M = 81 years (SD = 11)
Note: all values have been rounded to the nearest whole number for consistency; M stands for mean; SD stands for standard deviation.
As a first step, we present the results of 41 studies on wishes and needs of NH residents, excluding those that used the CANE questionnaire. Subsequently, we present the results of the remaining ten studies that collected data on wishes and needs with the CANE instrument. This separation seemed reasonable, as the CANE questionnaire is the only instrument that explicitly distinguishes between met and unmet needs. Therefore, the separate presentation and summary of the CANE studies provide a comprehensive overview of the results collected with this questionnaire. The wishes and needs found in the 41 studies presented first could be mapped to 12 themes. These are shown in detail in Table 3 .
Explicit description of the themes.
Themes | Outcomes |
---|---|
(1) Activities, leisure, and daily routine | |
(2) Autonomy, independence, choice, and control | |
(3) Death, dying, and end-of-life | |
(4) Economics | |
(5) Environment, structural conditions, meals, and food | |
(6) Health condition | |
(7) Medication, care, treatment, and hygiene | |
(8) Peer relationship, company, and social contact | |
(9) Privacy | |
(10) Psychological and emotional aspects, security, and safety | |
(11) Religion and spirituality | |
(12) Sexuality |
The need to make the day active and momentous has been addressed in several studies [ 27 , 28 , 38 , 46 , 49 , 58 , 60 ]. Accordingly, wishes for meaningful, person-specific, enjoyable, social, and recreational activities were mentioned [ 27 , 28 , 38 , 46 , 60 ]. Residents like to practice their hobbies and consider activities on special occasions and events as important [ 27 , 38 ]. Various pursuits and leisure activities that residents like to do could be classified under this theme: Reading, listening to music, having contact with animals, keeping up with the news, spending time outside, doing activities outside the NH, playing games, partying, tea-time, gardening, helping others, doing crafts, and spending time with others [ 27 , 38 , 46 , 49 , 58 ]. In addition to the need for specific activities, a general wish for a varied life with diverse offerings and activities was also mentioned [ 60 , 62 ], in which residents can experience self-sufficiency [ 49 ].
Moving into an NH can result in a loss of autonomy and independence. Over half of the 41 studies [ 20 , 22 , 25 , 26 , 28 , 30 , 31 , 32 , 33 , 35 , 36 , 38 , 39 , 49 , 50 , 52 , 57 , 58 , 60 , 62 , 63 ] demonstrate that it is essential for residents to do things for themselves, to have a say in decisions, and to maintain their autonomy to the greatest extent possible. In various studies, NH residents described an experienced dependence and a wish to gain more autonomy and independence: “The stroke nurse who was to do the swallowing test never came. She was to sign me off for swallowing so that I could eat bread… You see I am very determined to be as independent as I can be? I would love to be able to walk to the toilet on my own” [ 52 ]. Residents reported a wish to make decisions for themselves or to be involved in the decision-making process and that this is central to their well-being and quality of life [ 60 , 62 ]. The need to have a say relates to both day-to-day issues and far-reaching decisions. For example, residents wish to have control over daily concerns such as deciding when to get up and go to bed [ 28 , 38 , 39 ], what clothes to wear [ 38 , 58 ], what and when they eat [ 28 , 39 , 49 , 63 ], how they spend their day [ 49 ], who they share a room with [ 39 ], and whether they participate in social activities [ 49 ]. Residents also want to make their own decisions on issues related to hygiene and care routines, including bathing and showering type, how often to bathe or shower, and oral hygiene [ 35 , 36 , 38 , 39 , 63 ]. Control over medical matters is highly important to many residents. For instance, residents would like to have a choice regarding how often and which physician they consult [ 35 , 39 ]. Residents are concerned about their future and would like to make advance directives and living wills. According to one study [ 67 ], over one-third of residents have a written advance directive, i.e., either an advance directive, or a living will, or a combination of different documents. Residents who already have an advance directive most often want their son or daughter, or a close relative, to act as surrogate decision makers should their own decision-making capacity cease [ 26 , 50 ]. In decisions concerning care, residents wish to determine who has a say for themselves. Some residents wish to make all decisions on their own, but many would also like family members and relatives to have a say, while still others would like staff or the attending physician to make final decisions and hand over responsibility to them [ 22 , 25 , 31 , 32 , 35 , 62 ].
To maintain a sense of freedom and independence, residents feel the need to regularly leave the NH on their own and independently [ 39 , 57 , 63 ]: “I tell a member of staff when I leave the NH. This is not a problem. Sometimes I am not back before midnight. I have a key. So, I can come and go whenever I want. That’s great. Because the staff do not have to give a key to the residents” [ 57 ]. Some residents want to move out of the NH or want to have control over their own discharge. This is partly based on the need to live in familiar surroundings again, but also on the wish for more self-determination and freedom [ 33 , 39 , 62 ].
People often move into a NH at a late stage in life, when the issues of dying and death become increasingly important. Residents have different ideas about the end of their lives and dying in the home. NH residents wish not to become bedridden and in need of care in the last phase of life. Furthermore, they wish that their health condition does not deteriorate further allowing for a degree of mobility and activity. Despite impending death, residents want to continue to make plans and be content [ 40 , 41 ]. Contact with family members, friends, relatives, and other confidants, such as nursing staff, or the attending physician, plays an essential role in this phase of life [ 40 , 66 ]. The results show that residents are concerned about discussing the topics of dying and death with familiar people. Residents want to prepare for death and plan for the process of dying and the time after [ 57 ]. In addition to a general need to talk about the approaching death, residents are particularly concerned about symptom management, emotional, psychological, and spiritual support, possible counseling services, and funeral issues [ 27 ]. One study [ 32 ] found that there is often a lack of opportunities to discuss one’s values and needs regarding end-of-life treatment and care with the nursing staff. Resident reactions to such staff discussions vary greatly from unnecessary to a very strong need. Wishes for pain management and more personal and time-intensive care include maintaining personal hygiene and the requirement of additional medical care in the last phase of life [ 40 , 56 ]. There are also clear wishes and needs on the part of NH residents regarding the dying process. In this context, several studies shed light on the context in which people want to die, such as the place of dying, the condition in which they want to die, and the people they would like to have by their side when dying [ 26 , 41 , 50 , 66 , 67 ]. In most cases, residents would like to die in the NH and not be transferred to another facility, such as a hospital. [ 26 , 41 , 50 , 66 , 67 ]. However, needs for passing away at home, in hospice, or in a hospital are also cited [ 66 , 67 ]. Most residents in one study [ 66 ] reported wanting to pass away in their sleep (31%). Fewer residents would like to be unconscious or comatose during dying (7%) and a small percentage would like to experience the dying process while conscious (3%). The other residents were not clear at the time of the survey about the condition in which they would like to die or did not make any statement for other reasons.
The question of end-of-life care also seems to be essential for residents. For example, most residents wish to die in the presence of familiar people, such as relatives, friends, nursing staff, or hospice companions. “That I can cling somewhere,… to any hands…” [ 41 ]. Others would rather be alone when the time comes [ 22 , 41 ]. When dealing with dying people, physical closeness, human warmth, support, and respectful, open, and honest communication are of great importance [ 41 , 66 ]. Medical and nursing factors are also central. Residents do not want to suffer pain and thirst during the dying process and want to be able to breathe comfortably [ 22 , 40 , 41 , 56 , 66 ]. Many residents do not want to receive life-sustaining measures, including artificial nutrition, resuscitation, surgery, heart–lung machine, ventilator, or dialysis, during the dying phase [ 22 , 40 , 41 , 56 , 66 ]. However, others want to receive life-sustaining treatment in the event of a life-threatening condition [ 50 ]. Residents consider a natural and quick death, which they see as a release, important [ 22 , 49 ].
Spiritual factors also play an essential role when residents face death in a NH. Residents want to die quietly and peacefully, which means that they do not want to be a burden on anyone and want to die without much fuss. They wish for forgiveness and reconciliation, for their mistakes not to be of great relevance in retrospect, and for their loved ones to think back on them positively after their passing [ 41 ]. During the dying process, residents feel the need to maintain their dignity and self-respect and to leave the world laughing [ 66 ].
The wish to die or to actively end life has also been cited in studies [ 33 , 57 , 66 ]. Three of 18 residents interviewed in the Goodman et al. study [ 33 ] want their life to end. Van der Steen et al. [ 66 ] found that residents wish to have ways to end life if they feel it is necessary.
Four of the 41 studies [ 24 , 27 , 60 , 62 ] captured residents’ financial wishes and needs. All four studies found a desire for more money or financial support and financial security. Chuang et al. [ 27 ] also found that residents feel a need to be able to pay the monthly NH fee. If this cannot be accomplished, residents would be discharged or transferred to another NH with lower standards, which they try to avoid.
