Assisted Living Facility’s Culture
Long-term care facilities, such as assisted living facilities, were created to be safe places that promote a culture of care. However, due to such factors as changes in management, alteration in the organization’s priorities, or even neglect of the culture of change, many of them deteriorate over time. Over the past years, especially considering the current struggle with the global pandemic, the importance of a positive corporate culture at nursing homes and assisted living facilities has become unchallengeable. Residents live there through illness, loneliness, and disorder, and the organization’s culture can change their quality of life or recovery for better or for worse. The movement of culture change aims at transitioning care facilities from institutions to homes that optimize the quality of care and residents’ lives. This movement’s philosophy champions the person-centered approach and supports the upturn of the working conditions for staff. According to Chisholm et al. (2018), some of the main principles of the movement are patient-centered care and activities, home environment, collaborative management, staff empowerment, and the Continuous Quality Improvement process (CQI). More research is needed on efforts of culture change; however, its benefits have been documented by previous studies. For instance, culture change has been linked to a better quality of care and life for residents and greater satisfaction for families.
Current Problem
Feeding difficulties are common among patients with dementia, and this may be noted prior to a formal diagnosis. In the later stages of the disease, it sometimes becomes physically difficult for people to swallow. As noted by Davies et al. (2019), they fail to properly manage food in the mouth, or food/drink goes down the wrong path when swallowing happens. Whether the intervention of artificial feeding through a PEG tube, which is passed through the mouth or stomach wall, is to occur is a dilemma often faced by those who care for dementia patients.
First of all, the use of such a type of feeding has implications for an individual’s dignity. If one speaks about a person-centered approach to care, it has to be taken into account. However, specialists and caregivers often think tube feeding prolongs life, increases nutrition, and eliminates various complications. It has not proved to be true: as noted by Davies et al. (2019), no evidence has been found that tube feeding increased survival, improved quality of life, enhanced nutritional parameters, or reduced pressure ulcers. Moreover, there is data on the possibility of it leading to higher mortality and morbidity and lower life quality. In addition to that, ALFs are not equipped to handle tube feeding; only skilled nursing facilities (SNF) are. Yet families frequently do not want their loved ones moved to SNFs and, therefore, have to accept the practice of assisted oral feedings as an alternative.
Meanwhile, there is evidence that assisted oral feeding is as good as tube feeding, if not better. According to Ijaopo and Ijaopo (2019), the American Geriatrics Society states that the former is beneficial for the outcomes of comfort, functional status, aspiration pneumonia, and death while escaping the complications related to tube feeding. There is also data on the involvement of dietitians in prescribing dietary supplements as being effective in sustaining nutritional status in people with late-stage dementia.
The lack of superiority of tube feeding over oral feeding is supported by physicians. Ijaopo and Ijaopo (2019) speak about a study that evaluated physicians’ knowledge and perception of tube feeding in advanced dementia patients. The authors report that more than 70% of the participants believed that careful hand-feeding provided almost as much comfort as tube feeding (Ijaopo and Ijaopo, 2019). In addition to that, Ijaopo and Ijaopo (2019) note half of them assumed that nutritional status was rarely improved by tube feeding.
In their turn, American gastroenterologists consider a PEG tube placement to not be efficient for persons with advanced dementia. In fact, as per Ijaopo and Ijaopo (2019), one study found that during the two years of estimated follow-up, feeding tubes of nearly a fifth of advanced dementia tube-fed patients were either repositioned or replaced. It led to their more frequent visits to emergency rooms and, consequently, cost more money to hospitals. Therefore, the stakeholders involved are not only patients, their families, and clinicians but also investors in the field of healthcare. In terms of risks associated with assisted oral feeding implementation, it requires time and resources that might not be available everywhere, especially in acute medical settings.
EBP Approach: Idea for a Change
The evidence-based idea for a change in practice is the education of nurses and patients’ families about less invasive interventions such as assisted oral feeding, which also allow residents to remain in assisted living facilities. These interventions might delay the consideration of artificial feeding and prove to be a much better option overall. Nurses are to play a key role both in assessing feeding difficulties and implementing innovative nutrition programs. In addition to that, they are to inform families about strategies to advance oral intake. Moreover, Candy et al. (2009) speak about interdisciplinary assessment being important, much like simple steps: checking for the fitting of dentures, checking oral health, and asking about food preferences and cultural or religious nutritional needs. A speech/language therapist or nutritionist can help with developing plans to facilitate swallowing. As can be seen from the above, careful assisted oral feeding is a high-potential alternative to tube feeding and might be one of the few times in a day when a dementia patient gets normalized social interaction.
Knowledge Transfer Plan
When it comes to a knowledge transfer plan, the first step is to identify what knowledge is needed and collect it. For the knowledge to be as reliable as possible, its collection is to be assigned to different people who know enough about different aspects of the issue. The next step is to store the data: if there are hundreds or thousands of documents, they are to be stored correctly so that the knowledge in them can be accessed at any time. However, it is important for the information not to be available to industry competitors and, therefore, for the organization to have relevant tools to protect it.
After that, the knowledge is transferred and shared with others in the organization and patients’ families. The success of this transfer and sharing depends on how the knowledge is applied, which is what is done next. To ensure that the information is understood and used correctly, the company’s leaders might have to monitor the process of knowledge application by employees and patients’ families. It provides a basis for the next step of measuring the outcomes and taking necessary steps to optimize the knowledge transfer process. As a result, new knowledge is developed on the foundation of information being transferred and implemented into practice.
