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Einleitung: In Deutschland wird die steigende Zahl pflegebedürftiger Menschen zunehmend in stationären Einrichtungen versorgt. Dieser Zuwachs bringt neue Herausforderungen, nicht zuletzt für die medizinische Versorgung der Pflegebedürftigen, mit sich. Qualitative Interviews mit beteiligten Akteuren können Erkenntnisse zum „Status quo“ liefern. Die vorliegende Arbeit beschäftigt sich mit der Perspektive der Angehörigen, da diese häufig in die medizinische Versorgung eingebunden sind und einen differenzierten Blick auf die Versorgungsqualität haben. Fragestellung: Welche Erfahrungen haben Angehörige im Pflegeheim mit der medizinischen Versorgung gemacht und wie wird die Zusammenarbeit zwischen Ärzten und Pflegekräften wahrgenommen? Welche Aufgaben übernehmen Angehörige bei der medizinischen Versorgung? Methoden: Die Arbeit ist eingebettet in die qualitative, multizentrische Studie „INTERPROF - Interprofessionelle Zusammenarbeit und Kommunikation im Pflegeheim“. In drei Regionen Deutschlands wurden hier unter anderem 23 offene Leitfadeninterviews mit 27 privaten Bezugspersonen in 14 Pflegeheimen durchgeführt. Die Interviews wurden, angelehnt an die Methode der Grounded Theory, ausgewertet. Ergebnisse: Als zentrales Phänomen wurde das „Einbezogensein“ der Angehörigen in die medizinische Versorgung erarbeitet. Angehörige versuchen, aktiv auf die medizinische Versorgung der Bewohner Einfluss zu nehmen. So werden neben der aktiven Hilfe bei der Pflege und Medikamentenbeschaffung zum Teil Hausarztbesuche initialisiert, Facharzttermine ausgemacht und Bewohner bei deren Praxisbesuchen begleitet. Darüber hinaus zeigt sich Einbezogensein durch den Kontakt der Angehörigen zum Hausarzt. Die Gründe hierfür sind vielfältig und lassen sich etwa auf ein Verantwortungsgefühl für den Bewohner oder auch den Wunsch des Bewohners nach Beteiligung der Angehörigen zurückführen. Angehörige üben zum Teil eine gewisse „Kontrollfunktion“ aus, dies führt mitunter zu emotionaler und zeitlicher Belastung. Es vermittelt andererseits eine gewisse Sicherheit, über Vorgänge informiert zu sein und diese beeinflussen zu können. Angehörige sind jedoch weniger „einbezogen“ oder wollen weniger „einbezogen“ werden, wenn sie die medizinische Versorgung gewährleistet sehen oder die Bewohner noch selbstständig sind. Folglich fühlen sie sich durch die bewusste Verantwortungsabgabe an die Pflegeeinrichtung entlastet. Schlussfolgerungen: Angehörige von Pflegeheimbewohnern stellen eine wichtige Personengruppe im Pflegeheim dar und bringen sich häufig intensiv, auch hinsichtlich der medizinischen Versorgung, zum Wohle der Bewohner ein. Wesentliche Anliegen sind eine patientenzentrierte, regelmäßige medizinische Versorgung. Es erscheint erstrebenswert, die Akzeptanz und Einbeziehung der Angehörigen durch die beteiligten Akteure im Heim und die Politik zu fördern. Auch die Einrichtung von organisatorischen Strukturen im Heim, z. B. durch die selbstverständliche Aufstellung eines Angehörigenkreises und die zunehmende unaufgeforderte Berücksichtigung von Angehörigen in medizinischen Entscheidungen (bei Einverständnis des Bewohner) wäre wünschenswert. Zudem sollte ihre Position in Heimbeiräten gestärkt werden. Das übergeordnete Ziel wäre es, Angehörige so in die Heimarbeit einzubeziehen, dass letztlich der Bewohner hinsichtlich der medizinischen Versorgung profitiert.