Studies reported facility-related needs and needs at the structural level, for example, concerning the room occupied [ 19 , 20 , 36 , 38 , 46 , 47 , 60 , 62 ]. Residents wish for a comfortable bed [ 19 ], larger [ 62 ] and temperature-controlled rooms [ 36 ], and the ability to personally furnish the rooms with their own furniture, objects, photos, a television, and a radio [ 46 , 60 ]. Further, needs were expressed for housing facilities that are designed for the elderly and disabled such as the presence of elevators [ 62 ]. Clean housing and sanitary facilities are also important to residents. Regarding these, the wish for improvement was mentioned [ 20 , 62 ]. It is also essential that residents can take care of their own belongings and have a way to lock and store smaller items safely [ 19 , 36 , 38 ]. Other needs related to facility structure include a wish to separate residents with dementia from those without dementia and a wish for more flexible routines. For example, residents would like more flexibility in the timing of taking pills [ 62 ]. Culinary care in the NH also plays an essential role for residents. According to Sonntag et al. [ 62 ], residents feel the need for better food that is age-appropriate and not so monotonous. In addition, residents want to decide what food they get, how much of it, and whether they eat according to a recommended diet. Some wish for more traditional food to be offered and to take meals at their leisure, without time stress, at set times of the day, and with patient and respectful assistance if necessary [ 47 ]. Housen et al. [ 38 ] reported that it is important for residents to have snacks available at their convenience in the NH.
An inability of older people living alone with deteriorating health and physical condition often requires a transition to NH. Thus, the issue of health is of high importance for these NH residents. Most common among this theme was the need to maintain and improve health or to prevent a decline in health [ 33 , 49 , 57 , 60 , 61 , 62 ]. In this context, maintaining both cognitive and physical health status is of high importance. The abilities are seen as a prerequisite for enjoying the last years in the NH: “The few years I have left to live, I want to enjoy them. I can still walk, more or less, well around what you can call walking. You don’t need to put me in a chair yet, a wheelchair or one of them frames. Yeah, I do and wash myself and everything” [ 60 ]. As the worst imaginable scenario, residents describe their condition as a nursing case: “I have no expectations anymore. The principal thing is not to become a nursing case. I do not want to become an invalid like some of the other residents. I do not want to lose my mind. In this case, I would rather die” [ 57 ]. According to Schmidt et al. [ 61 ], residents wish to maintain their physical and sensory awareness.
Additionally, full and honest information about one’s health status is also noted to be essential. While three studies [ 20 , 26 , 60 ] reported that residents want to be fully informed about health status and, if applicable, fatal diagnoses, Gjerberg et al. [ 32 ] found that a small number of residents were unsure whether they might want to receive information of a severe nature or indicated that they did not want to receive information. This is due to fear of harmful consequences, “…that will just leave me thinking. And I would rather not”.
Wishes for mobility or physical activity [ 57 , 60 , 61 ], for physical comfort [ 63 ], and for restful sleep and sleep comfort [ 58 , 60 , 61 ] were also mentioned under the topic of health condition.
Thirteen of the 41 studies [ 18 , 19 , 20 , 27 , 30 , 33 , 35 , 37 , 42 , 46 , 49 , 58 , 62 ] addressed needs related to the behaviors or characteristics of nursing staff or care received. For example, residents want to receive care that is good [ 37 , 58 ], humane [ 62 ], continuous [ 37 , 42 ], competent, skilled [ 27 , 62 ], affectionate [ 62 ], encouraging [ 42 ], and professional [ 19 ]. According to Bangerter et al. [ 19 ], professional care in this regard can be defined as friendly, kind, courteous, emphatic, respectful, and characterized by symmetrical communication. Further, residents want to be perceived as individuals, treated personally and with dignity, and taken seriously [ 30 , 37 , 62 ]. This includes addressing residents personally by name [ 19 ]. They wish staff would reliably take care of them and be concerned about them [ 18 , 27 , 33 , 35 ]. Residents feel the need to trust the nursing staff [ 20 ] and have a good relationship with them [ 33 ]. Sensitivity and motivation on the part of caregivers are necessary to form a trusting relationship possible according to residents [ 42 ]. This does not always seem to be guaranteed: “Not too many of them help too much when we’re not well-they don’t have feelings… They are tired-they have to lift me and I’m heavy. If they have a bad day or bad night, they lose the ability to be sensitive to our condition. Sometimes I feel that they take their frustrations out on us. They lack a little sensitivity” [ 42 ]. Residents wish they were not treated as if they were a nuisance, a problem case, or a child [ 46 , 49 ].
In addition to needs primarily related to nursing staff, residents also reported wishes and needs related to medical care and hygiene. According to different studies [ 42 , 58 , 61 ] personal hygiene is important to residents. This includes bathing and washing facilities [ 58 ], oral hygiene, and regular changing of linens [ 42 ]. In one qualitative study with 10 women and 10 men, some women reported a gender-specific need for personal care to be performed by a caregiver who is a woman herself [ 37 ]. High-quality medical care includes the use of proper equipment during treatments [ 20 ], good skin and wound treatment, expert pain management to prevent discomfort due to physical illness [ 61 ], and monitoring for adverse drug reactions [ 46 ]. Referring to the study by Michelson et al. [ 45 ], residents refuse aggressive medical treatment unless the intervention alleviates pain or results in greater patient comfort or safety. Nakrem et al. [ 49 ] and Sonntag et al. [ 62 ] found that residents hope to receive more active care in the NH, more therapeutic interventions, more physical therapy, and regular fall prevention by NH staff. To provide more quality of life in the NH, residents wish for more help and support with daily living activities [ 27 , 62 ]. Frustration is reported because this support is not provided by staff without being asked [ 42 ]. Residents reported care needs for eating and drinking, excreting, constipation, sleep disturbances, loss of appetite, chronic illnesses (including asthma, arthritis, hypertension), and visual impairment [ 23 , 61 ]: “The constipation has given me piles in that my whole body is affected” [ 23 ].
In the study by Levy-Storms et al. [ 42 ], excessive cross-boundary support from nursing staff is sometimes reported: “Let me eat (feed myself) with a spoon, like normal people”. This is countered by the reports of residents who experience a lack of individualized and skilled care and attention from NH staff. This is seen as a problem of limited staff capacity, which is why the wish for more staff was mentioned to make the above-mentioned needs and wishes feasible [ 62 ].
Contact with other people is a central need for many NH residents. While a good and trusting relationship with the nursing staff has already been presented as the basis for humane and personal care, residents name social contacts and friendships as significant for a satisfying life in the NH. Residents described needs for sociability and conversation in their lives [ 30 , 62 ], for human connection [ 52 ], for belonging [ 30 ], for a good and personal atmosphere in the home [ 60 ], for harmony [ 23 ], and for meaningful relationships [ 55 ].
Relationships with other NH residents are highly relevant, as these play a significant role in determining the daily environment. Residents actively choose their contacts in the NH, talking about their experiences in the home, their past lives, and their families. They spend time together and do things together: “I am in touch with Anna. She lives down the corridor. She is lucid, and we can talk. She comes to visit me, and then we talk… and if she gets some sweets, she comes to me [to share] and if I get something she appreciates from my family, then I share it with her” [ 21 ]. Residents reported a wish for all residents to live better together [ 62 ] and a desire for personal and social relationships with other residents [ 21 , 27 , 28 , 49 , 60 ].
In addition to the need for in-home relationships with peer residents, the wish for good relationships with family members, relatives, and friends outside the home was also frequently mentioned. For example, residents would like to maintain family and friendship ties [ 21 , 27 , 28 , 52 , 60 , 63 ] and spend more time with and are regularly visited by their loved ones [ 18 , 20 , 21 , 30 , 35 , 62 ].
Residents also wish to maintain contact with their former social environment and the community they lived in before moving. Residents do not want to lose connection to their former lives and the world outside the NH [ 28 , 49 , 52 , 63 ]: “I like getting out to the town, you know. I just like to see if there is any building going on or what’s happening in the town” [ 52 ]. Residents indicate they want to maintain their past relationships and ties because they are identity-building [ 52 ]. Ways to maintain a connection to the outside world include: watching television, listening to the radio, reading the newspaper, or sitting at the front door to watch people come and go [ 63 ].
As important as human contact is, a certain degree of privacy is likewise important. This was shown by seven studies [ 19 , 20 , 27 , 28 , 33 , 38 , 60 ]. Residents desire privacy when using the restroom and performing personal hygiene [ 19 , 60 ]. The wish for privacy further includes the need for a private space [ 60 ], which residents understand to mean, for example, occupying a single room [ 28 ], but also being able to receive visits or make telephone calls in a private setting [ 38 ].
Quietness in the NH is also crucial to residents’ privacy. They wish to rest undisturbed [ 33 ] and that they are not disturbed by loud noises [ 60 ].
Residents who inevitably interact with others due to the institutional setting want to spend time alone [ 60 ] and consider it important for social and psychological privacy that nursing staff knocks upon entering the room [ 28 ]. Cooney et al. [ 28 ] found that residents of large facilities particularly complained about a lack of privacy. In some cases, beds are separated only by curtains, which ensures a very low level of quiet and privacy: “You only have a curtain separating you” [ 28 ].
Many of the wishes and needs of residents are also in the psychological, emotional, and safety domains. Inner-personal and psycho-emotional needs, for example, were named in the study by O’Neill et al. [ 52 ]. Residents wish to have a positive attitude and maintain their own identity, self-efficacy, resilience, and coping strategies. They would like to take each day as it comes and not worry too much about tomorrow. According to Franklin et al. [ 30 ] and Schmidt et al. [ 61 ], residents want to experience a daily routine, to be able to enjoy the little things in everyday life, and to find a sense of meaning in the NH’s daily routine to experience themselves as part of the environment. It seems essential for residents to have a sense of belonging, to feel understood, and to have a sense of community [ 60 ]. Other studies report similar findings [ 28 , 61 , 63 ]: residents want to be themselves, not lose a sense of self, and be recognized as independent individuals. To ensure this, residents are concerned about their appearance among others. One qualitative study showed that some women want to take care of their appearance. They state that this has a positive effect on their self-expression and self-esteem [ 28 ].
