1. Perceptions for Alternative and Traditional Nursing Home Care: Perspectives of Residents, Informal Caregivers, and Health Professionals Catherine Nguyen, OTS, Sara Christiana, OTR/L, Sarah Ciman, OTR/L, Jo Schweitzer, OTR/L, MS, & Machiko Tomita, Ph.D. Department of Rehabilitation Science, University at Buffalo INTRODUCTION The reality in many traditional nursing homes today is that the residents spend a lot of their time alone and are unable to provide self-care for themselves. Dr. William Thomas, who developed the concept of the Eden Alternative in the early 1990’s after extensive interactions and observations with nursing home residents, believes that loneliness, helplessness and boredom will steadily decrease the quality of life for residents in nursing homes (Bergman-Evans, 2004). He proposed an alternative to the medical model based nursing home that represents more of a “human habitat.” In this alternative, the environment was diverse, natural, and spontaneous. (Barba, Tesh, & Courts, 2002). The alternative approach has spread into nursing homes in the United States, Canada, Europe, Australia, and Japan. (Bergman-Evans, 2004). Purpose In Western New York, there is one nursing home that is transforming to an alternative setting. The purpose of this study was to evaluate the differences of perceptions among residents, their family members, and health professionals of nontraditional long -term care settings versus those in traditional long term care settings. This facility is still in the early stage of transition. It has transformed living units to allow more freedom to residents in an alternative setting. These specific research questions (RQ) were proposed to identify differences of perceptions between the traditional and alternative nursing homes. 1. Are there differences in residents’ perception of the two types of settings regarding activities, care and services, staff, environment, meals, and well-being? 2. Are there differences in the informal caregivers’ (family and fiends) perception of the two types of settings regarding residents’ quality of life, the physical environment, the staff and management, and their overall satisfaction level? 3. Are there differences in health professionals’ perception of the two types of settings regarding management style, quality of care, and job satisfaction? Conceptual Framework The Person-Environment-Occupation (PEO) (Christiansen & Baum, 2004) was used for this study. Occupational performance (meaningful activities) is an outcome of the interaction of three factors: person, environment, and occupation. Eden Alternative emphasizes the environmental changes that give individuals more choice in activities and provide more opportunity for activities that lead to individuals’ meaningful occupations. METHOD Study Design Investigators employed a cross sectional study design using two survey techniques: person-to person interviews for residents and health professionals, and mail survey for informal caregivers. Participants The participants in this study were recruited using a convenience sampling method. Inclusion criterion of residents was that they were cognitively intact (MMSE >19). Health care professionals included OTs, PTs, PTA, nurses, CNAs, social workers, dentists, and dieticians. For the mail survey, the return rate was 80%. Informal caregivers who responded to this study were not necessarily related to residents who participated in this study. The number of final participants in each group was: Traditional Alternative Total Residents: 35 13 48 Family caregivers: 65 15 80 Health care professionals: 7 8 15 Questionnaires Structured questionnaires were adapted from existing questionnaires and modified for these three study groups separately. Analytical Scheme A Likert scale was used to evaluate each item; therefore, nonparametric statistics was used. Mann-Whitney U-tests for each item, and independent t-tests for the total score were applied for two independent group comparisons. A significance level of.1.0 was used to capture this early stage transformation to the alternative care in the nursing homes. SPSS 14.0 was used for all analyses. RESULTS RQ 1: Residents’ Perceptions Demographic characteristics of residents in two types of settings were very similar. The mean age was 86 years old, 83% were females, 90% were Caucasians, 61% had a high school diploma or some college education, and 80% were not married. They lived in the nursing home for about 3.4 years and 96% of them had family or friends who visited them at the facility. A significant difference between the two settings appeared in 15 items (Table 1) and 2 categories in the total scores. The two categories were Staff Members (t=2.212, p=.017) and Meals (t=1.618, p=.056). The alternative care setting was rated higher than the traditional care setting for both categories and for all items but one. Higher scores indicate more positive ratings. RQ 2: Perceptions of Informal Caregivers Demographic characteristics of informal caregivers were similar in the two settings. Their age tended to be older for the alternative setting (75 vs. 68). About 33% were males, 96.3% were Caucasians, 22.5% each had bachelor's degrees or master’s degrees. The majority (70%) of caregivers were adult children, 11% were siblings, and 7.5% were spouses. The majority of caregivers had provided care between one to three years. A significant difference between the two settings appeared in nine items (Table 2) in which six items were rated higher for the alternative