Knowledge Dissemination Strategy
Knowledge dissemination strategies in the field of healthcare are defined on the basis of the classification of Health Systems Evidence for consumer-oriented strategies. According to Chapman et al. (2020), these include information or education provision, skills and competencies development, communication and decision-making facilitation, system involvement, personal support, and behavior change support. Information or education provision is the strategy of choice for this particular project because it enables consumers to learn more about their health and treatment. Seeing how information on less invasive feeding interventions for patients with advanced dementia or Alzheimer’s disease is what needs to be distributed to nurses and patients’ families, this strategy is the most relevant of all.
The dissemination could be done verbally, in a written way, or both verbally and in a written way with the help of ICT; moreover, it could be done in groups or individually. Since feeding interventions for dementia patients is a delicate issue when dealing with them, many things have to be taken into account. Pamphlets or booklets are the best way to cover all that information. Moreover, these are convenient for nurses and patients’ families to carry around and turn to whenever needed. In addition to that, this problem can be talked about at seminars or conferences where broader masses will have the opportunity to learn about it.
Expected Outcomes
Descriptive studies that compare people with dementia who receive feeding via a PEG tube with people who receive assisted oral feeding clearly point to why the latter is the better option. Therefore, with the implementation of this evidence-based change, it is reasonable to expect positive outcomes. First of all, it is expected for persons with assisted oral feeding to have the same survival benefit or higher as those who are fed through a tube. In addition to that, these patients’ wounds are expected to at least not heal worse than patients who are tube-fed. Moreover, people who had a feeding tube inserted when hospitalized to receive acute care are reported to be at higher risk of pressure ulcer development. Therefore, people fed orally are expected to have lower risks of developing a pressure ulcer.
Furthermore, families of patients are expected to be more satisfied if their loved ones receive assisted oral feeding since it helps patients stay at assisted living facilities. By being fed orally, patients are expected to have a more balanced diet since dietitians are to be involved in formulating feeding plans in this evidence-based change. Finally, people are expected to be more content with their treatment since there are many reports of those who were fed with a tube being bothered by it.
Lessons Learned
Summary of the Critical Appraisal
When it comes to the critical appraisal of the articles that were used for the exploration of this issue, all of them had evidence level I. Davies et al. (2019) used the protocol for a Cochrane Review as the conceptual framework for their study, and Chou et al. (2020) used the principle of hand-feeding as the foundation for theirs. The other two articles did not have a specific theoretical basis mentioned. In terms of the methods used, Candy et al. (2009) resorted to a theoretical analysis, and Davies et al. (2019) utilized a theoretical meta-analysis. The studies of Chou et al. (2020) and Zain et al. (2020) both used the method of a practical experiment. All studies had established dependent and independent variables and used various statistics to answer clinical questions.
The findings of the articles regarding enteral tube feeding ranged from evaluating it as preferable to other options to reporting that it has more drawbacks than benefits. For one, Candy et al. (2009) stated that there is insufficient evidence to support the use of tube feeding in many cases. Davies et al. (2019) reported that tube feeding was efficient for patients with severe dementia, but that evidence was of poor quality. However, Chou et al. (2020) and Zain et al. (2020) recommended using tube feeding instead of hospice or palliative care. Consequently, further research is needed to draw more definite conclusions in regard to the topic.
Evaluation Table
One thing that I learned from completing the Evaluation Table is that academic articles are complex bodies of work that need structure and organization for them to be informative and valuable. Many different sections and topics need to be covered, and there must be a logical disposition of these in the paper for the reader to understand from where each next statement or idea comes. Moreover, there is a plethora of methods and techniques to conduct a study, and one is not better than the other; all of them are valid.
In addition to that, I learned about the strengths of systemic reviews, articles that offer a systematic approach to literature reviews. Compiling such a review helps a researcher reduce bias and random errors regarding any topic that they choose. A comprehensive and transparent process that utilizes previously published data is used for this type of paper. For instance, I might have an opinion about my topic of choice, tube feeding in patients with advanced dementia. If I were to make a systematic review of it, I would present previously researched evidence, regardless of whether I agree with it or not, thus preventing bias in my study.
References
Candy, B., Jones, L., & Sampson, E. L. (2009). Enteral tube feeding in older people with advanced dementia: Findings from a Cochrane systematic review.International Journal of Palliative Nursing, 15(8), 396–404. Web.
Chapman, E., Haby, M. M., Toma, T. S., De Bortoli, M. C., Illanes, E., Oliveros, M. J., & Barreto, J. O. M. (2020). Knowledge translation strategies for dissemination with a focus on healthcare recipients: an overview of systematic reviews. Implementation Science, 15(1), 1-14. Web.
Chisholm, L., Zhang, N. J., Hyer, K., Pradhan, R., Unruh, L., & Lin, F. C. (2018). Culture change in nursing homes: What is the role of nursing home resources? INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 55, 1-6. Web.
Chou, H. H., Tsou, M. T., & Hwang, L. C. (2020). Nasogastric tube feeding versus assisted hand-feeding in-home healthcare older adults with severe dementia in Taiwan: a prognosis comparison.BMC Geriatrics, 20(1). Web.
Davies, N., Barrado-Martin, Y., Rait, G., Fukui, A., Candy, B., Smith, C. H., Manthorpe, J., Moore, K. J., Vickerstaff, V., & Sampson, E. L. (2019). Enteral tube feeding for people with severe dementia. Cochrane Database of Systematic Reviews. Web.
Ijaopo, E. O., & Ijaopo, R. O. (2019). Tube feeding in individuals with advanced dementia: A review of its burdens and perceived benefits.Journal of Aging Research, 2019, 1–16. Web.
Zain, Z., Mohamad, H., Seow, D., Hum Yin Mei, A., Allen, J. C., Tong, K., Malhotra, R., Balasundaram, B., & Malhotra, C. (2020). Caregiver preference for tube feeding in community‐dwelling persons with severe dementia. Journal of the American Geriatrics Society, 68(10), 2264–2269. Web.