Further, having options to do what they want when they are miserable is essential [ 18 , 36 ]. Fundamental to residents is that they feel needed, valued, and welcomed [ 27 ]. Schmidt et al. [ 61 ] also found that expressing emotions, expressing one’s will, being talked to and touched, as well as touching others are important for residents’ emotional and psychological well-being. NH residents wish for social and emotional support in the home [ 46 ] and psychological support for depression, confidence loss, memory loss, anxiety, anger, and irritability [ 23 ].
A sense of security is also important to residents. They wish to be safe and secure in the NH [ 49 , 60 , 61 ]. This includes knowing that the home has safety and security measures installed and that residents always have quick access to emergency services [ 20 , 49 ]. Being protected from self-harm and from disturbance by other residents is also part of living safely in an NH [ 46 ].
Religiosity and spirituality play an important role for many residents. For example, they wish to participate in religious ceremonies [ 27 , 38 , 43 , 58 , 61 ]. They want to express themselves religiously in their lives, follow cultural customs, and feel spiritually connected to others [ 27 , 38 , 61 , 63 ]: “I can’t go to the Sunday ceremony, but I read the Bible by myself… You will feel consoled after you read it” [ 27 ]. Specific activities that residents undertake to meet their religious and spiritual needs are cited by Man-Ging et al. [ 43 ]: praying for themselves, reflecting on past lives, turning to a higher presence, and plunging into the beauty of nature.
One study [ 48 ] addressed the sexual needs of NH residents. More than half (51%) of the residents surveyed reported a sexual tension, including more men (65%) than women (41%). In addition, residents reported the following as their most important sexual needs: need for conversation, need for respect, need for tenderness, need for support in any situation, and need for giving and receiving emotional support, by which residents primarily mean empathy and understanding.
The ten studies that used the CANE questionnaire for data collection are presented separately. The CANE questionnaire covers 25 areas of daily life in the NH to assess older people’s physical, psychological, social, and environmental needs. A distinction is made between met and unmet needs. Table 4 shows the outcomes of CANE studies and gives an overview of the five most frequently mentioned needs in each of these ten studies. Eight studies reported both unmet and met needs [ 29 , 34 , 44 , 51 , 54 , 59 , 64 , 68 ]. One study reported only unmet needs [ 53 ], and the study by van der Ploeg et al. [ 65 ] reported the sum of met and unmet needs differentiated between residents with dementia, residents without dementia, and relatives. Looking at the results without including the study by van der Ploeg et al. [ 65 ], the five most frequently mentioned met needs are in the areas of food, household skills, physical health, accommodation, and self-care. In comparison, the five most frequently unmet needs are in the areas of daytime activities, psychological distress, company, eyesight/hearing, and memory. Some of the five most frequently identified needs that residents have according to CANE studies were also highlighted by the analysis of the 41 other studies. These include the following needs in the area of unmet needs: daytime activities, psychological distress, and company. The met needs, which have also been addressed by the other studies, are as follows: food, physical health, and accommodation. Additional needs identified through the CANE studies that have not been mentioned in the previous analysis are household skills and self-care in the area of met needs and memory and eyesight/hearing related to unmet needs.
Outcomes CANE studies.
Study | Met Needs Top 5 | Unmet Needs Top 5 | |
---|---|---|---|
Ferreira et al. (2016) Portugal [ ] | 1. Household Skills 2. Food 3. Physical health 4. Drugs 5. Money | 1. Daytime activities 2. Eyesight/hearing 3. Psychological distress 4. Company 5. Memory | |
Hancock et al. (2006) UK [ ] | 1. Household skills 2. Accommodation 3. Self-care 4. Money 5. Food | 1. Daytime activities 2. Psychological distress 3. Memory 4. Eyesight/hearing 5. Behavior | |
Mazurek et al. (2015) Poland [ ] | 1. Food 2. Physical health 3. Household skills 4. Accommodation 5. Mobility/falls | 1. Company 2. Psychological distress 3. Eyesight/hearing 4. Intimate relationships 5. Daytime activities | |
Nikmat and Almashoor (2015) Malaysia [ ] | 1. Accommodation 2. Looking after home 3. Food 4. Money 5. Self-care | 1. Intimate relationships 2. Company 3. Daytime activities 4. Caring for another 5. Memory | |
Orrell et al. (2007) UK [ ] | n.a. | 1. Daytime activities 2. Memory 3. Eyesight/hearing 4. Company 5. Psychological distress | |
Orrell et al. (2008) UK [ ] | 1. Food 2. Accommodation 3. Household skills 4. Mobility/falls 5. Self-care | 1. Daytime activities 2. Company 3. Psychological distress 4. Eyesight/hearing 5. Information | |
Roszmann et al. (2014) Poland [ ] | 1. Drugs 2. Physical health 3. Self-care 4. Household skills 5. Continence | 1. Accommodation 2. Memory 3. Food 4. Psychological distress 5. Company | |
Tobis et al. (2018) Poland [ ] | 1. Looking after home 2. Food 3. Physical health 4. Accommodation 5. Self-care | 1. Company 2. Psychological distress 3. Eyesight/hearing 4. Intimate relationships 5. Daytime activities | |
van der Ploeg et al. (2013) Netherlands [ ] (Here presented the sum of met and unmet needs distinguished between residents with and without dementia and relatives as proxies) | Residents with dementia 1. Household skills 2. Food 3. Mobility/falls 4. Self-care 5. Physical health | Residents without dementia 1. Household skills 2. Mobility/falls 3. Food 4. Accommodation 5. Physical health | Relatives 1. Food 2. Household skills 3. Accommodation 4. Mobility/falls 5. Self-care |
Wieczorowska-Tobis et al. (2016) Poland [ ] | 1. Physical health 2. Caring for another 3. Mobility/falls 4. Food 5. Continence | 1. Daytime activities 2. Company 3. Psychological distress 4. Eyesight/hearing 5. Intimate relationships |
The objective of this scoping review was to identify the wishes and needs of NH residents. The results show numerous needs that were mapped to 12 themes. In 35 studies, residents were interviewed; in 12 studies, residents and proxies were interviewed; and only proxies were interviewed in four studies. This shows that residents can be aware of perceived needs and wishes and can communicate them. This is valid not only for residents without cognitive impairment [ 69 ], but also for residents with dementia [ 11 ]. Studies show that third-party assessments of needs sometimes differ from what NH residents report [ 20 , 35 , 44 , 46 , 54 , 65 ]. This finding is especially important for residents with dementia, as needs elicitation for these individuals is often only collected through a proxy survey [ 11 ]. It is essential to directly survey NH residents, including residents with dementia, about their wishes and needs. Interviewing proxies can provide additional and helpful information, but is not a substitute for speaking directly with the affected resident.
The scoping review results further indicate that wishes and needs on specific topics differ between individual residents. For example, some would like to receive life-sustaining measures, while others reject them. This high degree of individuality and complexity must be considered in assessing needs. The wishes and needs should be recorded with the individual residents in private conversations, reflected on repeatedly, and the way they are dealt with should be adjusted if necessary. This requires time, expertise, and willingness. Often, there is a lack of human resources to ensure this task is completed. Complaints about a shortage of skilled workers and high workloads in NHs are frequent. [ 70 , 71 ]. These circumstances can lead to less quality in care and can make it difficult to have an individualized approach to residents [ 72 ]. Assessment tools, such as the PELI-NH or CANE questionnaire, can be helpful in conducting a comprehensive needs assessment. Such tools can provide clues to existing needs and wishes and present an overview. The CANE questionnaire, for example, does not address all the areas in which NH residents experience needs. Topics that are relevant for residents according to the present study, such as death/dying, autonomy, interaction of nursing staff with residents, and religion/spirituality, are not surveyed by this instrument. When caregivers or other persons refer to the CANE questionnaire in order to assess needs, they should be aware of this. Accordingly, in-depth and recurring interviews with residents are indispensable to consider the high complexity and individuality of wishes and needs. Only in this way can the results be validated and unmet needs can be discovered.
Themes of high relevance seem to be the following, as they were mentioned frequently and in multiple studies: “autonomy, independence, choice, and control”, “death, dying, and end-of-life”, and “medication, care, treatment, and hygiene”. Notably, needs cannot be categorized in a blanket way in which some needs are of higher importance than others. For example, needs in the nursing area may weigh the heaviest for some residents, while others consider the needs for autonomy and self-determination to be most important.
