New Study Finds Staff Assumptions about Race Play a Role in the Variability of Care of Nursing Homes Residents with Advanced Dementia

Remedies include addressing staff biases, increasing funding for facilities, standardizing advance-care planning, and educating staff and families about evidence-based care and shared decision making.

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BOSTON – A new study published today in the Journal of the American Medical Association Internal Medicine (JAMA IM) found several factors – including staff assumptions about minoritized groups – may play a role in the variability in the quality of care provided to U.S. nursing home residents with advanced dementia.

The study, “Nursing Home Organizational Culture and Staff Perspectives Influencing Variability in Advanced Dementia Care: The ADVANCE Study,” identified organizational factors and staff perceptions at nursing homes that may drive known variability in the type of care provided  nursing home residents with advanced dementia, especially in the use of more aggressive interventions like tube-feeding or hospitalizations. These aggressive interventions are considered by many to be markers of poor quality of care, as they often do not promote clinical benefits or comfort among persons with advanced dementia.

Prior research has shown Black residents (versus white residents and those in facilities in the southeastern part of the United States) get more aggressive care, including greater use of feeding tubes and hospital transfers.

Ruth Palan Lopez, Ph.D., G.N.P.-B.C., F.A.A.N., Professor and Associate Dean of Research, Jacques Mohr Chair at MGH Institute of Health Professions School of Nursing, and Susan L. Mitchell, M.D., M.P.H., Senior Scientist, Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife and Professor of Medicine at Harvard Medical School, are the lead authors of the study. Their research was supported by the National Institute on Aging of the National Institutes of Health Award Number R01AG058539. 

“The study identified several factors that nursing homes could target to improve delivery of goal-directed care to all residents. One is to improve provider knowledge and communication skills that less aggressive interventions may be more in line with the residents’ wishes and best evidence,” said Dr. Lopez. “For example, many nurses may believe that feeding tubes prolong the life of advanced dementia patients, but this is not borne out by existing studies. Nursing homes need to make sure their staff is aware that hand feeding is better for residents. Based on prior research, aggressive interventions can be less effective compared to less-intensive interventions, like feeding residents manually, while requiring more time of the nursing staff provides better care to their patients.”

The most concerning finding was that staff in nursing homes had preconceptions that families of Black residents did not want to engage in advance care planning and preferred more aggressive care. 

“Staff preconceptions that Blacks are less willing to engage in advance care planning and want more aggressive care speaks to the need to address systemic racial biases in nursing homes,” said Dr. Mitchell, noting that nursing homes in the United States tend to be racially segregated and low-resource homes tend to have more Black residents. “Achieving health equity for all nursing home residents with advanced dementia must be the driving force behind all efforts aimed at reducing disparities in their care.”

Researchers conducted 169 staff interviews at 14 nursing homes in four states. They identified factors that were typical of nursing homes that provided less intensity of care including: the quality of the physical environment (e.g., good repair, non-malodorous), the availability of standardized advance care planning, greater staff engagement in shared decision-making, and staff understanding that feeding tubes do not prolong life. Aggressive intervention was considered suboptimal. 

More equitable advanced dementia care, the study concluded, may be achieved by addressing several factors, including staff biases towards Black residents. Other solutions include increasing support and funding for low-resourced facilities, standardizing advance-care planning, and educating staff, patients, and their families about evidenced-based care and goal-directed decision-making in advanced dementia. 

Other researchers collaborating in this study work at Beth Israel Deaconess Medical Center, Harvard Medical School, Meyers Primary Care Institute, University of Massachusetts Medical School, Oregon Health & Science University School of Nursing, the University of Tennessee at Martin, Emory Center for Health in Aging and the Nell Hodgson Woodruff School of Nursing at Emory University, the Center for the Study of Aging and Human Development at Duke University School of Medicine, and the Geriatrics Research Education and Clinical Center at Veteran Affairs Medicine Center.

About MGH Institute of Health Professions

Team-based care, delivered by clinicians skilled in collaboration and communication, leads to better outcomes for patients. That’s why MGH Institute of Health Professions graduate school in Boston integrates interprofessional education into its academic programs. Approximately 1,600 students at its Charlestown Navy Yard campus learn and collaborate in teams across disciplines as they pursue post-baccalaureate, master’s, and doctoral degrees in genetic counseling, nursing, occupational therapy, physical therapy, physician assistant studies, speech-language pathology, health professions education, and rehabilitation sciences. The interprofessional learning model extends to hundreds of hospital, clinical, community, and educational sites in Greater Boston and beyond. The MGH Institute is the only degree-granting affiliate of Mass General Brigham, New England’s largest health provider. It has educated more than 9,000 graduates since its 1977 founding. It is fully accredited by the New England Commission of Higher Education. Several programs are highly ranked by U.S. News & World Report. 

About Hebrew SeniorLife 
Hebrew SeniorLife, an affiliate of Harvard Medical School, is a national senior services leader uniquely dedicated to rethinking, researching, and redefining the possibilities of aging. Hebrew SeniorLife cares for more than 3,000 seniors a day across six campuses throughout Greater Boston. Our locations include: Hebrew Rehabilitation Center-Boston and Hebrew Rehabilitation Center-NewBridge in Dedham; NewBridge on the Charles, Dedham; Orchard Cove, Canton; Simon C. Fireman Community, Randolph; Center Communities of Brookline, Brookline; and Jack Satter House, Revere. Founded in 1903, Hebrew SeniorLife also conducts influential research into aging at the Hinda and Arthur Marcus Institute for Aging Research, which has a portfolio of more than $63 million, making it the largest gerontological research facility in the U.S. in a clinical setting. It also trains more than 1,000 geriatric care providers each year. For more information about Hebrew SeniorLife, visit our website or follow us on our blogFacebookInstagramTwitter, and LinkedIn. 

About the Hinda and Arthur Marcus Institute for Aging Research 
Scientists at the Boston-based Marcus Institute seek to transform the human experience of aging by conducting research that will ensure a life of health, dignity, and productivity into advanced age. The Marcus Institute carries out rigorous studies that discover the mechanisms of age-related disease and disability; lead to the prevention, treatment, and cure of disease; advance the standard of care for older people; and inform public decision-making.

Research Areas

A scene of a hospital floor at Hebrew Rehabilitation Center in Boston, MA, with a nurse standing and working on a computer in the background and a blood pressure monitor in the foreground.

Health Care Services and Policy

The Marcus Institute seeks to effect change in policies that impact the care of older adults by identifying age-related conditions that have an outsized impact on health care utilization and costs, while developing interventions that mitigate the issues.

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