SENGA BOND, JOHN BOND
Summary This paper reports outcome data from a multiple-case study of the three experimental NHS nursing homes and six hospital wards undertaken as part of the evaluation of the experimental NHS nursing homes. While all subjects were very frail, NHS nursing home residents were found to be less frail than those in hospital wards. Significant differences in favour of the NHS nursing homes were found in the proportion of subjects engaged in meaningful activity during the mornings and afternoons, in the amount of activity and contact with others during the hour preceding lunchtime, and in amount of verbal interactions over lunchtime, particularly when choices were offered. These outcome data support the findings of other studies carried out as part of the evaluation that there is no evidence to imply that continuing-care accommodation should not be provided in NHS nursing homes.
Introduction This paper is the fourth in a series [1-3] reporting the results of an evaluation of the National Health Service (NHS) nursing homes. The primary aim of the evaluation was to provide information to policy makers about the effectiveness and efficiency of the NHS nursing homes, thus informing decision makers about the future provision of continuing-care accommodation. The second aim was to identify variations in the process of care between the different types of setting and the third was to provide an understanding of the factors which explain variations in the processes and outcomes of care. The evaluation comprised seven inter-
related studies [4] and was designed around a multicentred randomized controlled trial [1-3]. The trial aimed to determine the relative clinical and social effectiveness of the experimental NHS nursing homes compared with conventional care, usually provided by departments of geriatric medicine in hospital wards. While experimental studies may probe causal connections between particular forms of care and outcomes, they cannot in themselves explain why a treatment is or is not effective. Experiments treat the process of providing care as a 'black box'. In order to begin to provide explanations of outcomes it is necessary to enter the black box to discover what actually happens Age and Ageing 1990,19:11 18
Downloaded from http://ageing.oxfordjournals.org/ at Weizmann Institute of Science on June 9, 2016
Outcomes of Care within a Multiple-case Study in the Evaluation of the Experimental National Health Service Nursing Homes
S. BOND, J. BOND
Method A full account of the methods used has been presented elsewhere [24]. In summary, case studies were selected according to structural characteristics and comprised the NHS nursing home and two hospital wards in each of three centres (centres A, C and E). Behavioural ability of patients and residents was assessed using the modified Crichton Royal Behavioural Rating Scale (CRBRS) [25]. Activity was measured in three different ways. Engagement in meaningful activity was observed using a simple technique developed by Felce et al. [26]. Observations were made of all continuing-care patients and residents in public areas every 15 min over 1 h in the morning and for 2 h in the afternoon on every day of the week. Observation periods were centred on the provision of a hot drink. A more detailed analysis of activities was obtained using continuous observation of individual subjects and event recording over the hour preceding lunchtime [27]. The methods used had been found to discriminate between different care environments [7], Verbal interaction at lunchtime was observed for small groups of subjects over \ h until each subject was observed on five occasions. Interactions were categorized according to Davies and Snaith [22]. In each location, observations were carried out over approximately a 2-month period between February 1985 and December 1986 by two fieldworkers. Inter-observer reliability was ascertained in each centre for each of the methods used and acceptable levels were obtained. Only data for continuing-care subjects are reported for centres C and E while patients routinely receiving respite care in the hospital wards in centre A are included since they were eligible for inclusion in the RCT [2] and so there were similar types of residents in the NHS nursing home.
Results Behavioural ability: Figures 1 and 2 are boxand-whisker plots of CRBRS scores which range from 0 to 1 1 for the confusion subscale and from 0 to 17 for the physical ability subscale, higher scores indicating greater frailty. Using a Mann-Whitney U test on ungrouped data, more XHS nursing home residents were rated as less confused than hospital patients (p < 0.001) and less physically frail (p< 0.05).
Downloaded from http://ageing.oxfordjournals.org/ at Weizmann Institute of Science on June 9, 2016
in hospital wards and NHS nursing homes at first hand. For this reason an embedded multiple-case study was carried out [5]. The multiple-case study was principally concerned with yielding data to enable cases to be combined according to theoretical or structural variables in order to permit a comparison between them. Sufficient contextual detail is provided to explain the differences and similarities found. This paper reports a summary of the data collected as intermediate outcomes of care, comparing the pooled data from N H S nursing homes with conventional hospital wards. The intermediate outcomes described are different aspects of the activities of patients and residents. Previous studies have shown that continuing-care patients in hospitals spend a great deal of their time doing nothing [6-8] and that, when subjects are matched for level of disability, they spend a larger proportion of time doing nothing in hospital wards than in other forms of institutional and day care [7]. Environmental responsiveness of the activity of elderly people has been demonstrated when hospital patients were moved into less institutionalized settings and became more active [911], and when recreational materials and activities were provided for elderly people [12-14]. The provision of group living arrangements in residential homes also increases activity levels [15,16]. Descriptive studies of the social interaction of elderly hospital patients [6, 7, 17, 18] collectively show that there is little contact with others; most interaction is with staff, and overwhelmingly associated with the provision of physical care. Interactions between elderly hospital patients were increased when a stimulus-control procedure was introduced [19] and when furniture was rearranged [20]. Social interaction at mealtimes has also been shown to be influenced by the environment in which meals are eaten and the ways in which they are served, and can be increased by giving patients more control and grouping them around small tables [21-23]. The amount and quality of activity taking place among residents and patients was selected therefore as an outcome measure likely to discriminate between care settings offering differential social and physical environments.