Older adults are aware of their wishes and needs, but in many cases they do not communicate them [ 73 ]. Sometimes, when asked about their wishes and needs, residents report that they do not wish for anything because nothing would change anyway. The reason for this seems to be an experienced lack of respect for their wishes. For residents who have the feeling that their personal and subjective wishes and needs are not heard and that addressing them does not lead to any change, communicating their needs does not make sense [ 62 , 69 ]. As another reason for non-communication, older adults in home care state that they do not want to be a burden to anyone, and they do not want to complain about the age-related ailments that are common for them [ 73 ]. In these situations, caregivers should treat residents with appreciation and respect. It is important to schedule sufficient time to talk about wishes and needs. It is also important to take residents seriously and show them that expressing their wishes and needs will lead to positive changes in their lives by addressing them. The patronizing communication that often occurs on the part of NH staff may also contribute to NH residents not always openly communicating their wishes and needs, as satisfaction with such interactions can be low [ 74 ]. Further, the use of elderspeak due to stereotypical expectations of NH residents’ communication skills can lead to residents not feeling understood or respected and, as a result, they tend to be quiet and accept things without argument [ 75 , 76 ]. As a result, non-communicated needs go unrecognized and, accordingly, unmet. Communication training or person-centered interventions for caregivers could contribute to improved caregiver–patient communication, which could lead to more openness on the part of the residents and, consequently, fewer unmet residents’ needs [ 77 , 78 ].
Shared decision making was a frequently mentioned need. However, sometimes less is more. The study by Reed et al. [ 79 ] shows that older people prefer to have fewer options from which to choose than younger people. This suggests that some NH residents may be overwhelmed by too many options. NH staff should individually ask residents whether they prefer to choose from reduced options in some areas of their lives.
The present study has some limitations. First, it must be said that the concepts of “wishes” and “needs” are very complex, and there is no common definition [ 80 ]. This can lead to the fact that all researchers involved understand something different by the concept under investigation. A definition was created and applied throughout to prevent this from happening and to ensure consistent study inclusion, data extraction, and analysis. Further, the 51 included studies are diverse in research design, study population, and objectives. For example, there are studies that surveyed residents as well as studies that surveyed proxies. Some studies focused on residents with dementia, while others focused on residents without cognitive impairment, or on unbefriended residents. The research focus was not primarily on wishes and needs in all studies. Constructs such as quality of life, dignity, or thriving were sometimes of substantial research interest. However, relevant wishes and needs were mentioned in the survey on these constructs, which were analyzed here. In the analysis of the quantitative studies, only the five most frequently mentioned wishes and needs were recorded in each case. The disadvantage here is that some wishes and needs were not recorded as a result. As qualitative studies do not include frequencies and therefore no ranking, all needs and wishes were extracted in these, which can lead to an overweighting of the qualitatively surveyed wishes and needs. Further, only studies in English and German were included. This can be explained by the language skills of the researchers but presents the possibility that relevant studies were not included. Consequently, the results only represent an overview of possible wishes and needs as stated by residents or their proxies. In no way do the results claim to be exhaustive of all wishes and needs of NH residents.
Among this study’s strengths is a very extensive literature search of 12 databases that was conducted. Additionally, the evidence examined is extensive, with 51 studies, as demonstrated by the high richness of results.
Twelve topics were identified to which the wishes and needs of NH residents can be assigned. This reflects the high complexity and diversity of the needs and wishes of the heterogeneous group of NH residents.
For many NH residents, the NH represents the last phase of life before death. Residents should live a contented and fulfilling life in the home. Essential to achieving satisfaction is the fulfillment of individual wishes and needs. A comprehensive needs assessment on resident wishes and needs should take place in NHs. Speaking directly with the residents is essential to success.
The results of this study provide an evidence-based framework that can serve as a basis for holistic and person-centered care in NHs.
This research received no external funding.
R.S. contributed to the design, evidence search, data extraction, data analysis, and drafted the manuscript. J.L.O. contributed to the design, evidence search, data extraction, data analysis, and revised the manuscript. M.K. contributed to the design, evidence search, data extraction, data analysis, and revised the manuscript. S.N. initiated the study, contributed to the design, and revised the manuscript. A.T. initiated the study, contributed to the design, and revised the manuscript. All authors have read and agreed to the published version of the manuscript.
The authors declare no conflict of interest.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abuse and neglect in nursing homes, physical abuse of elders, discussion board post: adult health nursing, the american association of nurse assessment coordination, capstone project topic selection, clinical care and management of pressure ulcers, diet and physical activity to improve the outcomes in the nursing home, senior services of southeastern virginia.
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Guest Essay
By Linda H. Aiken
Dr. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
The Covid-19 pandemic exposed strengths in the nation’s health care system — one of the greatest being our awesome nurses. But it also exposed many weaknesses, foremost among them being chronic nurse understaffing in hospitals , nursing homes and schools .
More nurses died of job-related Covid than any other type of health care worker. The more than 1,140 U.S. nurses who lost their lives in the first year of the pandemic knew the risks to themselves and their families. And yet they stayed in harm’s way. They cared for their fallen co-workers. They went to New York from around the country to fight on the front lines in the first Covid surge. Nurses from Northwell Health in New York returned that support by deploying to the Henry Ford Health System in Detroit in December when a surge occurred there.
We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor prepandemic working conditions that led to high nurse burnout and turnover rates even before Covid.
As a nurse with extensive clinical experience in hospitals, I found it nearly impossible to guarantee safe, effective and humane care to my patients. And so I established the world’s leading research center on nursing outcomes to understand the causes of nurse understaffing in the United States and abroad and to find solutions to the problem.
The United States has a robust supply of nurses . And there is no evidence that recruits to nursing have been deterred by Covid. To the contrary, applications to nursing schools increased during the pandemic.
A short film offering a firsthand perspective of the brutality of the pandemic inside a covid-19 i.c.u..
I was looking through the window of a Covid I.C.U. And that’s when I realized I might see someone die. I didn’t even know who she was. But I was filled with immense grief as she edged closer to death by the hour. What I didn’t know yet was that by the time I left just two days later, at least three patients would be dead. The vaccine offers hope, but the sad truth is that the virus continues its brutal slaughter in I.C.U.s like this one in Phoenix, Ariz. The only people allowed in are health care workers. They’re overworked and underpaid in a deluged hospital. I wanted to know what it is like for them now, after a year of witnessing so much death. Eager to show us their daily reality, two nurses wore cameras so that for the first time we could see the I.C.U. through their eyes. “Unless you’re actually in there, you have no idea. Nobody can ever even imagine what goes on in there.” [MUSIC PLAYING] This I.C.U. contains 11 of the hospital’s sickest Covid patients. Most of them are in their 40s and 50s. And they are all on death’s door. It’s an incredibly depressing place. I blurred the patients faces to protect their privacy. But I also worried that blurring would rob them of their humanity. The family of this patient, the one who is rapidly declining, allowed her face to be shown. And they readily told me about her. Her name is Ana Maria Aragon. She’s a school administrator and a 65-year-old grandmother. Sara Reynolds, the nurse in charge of this I.C.U., organized a video call with Ana’s family to give them a chance to be with her just in case she didn’t make it. “It just breaks my heart when I hear families saying goodbye.” You might expect the doctors to be running the show. But it is really the nurses who are providing the vast majority of the care. “We do everything. We give them baths every night.” “Rubbing lotion on their feet.” “Shave the guys’ faces.” “Cleaning somebody up that had a bowel movement. It doesn’t even register as something gross.” “Look, I walk into the room. I say, hey, sounds like you have Covid. And I might order a chest X-ray. I might order blood work. I might order catheters. All that stuff is done by the nurse. I may have spent 10 minutes. The nurse might spend seven or eight hours actually in the room, caring for them. Let’s say there was a day that nurses didn’t come to the hospital. It’s like, why are you even opening?” “Ibuprofen.” 