setting. Higher scores indicate more positive ratings. None of the four categories varied significantly between the two settings. Items rated higher by informal caregivers for residents in the alternative setting reflect residents’ higher contentment, home like environment, staff’s high training level, and more frequent presence of administrators. However, the alternative setting was rated lower for such factors as bringing items from home, community people's involvement in the facility, and presence of animals and plants. Table 2. Perceptions of Informal Caregivers in Two Types of Settings Table 3. Perceptions of Health Professionals in Two Types of Settings CONCLUSION AND DISCUSSION In this study, nursing home residents were found to be very responsive to their environmental factors and they preferred alternative settings to traditional settings. Informal caregivers of residents in traditional settings rated higher for some of the environmental factors. It was attributed to the fact that two types of settings are adjacent to each other and the traditional settings allowed birds and plants also. Health professionals felt more positive in the alternative setting while performing their jobs. Therefore, use of alternative settings is strongly encouraged, although it may take time to improve perceptions of residents’ quality of life. This study captured an early stage of transformation and a follow-up study should be conducted to produce more conclusive evidences. REFERENCES Barba, Beth E., Tesh, Anita S., Courts, Nancy F. (2002). Promoting thriving in nursing homes: the Eden Alternative. Journal of Gerontological Nursing. 28(3): 7-13. Bergman-Evans, B. (2004). Beyond the basics. Effects of the Eden Alternative model on quality of life issues. Journal of Crepeau, E.B., Cohn, E.S., Schell, B.A.B. (2003) Willard & Spackman’s Occupational Therapy (10 th ed.). Philadelphia: Lippincott Williams & Wilkins. Table 1. Residents’ Perceptions of Settings RQ3: Perceptions of Health Professionals Demographic characteristics of health professionals in the two types of settings were very similar. The majority (46.7%) were between age 41 and 50. Categories of professions were: 3 social workers, 2 each of RN, OT, registered dieticians, and dietary technicians, and one each of CNA, LPN, PT, and PTA. A significant difference between the two settings was identified in four items (Table 3). In Table 3, lower scores indicated more positive attitudes. In the alternative setting, health professionals felt they could perform better than in the traditional setting. Since the traditional setting will eventually transform to an alternative setting, health professionals who work in the traditional setting felt they are better informed. ItemDisagreeNeutralAgreep-value You can get up and go to bed when you choose. Traditional Alternative 20 (57.1) 4 (30.8) 15 (42.9) 9 (69.2).054 There are enough staff people to meet your needs. Traditional Alternative 19 (54.3) 4 (30.8) 3 (8.6)13 (37.1) 9 (69.2).041 Visiting hours are not limited, so your family and friends can see you anytime. Traditional Alternative 3 (8.6)2 (5.7)35 (85.7) 13 (100).078 You can choose the time to be attended. Traditional Alternative 14 (40.0) 2 (15.4) 11 (31.4)10 (28.6) 11 (84.6).002 The administrators know your name. Traditional Alternative 1 (2.9)5 (14.3)29 (82.9) 13 (100).058 Staff members are well trained and know what they are doing. Traditional Alternative 1 (2.9)4 (11.4)30 (85.7) 13 (100).078 You trust your medical team, such as physicians, nurses, and therapists. Traditional Alternative 1 (2.9)4 (11.4)30 (85.7) 13 (100).078 You are treated like a family member. Traditional Alternative 9 (25.7) 2 (15.4) 7 (20.0) 1 (7.7) 19 (54.3) 10 (76.9).087 The staff members are not changing often Traditional Alternative 12 (34.3) 3 (23.1) 8 (22.9)15 (42.9) 10 (76.9).047 You can cook meals, if you want to. Traditional Alternative 34 (97.1) 4 (30.8) 1 (2.9) 5 (38.5) <.001 I like the setting here that has an atmosphere. Traditional Alternative 6 (17.1)0000 29 (82.9) 13 (100).057 Bad odors are not a common occurrence. Traditional Alternative 1 (7.7)0000 36 (100) 12 (92.3).050 You often see animals visiting here and you prefer that way. Traditional Alternative 5 (14.3) 1 (7.7) 2 (5.7)28 (80.0) 12 (92.3).091 The setting is surrounded with many plants. Traditional Alternative 7 (20.0)3 (8.6)25 (71.4) 13 (100).017 You like the setting that is surrounded with many plans. Traditional Alternative 5 (14.3)3 (8.6)27 (77.1) 13 (100).032 ItemAlternativeTraditionalP-value The elders appear content.4.1 (1.1)3.7 (1.1).060 Elders can bring personal items from home. 4.5 (.64)4.7 (.52).045 People from the community are involved in the facility. 3.3 (1.12)3.8 (.99).049 Animals and plants are seen in the facility.3.8 (1.3)4.4 (.81).051 The kitchen has a home-like atmosphere.4.3 (1.2)3.0 (1.3)<.001 The setting of the unit resembles someone’s home. 4.0 (1.2)2.7 (1.3)<.001 I like the physical environment of the facility 4.5 (.83)3.6 (1.3).007 The employees are well trained and know what they are doing 4.5 (.64)4.0 (1.1).039 I often see the administrator.3.7 (1.3)3.2 (1.3).063 ItemAlternativeTraditionalP-value I am kept up-to-date on changes occurring that affect my job. 2.3 (.71)1.6 (.53).033 When I try to do my work, I do not run into obstacles. 2.4 (1.5)3.4 (1.4).095 I don’t have to work under a great deal of tension. 2.6 (1.1)4.0 (.82).014 I am given opportunities to use my talents for the facility’s benefit. 1.4 (.74)2.0 (.82).056