attitudes as inhibiting efforts to adopt alternative approaches to care. This issue should be explored with resident and family councils (in collaboration with CNA training) to facilitate care partnerships among residents, families, and CNAs. Creative educational programming may be directed toward:
SELECTED COiWMENTS FROM CNAs REGARDING NECESSARY SUPPORTS TO BETTER CARE FOR RESIDENTS
SELECTED COMMENTS FROM NURSES REGARDING FUTURE NEEDS TO IMPLEMENT CHANGE
* Encouraging these groups to understand respective roles and responsibilities.
* Exploring how they can work together to create better care for residents.
* Developing pilot programs to be implemented and evaluated.
In terms of changing practices, the fact that CNAs viewed inadequate staffing as a barrier more often than nurses raises questions as to staffing ratios and allocation of responsibilities necessary to institute new care approaches. Nurses were more likely to view lack of administrative support as problematic, which is perhaps a reflection of their closer interaction with administrators within the nursing home. Because nurses mentioned costs associated with individualized care as a barrier, it may be useful to incorporate information about administrative and cost issues into staff development and training for nurse managers.
While nurses may perceive a more substantive involvement of all disciplines in care planning, CNAs expressed a different experience. A thorough and candid assessment of the nature of staff contributions to the care planning process is essential, including discussions with CNAs regarding their perceived participation. Models that truly conceive of CNAs as integral to the resident care team include CNAs in assessments of care needs as well as all care plan decisions.
Several interesting areas of concordance were reflected in the quantitative and qualitative data regarding needs for:
* Additional staff.
* Improvement of staff attitudes.
* Enhanced communication among team members.
Another theme strongly identified in the qualitative data for both nurses and CNAs was the importance of recognizing the value of CNAs and respecting their knowledge of residents. While nurses supported participation of CNAs in multiple levels of resident care, the CNA comments suggested this does not happen routinely.
Developing approaches to individualized care offers important opportunities to stimulate change through education and support of both nurses and CNAs. Broadly collaborative educational programs that include providers, advocates, and regulators are one strategy. Mentoring models also may be a timely approach because nurses appear to be increasingly aware of the need to involve CNAs as true members of the team and CNAs are expressing the need and desire to become more professionalized (Feldt, & Ryden, 1992; Wagner & Colling, 1993). Successful development and adoption of individualized care philosophies can only occur when members of a team share mutual respect and a commitment to collaboration. Multidisciplinary educational programs and mentorship approaches can support and facilitate such relationships among those interested in improving the quality of care in nursing homes - advocates, regulators, and all health care professionals, including CNAs.
- Boyd, C. (1994). Residents first: A long-term care facility introduces a social model that puts residents in control. Health Progress, 75(7), 34-39, 50.
- Brandriet, L.M. (1995). Changing nurse aide behavior to decrease learned helplessness in nursing home elders. Gerontology & Geriatrics Education, 16(2), 3-19.
- Dunbar, J.M., Neufeld, R.R., White, H.C., & Libow, L.S. (1996). Retrain, don't restrain: The educational intervention of the national nursing home restraint removal project. The Gerontologist, 36(4), 539-542.
- Feldt, K., & Ryden, M. (1992). Aggressive behavior: Educating nursing assistants. Journal of Gerontological Nursing, 18(5), 3-12.
- Hill, J., & Schirm, V. (1996). Attitudes of nursing staff toward restraint use in longterm care. The Journal of Applied Gerontology, 1S(3), 314-324.
- Janelli, L.M., Kanski, G.W., & Neary, M.A., (1994). Physical restraints: Has OBRA made a difference? Journal of Gerontological Nursing, 20(6), 17-21.
- Neary, M.A., Kanski, G., Janelli L., Scherer, Y., & North, N. (1991). Restraints in the 90s: Restraints as nurse's aides see them. Geriatric Nursing, 12(4), 191-192.
- Rader, J. (1995). Individualized dementia care: Creative, compassionate approaches. New York: Springer.
- Rader, J., Lavelle, M., Hoeffer, B., & McKenzie, D. (1996). Maintaining cleanliness: An individualized approach. Journal of Gerontological Nursing, 22(3), 32-38.
- Sundel, M., Garrett, R., & Horn, R. (1994). Restraint reduction in a nursing home and its impact on employee attitudes. Journal of the American Geriatrics Society, 42(4), 381-387.
- Wagner, A., & Colling, J. (1993). Resistance to change: Understanding the aides' point of view. The Journal of Long-Term Care Administration, 21(2), 27-30.
- Werner, P., Koroknay, V., Braun, J., & CohenMansfield, J. (1994). Individualized care alternatives used in the process of removing physical restraints in the nursing home. Journal of the American Geriatrics Society, 42(3), 321-325.
- Williams, C.C. (1989). Liberation: Alternative to physical restraints. The Gerontologist, 29(5), 585-586.
SELECTED COiWMENTS FROM CNAs REGARDING NECESSARY SUPPORTS TO BETTER CARE FOR RESIDENTS
SELECTED COMMENTS FROM NURSES REGARDING FUTURE NEEDS TO IMPLEMENT CHANGE