12-hour-plus shifts, isolated in this windowless room, these nurses survive by taking care of each other. “Aww, thank you.” And by finding small doses of levity. [MUSIC - JAMES BAY, “LET IT GO”] “(SINGING) Wrong. Breeze.” “I’m getting older now, and there’s all these new young nurses coming out. And I feel like a mom to all of them. Morgan, she’s got big aspirations. She loves to snowboard, and she’s so smart. And Deb, Deb’s just— she’s funny.” “I tease her all the time. I can tell her to do anything, and she’ll just do it because I think she’s scared of me because I just always say, make sure you have no wrinkles in those sheets.” The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores. There was one woman in her 50s who was so critical that this simple procedure risked killing her. “Even just turning them on their side, their blood pressure will drop. Their oxygen levels will drop.” “Her heart had actually stopped the day before. And so the concern was if it was going to make her heart stop again.” “Then come over. Push.” “We were all watching the monitors.” “I felt relieved like, whew, we did it.” Arizona’s a notoriously anti-mask state. And it faced a huge post-holiday surge in Covid cases. In January, the month I was there, Arizona had the highest rate of Covid in the world. As a result, I.C.U.s like this one have too many patients and not enough nurses. “Because they’re so critical, they need continuous monitoring, sometimes just one nurse to one patient with normally what we have is two patients to one nurse. But there definitely are times when we’re super stretched and have to have a three-to-one assignment.” A nurse shortage has plagued hospitals over the past year. To help, traveler nurses have had to fly into hotspots. Others have been forced out of retirement. Especially strained are poorer hospitals like Valleywise, which serves a low-income, predominantly Latino community. “Many of our patients are uninsured. Some of them have Medicaid, which pays something but unfortunately not enough.” This means they simply can’t compete with wealthier hospitals for nurses. “There is a bidding war. The average nurse here, give or take, makes about $35 an hour. Other hospitals, a short mile or two away, might pay them $100.” “We lost a lot of staff because they took the travel contracts. How can you blame them? It’s sometimes a once-in-a-lifetime opportunity to make a lot of money.” “Every single day I’m off, I get a call or a text. ‘Hey, we desperately need help. We need nurses. Can you come in?’” This nursing shortage isn’t just about numbers. “Physically it’s exhausting. We’re just running. We don’t have time to eat or drink or use the restroom.” “They have kids at home, doing online school. And I think, gosh, they haven’t even been able to check on their kids to see how they’re doing.” “My days off, I spend sleeping half the day because you’re exhausted. And eating because we don’t get to eat here often.” Nurses have been proud to be ranked the most trusted profession in America for nearly two decades. But during Covid, many worry they aren’t able to uphold the standards that earned them such respect. “I can’t give the quality of care that I normally would give.” “It’s absolutely dangerous.” “That’s demoralizing because we care. We’re nurses. It’s our DNA.” Ana had been in the hospital for over a month. Her family told me she was born in Mexico. She came to the States 34 years ago, first working in the fields before eventually landing her dream job in education. She’s beloved at her school. Former students often stop her in town and excitedly shout, Miss Anita. She was very cautious about Covid. She demanded her family always wear a mask and yelled at them to stay home. Yet, tragically, she somehow still caught it. “She had been declining over the course of several days. It’s a picture we have seen far too often that we know, this one is going to be coming soon.” Because there is no cure for Covid, the staff can only do so much. Once all the ventilator settings and the medications are maxed out, keeping a patient alive will only do more harm than good. So Ana’s family was forced to make a tough decision. “And I talked to family and let them know that we have offered her, we have given, we have done everything that we can, there’s nothing more that we can do. The family made the decision to move to comfort care.” “If I’m there while someone’s passing, I always hold their hand. I don’t want somebody to die alone. That’s something that brings me peace.” “Thank you.” “Thank you.” “Dance floor is packed. People hugging, holding hands, and almost no one wearing a face mask.” “I think like many health care workers, I’m angry a lot. And my faith in humanity has dwindled.” “How can you think this isn’t a real thing? How can you think that it’s not a big deal?” “Free your face. Free your face.” Arizona Gov. Doug Ducey has advocated for personal responsibility over mask mandates even though he’s been photographed maskless at a gathering and his son posted a video of a crowded dance party. “Even on the outside, they go, I don’t care. I’m not wearing a mask. I’m not getting the vaccine. That’s bullshit. The second they come into the hospital, they want to be saved. Never do they say, ‘I made the decision. I’m accepting this. Don’t do anything, doctor.’” Half a million people in this country have died from Covid. Many have been in I.C.U.s with nurses, not family members holding patients’ hands. “I always wonder, are they still going to be there when I get to work? It’s on my mind when I get home. Are they going to make it through the night? There’s one that I can think of right now.” One patient in his late 50s was so critical that he required constant supervision. Each of his breaths looked painful. “There was one day that he was kind of— he was looking a little bit better. And so he was able to shake his head and smile. And we set up a video call for him. And it was just the sweetest thing ever. I could hear his little grandson— he was probably 4 years old or so. And I saw him on the screen, too. And he was just jumping up and down, so excited. ‘You’re doing it, Grandpa. You’re doing it. We love you. Look at you. You’re getting better.’ It just broke my heart. It broke my heart. He’s one that I don’t think is going to be there when I get back on Sunday.” But I’d already been told something Sara hadn’t. The patient’s family had decided to take him off life support. “Yesterday they did? Oh. And I just think of his little grandson. And ‘you’re doing it, Grandpa. You’re doing it.’” He wasn’t the only patient who didn’t make it. When I went back to the hospital, I noticed that the bed of the patient I’d seen get flipped over was empty. My heart sank. I knew this meant she’d passed away. “What’s sad is when I go back, those beds will be full. They’ll have somebody else there just as sick with another long stretch of a few weeks ahead of them before it’s time for their family to make that decision.” I’d never before seen someone die. And even though I didn’t know these people, witnessing their deaths left me sleepless, exhausted, and depressed. It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one. “I’ve always loved being a nurse. It’s what I’ve always wanted to do. And these last couple months, it’s definitely made me question my career choice.” And what makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through. I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden when it— that it is a lot. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.” Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves. I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored. “Thank you. Thank you. I feel, yeah. And you’re all amazing.” [MUSIC PLAYING]
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3-minute read.
Just last year, the for-profit nursing home Princeton Care Center’s abrupt and chaotic 24-hour shutdown disrupted, displaced, and, in some cases, traumatized the lives of 72 nursing home residents and their families. Despite the closure being months in the making , residents were given only hours to find a new home, with their belongings packed in garbage bags. The care being provided to these residents was so poor that weeks earlier, the New Jersey Department of Health had suspended new admissions to the facility. State regulators and local and state officials knew this taxpayer-funded facility was in financial and medical trouble. Yet, residents were unaware of the situation or why it was closing.
This incident highlights why — despite millions of new state and federal taxpayer dollars being invested in New Jersey’s nursing homes since 2019 — a full, clear, and constant view into their workings is essential. Without transparency and accountability, more families may suffer through similar situations in other nursing homes. This past budget season New Jersey's legislature had an opportunity to include budget language that would enforce improved transparency and accountability tied to an increase in funding for nursing homes. Instead, nursing homes received an additional, last-minute $60 million appropriation — above and beyond what Gov. Phil Murphy proposed for this year — with no strings attached.
After the tragic deaths of over 9,000 long-term care residents during the COVID crisis, individuals living in nursing homes and their families deserve an independent audit of where our current dollars are going, what they are being spent on, and whether their money is improving the safety and quality of care of these centers.
Business as usual simply will not do. Unfortunately, business as usual is what New Jersey keeps delivering. Nursing homes are primarily funded through Medicaid, and today, they receive more than $2 billion from taxpayers. In the final days and hours of last year’s state budget negotiations, a back-room deal quadrupled the proposed increase to the taxpayer-funded Medicaid reimbursement rate — a $120 million windfall. This increase was over and above basic Medicaid rates for nursing homes and is now embedded in their rates for the new fiscal year — along with the additional $60 million.
Most concerning is there is no requirement to use these taxpayer dollars to improve quality care like infection control, to improve the wages and working conditions for direct care staff despite nursing homes being chronically understaffed, or to provide any information to consumers, policymakers, and regulators on how the additional money would be spent. Once again, this year’s state budget fails to require improved transparency on how our tax dollars are spent, information that is also very important to the residents and their families who call a nursing home home. Greater transparency would reveal where our dollars are flowing. For example, how much is being spent on residents’ direct care needs and personal care plans? How much is being spent on direct care staff salaries instead of nursing home profits? This vital information will help hold nursing homes accountable for how they are using taxpayer dollars and how they are providing care. Legislation was re-introduced this year to revise reporting requirements for nursing homes’ financial disclosures and ownership structure. Rather than more back-room deals directing millions more of taxpayer dollars to an industry where stronger accountability and transparency are needed, the governor and Legislature should continue to work together to enact this bill to ensure that the billions in funding that nursing homes receive from New Jersey taxpayers go towards improving the quality of care for residents.
Katie Squires isassociate state director of advocacy for AARP New Jersey .
Staff and residents are ‘scared to death’ of violent patients at dementia care homes.
Casey Shively holds a photo of a family ski trip with his sister, Katie, and his father, Dan, in 1996. Dan Shively died in a memory care home after being violently attacked by another resident. Jessica Plance; skiing photo by Crystal Images Photography/KFF Health News hide caption
Dan Shively had been a bank president who built floats for July Fourth parades in Cody, Wyo., and adored fly-fishing with his sons. Jeffrey Dowd had been an auto mechanic who ran a dog rescue and hosted a Sunday blues radio show in Santa Fe.
By the time their lives intersected at Canyon Creek Memory Care Community in Billings, Mont., both were deep in the grips of dementia and exhibiting some of the disease’s terrible traits.
Shively had been wandering lost in his neighborhood, having outbursts at home, and leaving the gas stove on. Dowd previously had been hospitalized for being confused, suicidal, and agitated, medical records filed in U.S. District Court in Billings show. When Dowd entered Canyon Creek, managers warned employees in a note later filed in court that he could be “physically/verbally abusive when frustrated.”
On Shively’s fourth day at Canyon Creek, carrying a knife and fork, he walked over to a dining room table where Dowd was sitting. Dowd told Shively to keep the knife away from his coffee, according to a witness statement filed in court. Shively, who at 5-foot-2 and 125 pounds was half Dowd’s weight and 10 inches shorter, turned to walk away, but Dowd stood up and shoved Shively so hard that when he hit the floor, his skull fractured and brain hemorrhaged, according to a lawsuit his family filed against Canyon Creek.
“The doctor said there’s not much they could do about it,” his son Casey Shively said in an interview.
Dan Shively died five days later at age 73.
Police did not charge Dowd, then 66. He stayed at Canyon Creek for nearly three more years, during which time he repeatedly clashed with residents, sometimes hitting male residents and groping female ones, according to facility records filed in the court case. His anger would flare quickly. “I’m literally scared to death of Jeff,” one nurse wrote in a filed statement describing Dowd’s dispute with another resident.