This study concerns the characteristics of fund development directors employed in selected homes for the aged. The first purpose of this study is to develop a profile of job functions, through task analysis, among development directors in charitable homes for the aged. The second purpose of this study is to develop a profile of personal characteristics of development directors of charitable homes for the aged based on the following characteristics: age, sex, educational background, experience outside development, membership in community organizations and amount of specific training in fund development. One instrument was used to gather data for the study. It was distributed to a population of 29 development directors in charitable homes for the aged in Arkansas, Louisiana, Oklahoma, New Mexico, and Texas. This population was predetermined by an initial survey form sent to 193 chief executive officers in the five states mentioned above. Twenty-nine reported formalized programs employing a full-time person with at least a part-time involvement in fund development activities. Of the twenty-nine development directors surveyed, fifteen usable instruments were received (52 percent). A program was used for the survey that included crosstabulation of social characteristics, success in fund raising, length of time in position and educational preparation. Coded responses were manually typed into the computer. To accomplish the desired analysis, percentages and frequencies were used to treat the data. These non-Parametric procedures provide an understandable overview of the data obtained and are appropriate for the research questions. These procedures permit a summarization of the data in a manageable form. Following the tabulation of frequencies and percentages, Fischer's Exact Probability Test was computed to determine if significant relationships between actual preparation and needed preparation, personal characteristics, educational preparation, and success and usefulness of experience exist.

The purpose of the current study was to examine how job resources, job demands, personal resource, personal demands, and demographic characteristics predict job satisfaction and job search behavior of certified nursing assistants (CNAs) working in nursing homes. The study used data from the 2004 National Nursing Assistant Survey (NNAS). The job demands-resources (JD-R) model (Demerouti, Bakker, Nachreiner, & Schaufeli, 2001) provided the basis for the conceptual framework of the study. First, a series of multinomial logistic regression analyses were performed to determine how the five categories of predictor variables predicted the levels of job satisfaction among CNAs. Next, a series of binary logistic regressions was used to assess the effects of the predictor variables on job search behavior. Lastly, binary logistic regression was used to examine the effect of job satisfaction on job search behavior, controlling for other predictor variables. Findings indicated that job resource variables related to positive administrative climate, opportunity for self-advancement, supportive supervisory practices, peer support, and positive interactions with residents predicted job satisfaction. Among job demand variables, lack of perceived respect and physical demands significantly and negatively predicted job satisfaction. In the job search behavior model, CNAs who reported respectful administrative climate, opportunity for self-advancement, and supervisor quality were less likely to search for a new job. Among job demand variables, perceived lack of respect/appreciation for work, perceived racial/ethnic discrimination, and problems with scheduling predicted job search behavior. When the job satisfaction variable was entered into the final job search behavior model, two variables became insignificant: supervisor quality and perceived lack of respect/appreciation for work. In the final model, job satisfaction had the strongest explanatory power of job search behavior. The findings of this study did not support the role of personal resources and demands in determining job attitudes and behavior of CNAs working in nursing homes. Research, education, policy, and practice implications are addressed.

This comparative research explores the work experiences of dementia care workers in nursing homes. The aim of this study is to understand concepts central to care and to gain insights from the care workers‟ perspectives. A comparative framework and symbolic interactionist approach is used to analyse data collected using ethnographic methods from 59 dementia care workers in Canada, Scotland, and the United States. The fieldwork settings are institutionalised; dominated by for-profit ownership; and provide care for a resident population with high cognitive and physical needs. The comparative findings underscore the importance of work conditions that provide care workers with sufficient resources to do their job and enough time to complete their work. The absence of these critical components creates stressful work conditions for the care workers. The lack of time, staff and supplies such as towels, wash cloths, and continence products do not allow the residents‟ choices in their care and disregard their dignity and rights. The inability to deliver care for the residents according to the guaranteed government care standards often result in the violation of human rights for the care workers and residents. The care workers are unable to supply the quality of care they know the residents need and are capable of providing given better circumstances. There are frequently not enough care workers, resources, or time to meet the level of care that relevant standards mandate or the care workers know is possible. The analysis reveals that care workers struggle to provide more than basic physical care and are seldom able to meet essential social care needs for the residents. Unwritten rules are implemented in each setting that include separating people with dementia, placing these residents out of view of the public, not allowing the residents access to go outside, and not providing them with engaging and meaningful interactions. While policies are frequently developed with good intentions, many are counter-productive without dementia knowledge. This comparative research reveals care practices and routines share strong similarities across the fieldwork sites while the care worker characteristics as a workforce vary the most between countries. Some differences involve the training required, average age, pay and mode of dress or appearances. Too often researchers frame stress issues for care workers as problems with attitudes, motivation, training and incentives. Yet, the broader social structures and conditions that set the context in which these problems have their origins are commonly ignored. Good working conditions for care workers are precursors to good care for the residents. This thesis concludes with recommendations for practice, research and policy development.