OUTCOMES OF CARE WITHIN A MULTIPLE CASE STUDY
•3
Table I. Median percentage of subjects engaged in mornings and afternoons
10 8
Location
NHS nursing homes
Percentage of subjects Hospital engaged wards 4
0L
Hospital wards
X
< 0.0001 28.5
19.0
< 0.0001
NHS nursing homes
Figure I. Box-and-whisker plots of modified Crichton Royal Behavioural Rating Scale confusion subscale scores for subjects in hospital wards (n = 108) and NHS nursing homes (n = 78).
15
27.0
11.0
T
with another activity, then it was the other activity which was recorded. Table II shows comparisons between homes and wards. A higher proportion of engaged activity in the homes was devoted to social/recreational activities, otherwise the wards and homes were very similar. Table II Type of meaningful activity engaged in by subjects
10
Location Type of activity
Hospital wards
""JHS nursing homes
ivsical abihtv jspital wards subscale scores for subjects in n = 78). (n = 108) and NHS nursing homess ((n
Engagement: Table I shows median percentage of subjects engaged in the morning and afternoon periods. A Mann Whitney L test based on percentage of subjects engaged shows significant differences between the homes and wards for both morning and afternoon periods with a higher level of engagement in the homes. Meaningful activities were classified according to a single activity. When interaction between subjects and others occurred simultaneously
Hospital NHS nursing wards homes (n = 1961) (n = 1645) "
Talking Social and recreational Mobilizing Hating and drinking Personal care
8 23
23 44 4 23
8
6
26 34
Activity levels: Table 111 shows categories of activity for the hour preceding lunchtime, mean percentage of time occupied by each activity for those subjects who were observed to be involved, median percentage of time occupied for each activity by the whole sample, and statistically significant differences, using a Kruskal Wallis one way analysis of variance. While hospital patients could not be observed
Downloaded from http://ageing.oxfordjournals.org/ at Weizmann Institute of Science on June 9, 2016
2
Morning p value Afternoon p value
S. BOND, J. BOND
Table III. Activities of subjects in the pre-lunch hour
Position Sitting Lying Mobilizing Activities All activities Eating and drinking Personal care Treatment Informal recreation Organized activity Organized exercise Domestic activity Purposeless activity Contact with others All contact Verbal contact Physical support Supervision Personnel having contact Qualified nurses Unqualified nursing staff Domestic staff Doctors Remedial therapy staff All other staff Personal visitors Volunteers Other patients or residents All others
NHS nursing homes
Median Mean percentage of percentage Percentage observed of observed time—all of subjects time for subjects subjects involved involved (n = 113) (n=113)
Median Mean percentage of percentage Percentage observed of observed time—all of subjects time for subjects involved subjects (n = 69) (n = 69) involved
96 6 39
93.4 87.4
100
16.0
52
4.3 5.3 2.4
6.2
100 0.0 0.0
91 10 64
88.0 43.9
100 68 71 27 51
26 6 10.3
5.6
95.0 0.0 1.1
p value 0.001 0.24 0.005
18.4
3.1 0.8 0.0 0.3
< 0.0001 0.0001 0.001 0.06 0.01
28.1
43 15 30
16.4
8.9 0.3 0.0 0.0 0.0
7
14.8
0.0
13
25.0
0.0
0.16
8 5 11
8.2
0.0 0.0 0.0
4 4 16
16.0
0.0 0.0 0.0
0.35 0.79 0.51
94 93 49 9
10.9
4.2 1.9 0.0 0.0
99 97 62 25
19.8 13.9
15.8
5.6 6.1 4.4
5.7 6.3
9.2 1.1 0.0
< 0.0001 < 0.0001 0.07 0.005
50
2.8
0.3
67
7.6
2.2
0.0001
70
5.7
0.8
88
14.8
58
< 0.0001
35 1 16
1.4 1.0 5.0
0.0 0.0 0.0
23 0
4.3 0.0
12
12.1
0.0 0.0 0.0
0.19 0.11 0.45
10
5.1
38.0
Summary This paper reports outcome data from a multiple-case study of the three experimental NHS nursing homes and six hospital wards undertaken as part of the evaluation of the experimental NHS nursing homes. While all subjects were very frail, NHS nursing home residents were found to be less frail than those in hospital wards. Significant differences in favour of the NHS nursing homes were found in the proportion of subjects engaged in meaningful activity during the mornings and afternoons, in the amount of activity and contact with others during the hour preceding lunchtime, and in amount of verbal interactions over lunchtime, particularly when choices were offered. These outcome data support the findings of other studies carried out as part of the evaluation that there is no evidence to imply that continuing-care accommodation should not be provided in NHS nursing homes.