In court, Canyon Creek denied liability for Shively’s death. Its privately held corporate owner, Koelsch Communities, declined to answer questions from KFF Health News. Chase Salyers, Koelsch’s director of marketing, said in an email to KFF Health News that the company prioritizes “the health, well-being, safety, and security of our residents.”
Dowd’s relatives said in a statement via text they would not comment because they had no firsthand knowledge. “We were very pleased with the care Jeffrey received at Canyon Creek,” they added. Dowd was not named in the lawsuit and his current whereabouts could not be determined.
Violent altercations between residents in long-term care facilities are alarmingly common. Across the country, residents in nursing homes or assisted living centers have been killed by other residents who weaponized a bedrail , shoved pillow stuffing into a person’s mouth, or removed an oxygen mask .
A recent study in JAMA Network Open of 14 New York assisted living homes found that, within one month, 15% of residents experienced verbal, physical, or sexual resident-on-resident aggression. Another study found nearly 8% of assisted living residents engaged in physical aggression or abuse toward residents or staff members within one month. Dementia residents are especially likely to be involved in altercations because the disease damages the parts of the brain affecting memory, language, reasoning, and social behavior.
More than 900,000 people with Alzheimer’s or other types of dementia reside in nursing homes and assisted living centers. Many of the most seriously impaired live in the roughly 5,000 facilities with locked dementia floors or wings or the 3,300 homes devoted exclusively to memory care. These places are mostly for-profit and often charge thousands of dollars extra a month, promising expertise in the disease and a safe environment.
Casey Shively says that as his father’s dementia worsened, it became harder for the family to take care of him at home. “He would start walking the neighborhood and get lost,” Shively says. “He would turn on the gas stove but not light the stove and the room would start filling up with gas. He would put clothing in strange places. I found socks in a punch bowl. It got to the point where we couldn’t do this anymore.” Jessica Plance /KFF Health News hide caption
Clashes can be spontaneous and too unpredictable to prevent. But the chance of an altercation increases when memory care homes admit and retain residents they can’t manage, according to a KFF Health News examination of inspection and court records and interviews with researchers. Homes that have too few staffers or nonexistent or perfunctory training for employees have a harder time heading off resident conflicts. Homes also may fail to properly assess incoming residents or may keep them despite demonstrated threats to others.
“As much as long-term care providers in general do their best to provide competent, high-quality care, there is a real problem with endemic violence,” said Karl Pillemer, a gerontologist at Cornell University and lead author of the JAMA study.
“There needs to be much more of an effort to single out verbal and physical aggression that occurs in long-term care,” he said, “and begin to create a model of violence-free zones in the same way we have violence-free zones in the schools.”
A danger to others.
The first signs of Shively’s vascular dementia emerged in 2011 as confusion, but the disease accelerated in 2016, according to interviews with his wife and children and his medical records. He began referring to mountains he knew well by the wrong name and forgot how to tie flies on his fishing line. “The decline was so slow at first we thought we could manage,” his wife, Tana Shively, said in an interview before her death this year.
As the disease progressed, his outbursts became hard to handle. He took a swing at one of his sons when upset about the temperature in the house. He refused to swallow his medications and fell repeatedly.
“He would start walking the neighborhood and get lost,” Casey said. “He would turn on the gas stove but not light the stove, and the room would start filling up with gas. He would put clothing in strange places. I found socks in a punch bowl. It got to the point where we couldn’t do this anymore.”
Dowd, meanwhile, had lived in a Santa Fe nursing home and had a long history of dementia with behavioral issues, major depressive disorder with psychotic features, and hypertension, according to medical records filed in court. Dowd entered Canyon Creek in October 2018 to be closer to his brother, who lived nearby in Wyoming, according to an admission notice the facility provided to employees that was included in the court record. The notice said Dowd suffered from dementia caused by excessive and long-term alcohol use .
Two months later, Shively moved in.
Montana licenses Canyon Creek, which has 67 beds, as a Level C assisted living facility, which permits it to house people with cognitive impairments so severe that they cannot express their needs or make basic care decisions. Montana law says these facilities cannot admit or retain a resident who is “a danger to self or others.”
In the lawsuit, Shively’s family argued that given that law, Canyon Creek never should have accepted or kept Dowd. The Shively family’s lawyer, Torger Oaas, noted in court papers that Canyon Creek’s intake assessment form for Dowd categorized his behavior as “physically and/or verbally abusive/aggressive 1x per month.” Oaas also wrote in court papers that in Dowd’s first weeks at Canyon Creek, he mocked and threatened to hit other residents and threw someone’s silverware to the ground during dinner.
In its defense filings in the lawsuit, Canyon Creek said the Montana statute was too broad to be the basis of a negligence claim and argued that all memory care residents are unpredictable. And while Dowd had yelled and cursed at other residents at Canyon Creek, he hadn’t had physical confrontations — or any conflicts with Shively, Canyon Creek said. “The accident was not reasonably foreseeable,” Canyon Creek argued.
In the days after Shively’s fall, nurses noted that Dowd was “more anxious, angry toward others.” Dowd yelled at a nurse to get off the phone and “do your job,” a nurse wrote in a logbook entry filed in court.
“He got into my face,” the nurse wrote. “It looked like he was going to hit me — he had his hand/fist raised.”
Canyon Creek Memory Care Community in Billings, Mont., where Dan Shively died, is licensed as a Level C assisted living facility. Level C facilities are permitted to house people with cognitive impairments so severe that they cannot express their needs or make basic care decisions. Jessica Plance for KFF Health News hide caption
People with dementia will lash out because they no longer have social inhibitions or because it’s the only way they can express pain, discomfort, fear, disagreement, or anxiety. Some common triggers — overstimulation from loud noises, a frenzied atmosphere, unfamiliar faces — are hallmarks of dementia care institutions.
“We can’t expect someone who is constantly and unfailingly disoriented to adapt to our environment anymore,” said Tracy Wharton , a licensed clinical social worker and dementia researcher in Florida. “We have to adapt to them.”
Eilon Caspi, a University of Connecticut researcher, analyzed 105 fatal incidents involving dementia residents and found 44% were fatal falls in which one resident pushed another. “Some people are aggressive, and some are violent,” Caspi said, “but if you look closely, the vast majority are doing their best while living with a serious brain disease.”
Holly Harmon, a senior vice president at the American Health Care Association/National Center for Assisted Living, an industry trade group, said in a written statement that conflicts cannot always be averted despite facility operators’ best efforts. “If they do occur,” she said, “providers respond promptly with interventions to protect the residents and staff and prevent future occurrences.”
But Richard Mollot, executive director of the Long Term Care Community Coalition, a resident advocacy group, said many operators of assisted living centers, including memory care units, are driven by the bottom line. “The issue that we see quite often is that assisted living retains people they should not,” Mollot said. “They don’t have the staffing or the competency or the structure to provide safe care.” Conversely, he said, when facilities have enough rooms filled with paying customers, they are more likely to evict residents who require too much attention.
“They will kick them out if they’re too cumbersome,” Mollot said.
Teepa Snow, an occupational therapist who founded Positive Approach to Care , a company that trains dementia caregivers, noted that the space inside many facilities, with double rooms, tight common areas and restricted outdoor access, can fuel conflicts. She said the pandemic degraded conditions in long-term care, as dementia residents with limited social skills atrophied in isolation in their rooms and staffing grew even sparser.
“It’s as bad as I’ve ever seen it,” she said.
The following account of Dowd’s time at Canyon Creek is based on 44 pages of nurse’s notes, witness statements, and internal resident-on-resident altercation reports; all were contained in the facility’s records and filed as exhibits in the court case. After Shively’s death in December 2018, Dowd was given new prescriptions, although the court record is unclear if the change was because of Shively’s death. Still, the records show, Canyon Creek was unable to head off recurring altercations involving Dowd.
Some were verbal threats. Once, Dowd yelled at residents in the living room to shut up, called them “retards” and told them they should all die, a caregiver wrote in a witness statement. He grabbed one resident’s face and threatened to kill him, according to a nurse’s note. Another time, Dowd went up to a resident sitting on a sofa and grabbed his walker. Dowd shook it and told him to shut up. According to a witness statement, as a nurse took the resident to the bathroom, Dowd muttered under his breath: “Stuff his head in the toilet.”
Other conflicts were physical. Dowd shoved a resident “down on his back so hard his head bounced off the floor,” a nurse recorded in a note. In a different incident reported by a nurse, Dowd pushed a resident who had been agitated and cursing into a chair. On separate occasions, Dowd hit two residents on the head, once causing bleeding, according to two resident altercation reports.
The notes detail that Dowd was not always the initiator. Once, Dowd’s roommate scratched and punched him after Dowd told him to use the toilet rather than pee on the floor, resulting in a fight. Caregivers separated the two. Another day, a resident named Bill wandered into Dowd’s room and pulled Dowd’s hair and beard. Dowd told the nurses he “felt unsafe and VERY angry,” a nurse’s note said. The nurse led Bill out of Dowd’s room, but Dowd followed, yelling at Bill that he was “a fat bastard” and saying he was going to make Bill’s wife a widow.