Abstract This thesis explores the use of assistive in-situ technologies for formal caregivers in nursing homes. More specifically, focus is placed on improving context awareness and medication management. Although these topics have previously been researched for elderly care in general, few solutions targeting nursing homes have been generated. As the aging population further increases the burden on this care environment, it is important that solutions are found to help maintain care quality. The main findings in this thesis emphasise how technology can assist formal caregivers and facilitate increased patient wellbeing. The articles presented in this thesis describe our creation of a context-aware sensor system (named CARE) and a non-expert miniaturised near-infrared spectroscopy (MNIRS) solution. Both systems were designed iteratively with the help of nurses and were evaluated in a nursing home. CARE quantifies elderly residents’ behaviour, analyses the resulting data and produces valuable and actionable insights for nurses. Results from a two-month-long user study demonstrate that the system can facilitate increased awareness of patients’ needs and enhance care service. The custom MNIRS solution allows nurses to scan pharmaceuticals and obtain accurate identifications. This method significantly outperforms currently available tools in nursing homes and represents a promising solution that can reduce medication mismanagement. In the discussion section of the thesis, we revisit the research questions defined in the introduction and examine how each were answered. In addition, we discuss the augmentation of nursing home technology and various stakeholders’ perspectives. We then highlight how the work covered in this thesis was conducted in collaboration with industry and offer some conclusions, limitations and reflections. / Tiivistelmä Tämä väitöstyö tutkii paikkasidonnaisten teknologioiden käyttöä hoitajien työn helpottamiseksi vanhusten palvelukodeissa. Työn keskiössä on erityisesti kontekstitietoisuuden lisääminen ja lääkehoidon valvonta. Näitä aiheita on tutkittu laajalti aiemminkin, mutta aitoihin ympäristöihin keskittyviä ratkaisuja on vielä vain vähän. Väestön ikääntyminen aiheuttaa haasteita vanhustenhoidossa, ja siksi on tärkeää kehittää ratkaisuja hoidon laadun ylläpitoa varten. Väitöstyön löydökset painottavat teknologian roolia hoitajien avustajana sekä hoidettavien hyvinvoinnin ylläpitäjänä. Työn artikkelit kuvailevat kontekstitietoisen järjestelmän (CARE) koko kehitys- ja elinkaaren sekä lähi-infrapunaspektroskopiaan perustuvan ratkaisun lääkehoidon prosessien parantamiseksi. Molemmat järjestelmät kehitettiin iteratiivisesti hoitajien avulla ja koestettiin aidossa ympäristössä vanhainkodissa. CARE analysoi asiakkaiden liikkeitä ja toimintoja sekä visualisoi niistä korkeamman tason tietoa hoitajille. Kahden kuukauden kenttäkokeen tuloksena voidaan todeta, että järjestelmät yhdessä voivat auttaa hoitajia ymmärtämään asiakkaiden tarpeita sekä parantamaan hoidon laatua. Lähi-infrapunaspektroskopiaan perustuvalla kannettavalla ratkaisulla puolestaan hoitajat voivat varmistaa lääkehoidon oikeellisuuden. Tämä menetelmä on tarkempi ja parempi kuin tämänhetkiset käytössä olevat ratkaisut lääkkeiden oikeaksi toteamiseen. Väitöstyön keskusteluosuus palaa tutkimuskysymyksiin ja selventää, kuinka tehty työ ja saavutetut tulokset vastaavat niihin. Lisäksi keskustelu antaa yleiskuvan eri osapuolien näkemyksistä kehitetyn ratkaisun hyödyistä ja sen soveltuvuudesta käytännön työhön. Lopuksi väitöstyö luo katsauksen yhteistyön rooliin eri osa-alueiden toteuttamisessa ja esittää kriittisen näkökulman työn puutteisiin sekä yhteenvedon.