Introduction This paper is the fourth in a series [1-3] reporting the results of an evaluation of the National Health Service (NHS) nursing homes. The primary aim of the evaluation was to provide information to policy makers about the effectiveness and efficiency of the NHS nursing homes, thus informing decision makers about the future provision of continuing-care accommodation. The second aim was to identify variations in the process of care between the different types of setting and the third was to provide an understanding of the factors which explain variations in the processes and outcomes of care. The evaluation comprised seven inter-
related studies [4] and was designed around a multicentred randomized controlled trial [1-3]. The trial aimed to determine the relative clinical and social effectiveness of the experimental NHS nursing homes compared with conventional care, usually provided by departments of geriatric medicine in hospital wards. While experimental studies may probe causal connections between particular forms of care and outcomes, they cannot in themselves explain why a treatment is or is not effective. Experiments treat the process of providing care as a 'black box'. In order to begin to provide explanations of outcomes it is necessary to enter the black box to discover what actually happens Age and Ageing 1990,19:11 18
Downloaded from http://ageing.oxfordjournals.org/ at Weizmann Institute of Science on June 9, 2016
Outcomes of Care within a Multiple-case Study in the Evaluation of the Experimental National Health Service Nursing Homes
S. BOND, J. BOND
Method A full account of the methods used has been presented elsewhere [24]. In summary, case studies were selected according to structural characteristics and comprised the NHS nursing home and two hospital wards in each of three centres (centres A, C and E). Behavioural ability of patients and residents was assessed using the modified Crichton Royal Behavioural Rating Scale (CRBRS) [25]. Activity was measured in three different ways. Engagement in meaningful activity was observed using a simple technique developed by Felce et al. [26]. Observations were made of all continuing-care patients and residents in public areas every 15 min over 1 h in the morning and for 2 h in the afternoon on every day of the week. Observation periods were centred on the provision of a hot drink. A more detailed analysis of activities was obtained using continuous observation of individual subjects and event recording over the hour preceding lunchtime [27]. The methods used had been found to discriminate between different care environments [7], Verbal interaction at lunchtime was observed for small groups of subjects over \ h until each subject was observed on five occasions. Interactions were categorized according to Davies and Snaith [22]. In each location, observations were carried out over approximately a 2-month period between February 1985 and December 1986 by two fieldworkers. Inter-observer reliability was ascertained in each centre for each of the methods used and acceptable levels were obtained. Only data for continuing-care subjects are reported for centres C and E while patients routinely receiving respite care in the hospital wards in centre A are included since they were eligible for inclusion in the RCT [2] and so there were similar types of residents in the NHS nursing home.
Results Behavioural ability: Figures 1 and 2 are boxand-whisker plots of CRBRS scores which range from 0 to 1 1 for the confusion subscale and from 0 to 17 for the physical ability subscale, higher scores indicating greater frailty. Using a Mann-Whitney U test on ungrouped data, more XHS nursing home residents were rated as less confused than hospital patients (p < 0.001) and less physically frail (p< 0.05).
Downloaded from http://ageing.oxfordjournals.org/ at Weizmann Institute of Science on June 9, 2016
in hospital wards and NHS nursing homes at first hand. For this reason an embedded multiple-case study was carried out [5]. The multiple-case study was principally concerned with yielding data to enable cases to be combined according to theoretical or structural variables in order to permit a comparison between them. Sufficient contextual detail is provided to explain the differences and similarities found. This paper reports a summary of the data collected as intermediate outcomes of care, comparing the pooled data from N H S nursing homes with conventional hospital wards. The intermediate outcomes described are different aspects of the activities of patients and residents. Previous studies have shown that continuing-care patients in hospitals spend a great deal of their time doing nothing [6-8] and that, when subjects are matched for level of disability, they spend a larger proportion of time doing nothing in hospital wards than in other forms of institutional and day care [7]. Environmental responsiveness of the activity of elderly people has been demonstrated when hospital patients were moved into less institutionalized settings and became more active [911], and when recreational materials and activities were provided for elderly people [12-14]. The provision of group living arrangements in residential homes also increases activity levels [15,16]. Descriptive studies of the social interaction of elderly hospital patients [6, 7, 17, 18] collectively show that there is little contact with others; most interaction is with staff, and overwhelmingly associated with the provision of physical care. Interactions between elderly hospital patients were increased when a stimulus-control procedure was introduced [19] and when furniture was rearranged [20]. Social interaction at mealtimes has also been shown to be influenced by the environment in which meals are eaten and the ways in which they are served, and can be increased by giving patients more control and grouping them around small tables [21-23]. The amount and quality of activity taking place among residents and patients was selected therefore as an outcome measure likely to discriminate between care settings offering differential social and physical environments.