“Jeff kept making a closed fist as tho he was going to hit Bill,” the nurse wrote in a witness statement. “I was legit scared because there was nothing I could do to defuse the situation. I’m literally scared to death of Jeff. I’m scared to approach him and talk to him when he gets into these very common fits of rage.”
Dowd ultimately went back to his room and a worker locked his door so no other resident would go in.
The records describe how Canyon Creek caregivers intervened after altercations began, often separating the fighting residents and updating Dowd’s brother on the clashes. Nurses would remove Dowd or the other resident from a room and discourage such acts. “Tried to explain it was inappropriate to hurt others,” one nurse wrote after one incident.
Salyers, the company marketing director, said in his email that the workers at Canyon Creek and other Koelsch facilities are “highly qualified” and “extensively trained.” He said the company’s memory care communities are “distinctively designed and staffed” for people with Alzheimer’s and other forms of dementia.
The nursing notes and statements in the court file suggest that incidents were frequent enough that nurses commented on Dowd’s occasional serenity. “No agitated or aggressive behaviors this shift,” one note said. Another nurse note said Dowd “continues to isolate at meals, sitting at a table by himself.” While Dowd enjoyed reading books and doing puzzles, he was overheard saying he was depressed and was “wondering if he wouldn’t be better off if he wasn’t around anymore.”
Nurses noted Dowd repeatedly exhibited sexual behavior that was either inappropriate — making “crude oral gestures while looking at younger females” — or ambiguous, such as placing his hand on a resident’s shoulder and commenting, “It’s nice to have a girlfriend.” Someone saw Dowd “grabbing on multiple residents[’] private areas,” a witness statement said. When nurses caught the behavior, they separated those involved and rebuked Dowd. A staff member wrote in a statement that Dowd was inappropriate throughout her shift, making sexual jokes and “trying to grab me.”
According to nursing notes, in summer 2021, Dowd told one female resident he wanted to see her genitals and later touched her breast. In August, a caregiver walked into Dowd’s room and found him touching the same resident under her shirt and pants. The caregiver told Dowd to “stop it and not ever do that again” and brought the woman out to meet her family, who had come to visit her.
After that incident, Canyon Creek sent Dowd to the emergency room at Montana State Hospital, a public psychiatric facility, according to a nurse administrator’s testimony in a deposition filed in court. The nurse testified Dowd was no longer at Canyon Creek. That is the last mention of Dowd’s whereabouts in the public record. A spokesperson for the Montana Department of Public Health and Human Services, which oversees the hospital, would not confirm whether he was a patient.
At a pretrial hearing, the judge excluded discussion about Dowd’s altercations after Shively’s death. In a court filing, Shively’s lawyer asked permission to share evidence with the jury that Canyon Creek gave its executive director a bonus any month when 90% or more of the beds were filled so he could argue Canyon Creek had a financial motivation to admit Dowd. But the judge also barred that information from the trial, which Canyon Creek said in a court filing was irrelevant.
The Shively case went to trial in 2022 before a federal civil jury in Billings. Despite the exclusions, the jury decided Canyon Creek’s negligence caused Shively’s death. It awarded the family $310,000.
“For us, the money wasn’t a huge factor,” said Spencer Shively, another of Dan Shively’s sons, who called the damages so modest as to be a victory for Canyon Creek or its insurer. “At least they were negligent per se. But I don’t know it really changed anything. For me, I got some closure. I feel like these facilities are just continuing to do the same things they’re going to do because there hasn’t been systemic change.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source for health policy research, polling, and journalism.
The home improvement retailer, formerly known as lumber liquidators, is closing nearly 100 stores while 300 will remain open. the richmond, virginia-based company has filed for bankruptcy..
LL Flooring has announced that it will close 94 stores in more than 30 states as it filed for chapter 11 bankruptcy.
The company, formerly known as Lumber Liquidators, said that it is nearly $110 million in long-term debt in filings made in Delaware bankruptcy court on Sunday .
The Richmond, Virginia-based company said in the filings that slowing home sales and rising interest rates contributed to slower sales in the home improvement market. The company's 300 other stores will remain open.
LL Flooring said it will stop accepting gift cards at all of its locations, including the ones that aren't shuttering, on Sept. 4 as a part of the bankruptcy process, and that gift cards cannot be exchanged for cash. The company said in the filings that it has approximately $131 million in outstanding gift cards.
LL Flooring said in the filings that it has attempted to find a buyer but is willing to solicit offers to close more stores if one cannot be found.
"The company is engaged in discussions with potential buyers of the company, and this process will allow us to evaluate binding bids through a court-supervised process in order to maximize value for all of our stakeholders," LL Flooring wrote in a letter to its customers . "While this could change, the company currently anticipates closing a sale of the business by end of September if a buyer is identified."
The company said that it has garnered $130 million in Chapter 11 financing, funded through existing lenders led by Bank of America.
To see the stores closing in your area, click on the state name to go directly to the state or scroll through the list below
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LL Flooring is the latest in a string of retailers shutting down.
Big box discount store Big Lots announced this month that it may close up to 315 stores in a Securities and Exchange Commission filing.
Big Lots marked some stores as closing on the affected location's info page. The company did not release a list of stores it intended to close.
The Columbus Dispatch − a part of the USA TODAY Network − reported that the Columbus-based retailer had listed 293 locations as "closing soon"
"In 2024, the U.S. economy has continued to face macroeconomic challenges including elevated inflation, which has adversely impacted the buying power of our customers,” Big Lots said in the filing.
The company reported that sales in the first quarter of 2024, which ended in May, fell more than 10% compared to the previous year.
, Astrakhan Stock Exchange, , Nikolskaya Street | |
Anthem: | |
Show map of Astrakhan Oblast Show map of European Russia Show map of Caspian Sea Show map of Russia | |
Coordinates: 48°02′06″E / 46.35000°N 48.03500°E / 46.35000; 48.03500 | |
Country | |
Founded | 1558 |
City status since | 1717 |
Government | |
• Body | |
• Head | Oleg Polumordvinov |
Area | |
• Total | 208.70 km (80.58 sq mi) |
Elevation | −25 m (−82 ft) |
Population ( Census) | |
• Total | 520,339 |
• Estimate | 530,900 |
• Rank | in 2010 |
• Density | 2,500/km (6,500/sq mi) |
• Subordinated to | of Astrakhan |
• of | , city of oblast significance of Astrakhan |
• Urban okrug | Astrakhan Urban Okrug |
• of | Astrakhan Urban Okrug |
( ) | |
+7 8512 | |
ID | 12701000001 |
City Day | Third Sunday of September |
Website |
Modern history, administrative and municipal status, demographics, transportation, notable people, twin towns and sister cities, external links.
Astrakhan was formerly the capital of the Khanate of Astrakhan (a remnant of the Golden Horde ) of the Astrakhan Tatars , and was located on the higher right bank of the Volga, seven miles (11 km) from the present-day city. Situated on caravan and water routes, it developed from a village into a large trading centre, before being conquered by Timur in 1395 and captured by Ivan the Terrible in 1556 and in 1558 it was moved to its present site.
The oldest economic and cultural center of the Lower Volga region, [16] it is often called the southernmost outpost of Russia, [17] and the Caspian capital. [18] [19] The city is a member of the Eurasian Regional Office of the World Organization United Cities and Local Governments . [20] The great ethnic diversity of its population gives a varied character to Astrakhan. The city is the center of the Astrakhan metropolitan area .
The name is a corruption of Hashtarkhan, itself a corruption of Haji Tarkhan ( حاجی ترخان )—a name amply evidenced in the medieval writings. Tarkhan is possibly a Turco-Mongolian title standing for "great khan ", or "king", while haji or hajji is a title given to one who has made the Islamic requisite of pilgrimage to Mecca . Together, they denoted "the king who has visited Mecca". [ citation needed ] The city has given its name to the particular pelts from young karakul sheep , and in particular to the hats traditionally made from the pelts. [ citation needed ]
Colloquially, the city is known by the short form Astra . Another popular nickname is The Caspian Capital . [ citation needed ]
Astrakhan is in the Volga Delta , which is rich in sturgeon and exotic plants. The fertile area formerly contained the capitals of Khazaria and the Golden Horde . Astrakhan was first mentioned by travelers in the early 13th century as Xacitarxan . Tamerlane burnt it to the ground in 1395 during his war with the Golden Horde . From 1459 to 1556, Xacitarxan was the capital of Astrakhan Khanate by the Astrakhan Tatars . The ruins of this medieval settlement were found by archaeologists 12 km upstream from the modern-day city.