The purpose of this study was to compare Registered Nurse (RN) current and future demand between Tennessee rural and urban licensed hospitals and nursing homes. Comparisons of Registered Nurse demand by principal duty or position and by educational level were also undertaken. The educational level of RNs was examined using the proportion of RNs at each of five educational levels: diploma, associate, baccalaureate, master's, and doctorate. The variables examined were 1988 and 1989 vacancy rates and proportion of budgeted positions, change in vacancy rates and proportions from 1988 to 1989, projected changes in positions and proportions from 1988 to 1992 and to 1995. Nurse administrators from one hundred fifty four hospitals (63% response rate) and two hundred twelve nursing homes (72% response rate) were surveyed for responses about current and future RN demand. This study is a secondary analysis of data that were collected as a part of a larger research project conducted by the Tennessee Board of Regents Task Force on Nurse Supply and Demand. The findings were that rural hospitals had significantly higher vacancy rates for total nurse positions in 1988 and general duty positions in 1989. Urban hospital administrators reported higher vacancy rates for RN positions at the diploma level and projected significantly greater changes in clinical specialist and master's level positions for 1992 and 1995. Rural hospitals had a higher proportion of associate degree nurses in 1989, and urban hospitals had a higher percentage of master's prepared RNs for 1988 and 1989. Urban hospitals projected a greater change in the proportion of RNs at the doctoral level for 1995. Rural nursing homes projected higher numbers of associate degree nurses for 1992 and 1995. The major conclusion was that the nursing shortage in Tennessee hospitals was more severe than that reported on the national level and greater in rural hospitals. The shortage in Tennessee nursing homes was reported to be much less acute than the national shortage, and the critical shortages were limited to a few facilities, both rural and urban.

Readmission of skilled nursing facility (SNF) residents has become a financial and quality-of-care concern for facility leaders. SNF administrators do not know whether nurse staffing levels are impacting readmission rates. The Affordable Care Act included measures to monitor and improve quality and to penalize SNFs that have high readmission rates. The purpose of this quantitative correlational study was to examine the relationship between SNF nurse staffing levels and readmission rates using the Skilled Nursing Facility Readmission Measure (SNF RM). The theoretical framework for the study was Donabedian's structure, process, outcome model. The research questions addressed the relationship between nurse staffing levels and rehospitalization percentages for SNFs, and the relationship between RN staffing levels and rehospitalization percentages. A quantitative methodology was used to analyze publicly reported secondary data from Centers for Medicare and Medicaid Services staffing files and SNF Value-Based Purchasing (SNF VBP) program data. Pearson's correlation was used to examine the relationship and strength between nurse staffing levels and the SNF RM. The sample included 374 SNFs across Georgia that participated in the SNF VBP program. Findings from the multiple regression analysis and analysis of variance indicated no statistically significant relationship between nurse staffing levels and SNF RM rates. Facility characteristics across Georgia showed some variations in staffing levels and SNF RM rates. Findings promote positive social change by providing SNF leaders with needed information to make decisions about staffing needs when considering staffing above the state averages. Health care leaders and policymakers might use the findings when considering recommendations for staffing regulations.

Falls constitute a health care safety concern, specifically among the geriatric population institutionalized in health care facilities. From the pattern of observed falls at the project site, a discrepancy between fall prevention measures and expected outcomes was noted. Knowledge deficiency, inadequate practice skills, and insufficient organizational support were found to be the major obstacles to improving fall prevention. The purpose of this systematic literature review project was to identify evidence-based actions to reduce falls. The project was guided by Taylor's personality theory and Watson's theory of care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was used to evaluate and analyze 4 of the 47 screened publications. The evidence supported 5 interventions: furthering implementation facilitators, removing barriers, improving strategies, integrating personality, and using a fall risk assessment tool. The systematic review addressed practice gaps, organizational support, and barriers to curb recurrent falls. By contributing to the improvement of individual and population health, the project might lead to a positive socioeconomic change by reducing falls and their complications.

The National Quality Award Program, sponsored by the American Healthcare Association National Center for Assisted Living, was implemented to cultivate continuous quality improvement in nursing homes and assisted living facilities. Based upon the Baldridge Criteria for Performance Excellence, the program utilizes a systems-based or Big “Q” approach to quality and requires applicants to examine seven categories of their organizational environment including: 1) leadership, 2) strategy, 3) customers, 4) measurement, analysis, and knowledge management, 5) workforce, 6) operations, and 7) results. The subsequent dissertation examines whether award status is associated with better performance on publicly reported quality measures and financial performance within the nursing home setting. Findings suggest implementation of Baldridge principles may promote improved quality; however, further research is warranted to fully understand the relationship.