OUTCOMES OF CARE WITHIN A MULTIPLE CASE STUDY
•3
Table I. Median percentage of subjects engaged in mornings and afternoons
10 8
Location
NHS nursing homes
Percentage of subjects Hospital engaged wards 4
0L
Hospital wards
X
< 0.0001 28.5
19.0
< 0.0001
NHS nursing homes
Figure I. Box-and-whisker plots of modified Crichton Royal Behavioural Rating Scale confusion subscale scores for subjects in hospital wards (n = 108) and NHS nursing homes (n = 78).
15
27.0
11.0
T
with another activity, then it was the other activity which was recorded. Table II shows comparisons between homes and wards. A higher proportion of engaged activity in the homes was devoted to social/recreational activities, otherwise the wards and homes were very similar. Table II Type of meaningful activity engaged in by subjects
10
Location Type of activity
Hospital wards
""JHS nursing homes
ivsical abihtv jspital wards subscale scores for subjects in n = 78). (n = 108) and NHS nursing homess ((n
Engagement: Table I shows median percentage of subjects engaged in the morning and afternoon periods. A Mann Whitney L test based on percentage of subjects engaged shows significant differences between the homes and wards for both morning and afternoon periods with a higher level of engagement in the homes. Meaningful activities were classified according to a single activity. When interaction between subjects and others occurred simultaneously
Hospital NHS nursing wards homes (n = 1961) (n = 1645) "
Talking Social and recreational Mobilizing Hating and drinking Personal care
8 23
23 44 4 23
8
6
26 34
Activity levels: Table 111 shows categories of activity for the hour preceding lunchtime, mean percentage of time occupied by each activity for those subjects who were observed to be involved, median percentage of time occupied for each activity by the whole sample, and statistically significant differences, using a Kruskal Wallis one way analysis of variance. While hospital patients could not be observed
Downloaded from http://ageing.oxfordjournals.org/ at Weizmann Institute of Science on June 9, 2016
2
Morning p value Afternoon p value
S. BOND, J. BOND
Table III. Activities of subjects in the pre-lunch hour
Position Sitting Lying Mobilizing Activities All activities Eating and drinking Personal care Treatment Informal recreation Organized activity Organized exercise Domestic activity Purposeless activity Contact with others All contact Verbal contact Physical support Supervision Personnel having contact Qualified nurses Unqualified nursing staff Domestic staff Doctors Remedial therapy staff All other staff Personal visitors Volunteers Other patients or residents All others
NHS nursing homes
Median Mean percentage of percentage Percentage observed of observed time—all of subjects time for subjects subjects involved involved (n = 113) (n=113)
Median Mean percentage of percentage Percentage observed of observed time—all of subjects time for subjects involved subjects (n = 69) (n = 69) involved
96 6 39
93.4 87.4
100
16.0
52
4.3 5.3 2.4
6.2
100 0.0 0.0
91 10 64
88.0 43.9
100 68 71 27 51
26 6 10.3
5.6
95.0 0.0 1.1
p value 0.001 0.24 0.005
18.4
3.1 0.8 0.0 0.3
< 0.0001 0.0001 0.001 0.06 0.01
28.1
43 15 30
16.4
8.9 0.3 0.0 0.0 0.0
7
14.8
0.0
13
25.0
0.0
0.16
8 5 11
8.2
0.0 0.0 0.0
4 4 16
16.0
0.0 0.0 0.0
0.35 0.79 0.51
94 93 49 9
10.9
4.2 1.9 0.0 0.0
99 97 62 25
19.8 13.9
15.8
5.6 6.1 4.4
5.7 6.3
9.2 1.1 0.0
< 0.0001 < 0.0001 0.07 0.005
50
2.8
0.3
67
7.6
2.2
0.0001
70
5.7
0.8
88
14.8
58
< 0.0001
35 1 16
1.4 1.0 5.0
0.0 0.0 0.0
23 0
4.3 0.0
12
12.1
0.0 0.0 0.0
0.19 0.11 0.45
10
5.1
38.0