Starting in A.D. 1324, Ibn Battuta , the famous Berber Muslim traveler, began his pilgrimage from his native city of Tangier , present-day Morocco to Mecca. Along the 12,100-kilometer (7,500 mi) trek, which took nearly 29 years, Battuta came in contact with many new cultures, which he writes about in his diaries. One specific country that he passed through on his journey was the Golden Horde ruled by the descendants of Genghis Khan , located on the Volga River in southern Russia; which Battuta refers to as the river Athal. He then claims the Athal is, "one of the greatest rivers in the world". In the winter, the Khan stays in Astrakhan. Due to the cold water, Özbeg Khan ordered the people of Astrakhan to lay many bundles of hay down on the frozen river. He does this to allow the people to travel over the ice. When Battuta and the Khan spoke about Battuta visiting Constantinople, which the Khan granted him permission to do, the Khan then gifted Battuta with fifteen hundred dinars, many horses, and a dress of honor. [21] [22]
In 1556, the khanate was conquered by Ivan the Terrible , who had a new fortress, or kremlin , built on a steep hill overlooking the Volga in 1558. This year is traditionally considered to be the foundation of the modern city. [3]
In 1569, during the Russo-Turkish War , Astrakhan was besieged by the Ottomans, who had to retreat in disarray. A year later, the Ottoman sultan renounced his claims to Astrakhan, thus opening the entire Volga River to Russian traffic. [ citation needed ] The Ottoman Empire , though militarily defeated, insisted on safe passage for Muslim pilgrims and traders from Central Asia as well as the destruction of the Russian fort on the Terek River . [23] In the 17th century, the city was developed as a Russian gate to the Orient. Many merchants from Armenia , Safavid Persia , Mughal India , [24] [25] and Khivan Khanate settled in the town, giving it a cosmopolitan character.
Year | ||
---|---|---|
1897 | 112,880 | — |
1926 | 183,254 | +62.3% |
1939 | 253,595 | +38.4% |
1959 | 295,768 | +16.6% |
1970 | 410,473 | +38.8% |
1979 | 461,003 | +12.3% |
1989 | 509,210 | +10.5% |
2002 | 504,501 | −0.9% |
2010 | 520,339 | +3.1% |
2021 | 475,629 | −8.6% |
Source: Census Data |
For seventeen months in 1670–1671, Astrakhan was held by Stenka Razin and his Cossacks . Early in the following century, Peter the Great constructed a shipyard here and made Astrakhan the base for his hostilities against Persia, and later in the same century Catherine the Great accorded the city important industrial privileges. [26]
The city was held from 1707 by the Cossacks under Kondraty Bulavin during the Bulavin Rebellion until they were defeated the next year. A Kalmuck khan laid an abortive siege to the kremlin several years before that.
In 1717, it became the seat of Astrakhan Governorate , whose first governors included Artemy Petrovich Volynsky and Vasily Nikitich Tatishchev . Six years later, Astrakhan served as a base for the first Russian venture into Central Asia . In 1702, 1718 and 1767, it suffered severely from fires; in 1719 it was plundered by the Safavid Persians; and in 1830, cholera killed much of the populace. [26]
The Astrakhan Kremlin was built from the 1580s to the 1620s from bricks taken from the site of Sarai Berke . Its two impressive cathedrals were consecrated in 1700 and 1710, respectively. Built by masters from Yaroslavl , they retain many traditional features of Russian church architecture, while their exterior decoration is definitely baroque .
In March 1919 after a failed workers' revolt against Bolshevik rule, 3,000 to 5,000 people were executed in less than a week by the Cheka under orders from Sergey Kirov . Some victims had stones tied around their necks and were thrown into the Volga. [27] [28]
During Operation Barbarossa , the German invasion of the Soviet Union in 1941, the A-A line running from Astrakhan to Arkhangelsk was to be the eastern limit of German military operation and occupation. The plan was never carried out, as Germany captured neither the two cities nor Moscow . In the autumn of 1942, the region to the west of Astrakhan became one of the easternmost points in the Soviet Union reached by the invading German Wehrmacht , during Case Blue , the offensive which led to the Battle of Stalingrad . Light armored forces of German Army Group A made brief scouting missions as close as 35 km to Astrakhan before withdrawing. In the same period, elements of both the Luftwaffe 's KG 4 and KG 100 bomber wings attacked Astrakhan, flying several air raids and bombing the city's oil terminals and harbor installations.
In 1943, Astrakhan was made the seat of a Soviet oblast within the RSFSR . The oblast was retained as a national province of the independent Russian Federation in the 1991 administrative reshuffle after the dismemberment of the Soviet Union .
In the present day, Astrakhan is a large industrial centre of the Volga country, Russia, with a population of over 500,000. Starting nearly 400 years ago and continuing to the present day, Astrakhan has been Russia's main center of fish processing. The market for fish is a large component of the economy in this city. [29]
Owing to shared Caspian borders, Astrakhan recently has been playing a significant role in the relations between Russia and Azerbaijan. As the latter's government has been heavily investing into the wellbeing of the city, Astrakhan has recently begun to symbolize the friendship between both countries. In 2010 a bridge was constructed with donations from Azerbaijan, which was named "Bridge of Friendship". [30] Moreover, Azerbaijani government sponsored secondary school number 11, which carries the name of the national leader Heydar Aliyev , as well as a children's entertainment center named "Dream". [31] Apart from that, a park has been built in the center of Astrakhan which is dedicated to friendship between the two countries. In the last 5 years Astrakhan has been visited by top Azerbaijani delegations on several occasions. [32] [33] [34] [35]
After fraud was alleged in the mayoral election of 2012 and the United Russia candidate was declared the winner, organizers of the 2011–2012 Russian protests supported the defeated candidate, Oleg V. Shein of Just Russia , in a hunger strike . Protestors, buoyed by celebrities who support the reform movement, attracted 5,000 people to a rally on April 14. [36]
Astrakhan is the administrative center of the oblast . [10] Within the framework of administrative divisions , it is incorporated as the city of oblast significance of Astrakhan —an administrative unit with the status equal to that of the districts . [1] As a municipal division , the city of oblast significance of Astrakhan is incorporated as Astrakhan Urban Okrug . [11]
The city of Astrakhan is further subdivided into four administrative districts: Kirovsky, Leninsky, Sovetsky and Truskovsky.
Astrakhan is the archiepiscopal see of one of the metropolitanates and (as Astrakhan and Yenotayevka) eparchies of the Russian Orthodox Church , its only other suffragan being Akhtubinsk. [ citation needed ] There is also a Catholic community, served by the Church of the Assumption of Mary (Astrakhan) . There is also a substantial Muslim population made up of Astrakhan Tatars and other Muslims. [37] At 1777 the white Mosque was built, [38] and the Baku Mosque was built in 1907–1909.
According to the results of the 2021 Census, the population of Astrakhan was 475,629. [15]
At the time of the official 2021 Census, the ethnic makeup of the city's population was: [39]
Ethnicity | Population | Percentage |
---|---|---|
293,620 | 78.8% | |
23,965 | 6.4% | |
21,179 | 5.7% | |
4,213 | 1.1% | |
4,163 | 1.1% | |
2,823 | 0.8% | |
2,727 | 0.7% | |
2,469 | 0.7% | |
1,684 | 0.5% | |
1,681 | 0.5% | |
1,077 | 0.3% | |
12,926 | 3.5% |
The city lies on two banks of the Volga, in the upper part of the Volga Delta, on eleven islands of the Caspian Depression, 60 miles (100 km) from the Caspian Sea. At an elevation of 28 meters (92 ft) below sea level, it is the lowest city in Russia.
Astrakhan features a continental cold desert climate ( Köppen climate classification : BWk ) with cold winters and hot summers. Astrakhan is one of the driest cities in Europe. Rainfall is scarce but relatively evenly distributed throughout the course of the year with, however, more precipitation (58%) in the hot season (six hottest months of the year).
The below sea-level elevation and long distance from the ocean of Astrakhan significantly influences the climate. Winters are mild cold with average January temperature -3.6 °С (25.5 °F). Summer temperatures in Astrakhan are one of the highest in Russia with average Jule temperature 26.1 °С (79 °F) and may reach 40 °С (104 °F) and higher. The summers are much hotter than found further west on similar latitude in Europe and worldwide for 46°N with the notable exception of the interior Pacific Northwest of the United States. The mean annual temperature amplitude (difference between the mean monthly temperatures of the hottest and coldest months) is thus equal to 29.7 °С (85.5 °F) so the climate is truly continental. Spring and fall are basically transitional seasons between summer and winter.
Climate data for Astrakhan (1991–2020, extremes 1837–present) | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Month | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Year |
Record high °C (°F) | 14.0 (57.2) | 17.1 (62.8) | 24.0 (75.2) | 32.0 (89.6) | 36.8 (98.2) | 40.6 (105.1) | 41.0 (105.8) | 40.8 (105.4) | 38.0 (100.4) | 29.9 (85.8) | 21.6 (70.9) | 16.4 (61.5) | 41.0 (105.8) |
Mean daily maximum °C (°F) | −0.1 (31.8) | 1.5 (34.7) | 8.8 (47.8) | 17.6 (63.7) | 24.7 (76.5) | 30.1 (86.2) | 32.6 (90.7) | 31.4 (88.5) | 24.6 (76.3) | 16.8 (62.2) | 7.3 (45.1) | 1.3 (34.3) | 16.4 (61.5) |
Daily mean °C (°F) | −3.6 (25.5) | −3.0 (26.6) | 3.2 (37.8) | 11.3 (52.3) | 18.5 (65.3) | 23.8 (74.8) | 26.1 (79.0) | 24.6 (76.3) | 18.0 (64.4) | 10.9 (51.6) | 3.1 (37.6) | −1.8 (28.8) | 10.9 (51.6) |
Mean daily minimum °C (°F) | −6.5 (20.3) | −6.5 (20.3) | −1.0 (30.2) | 5.9 (42.6) | 12.7 (54.9) | 17.7 (63.9) | 19.9 (67.8) | 18.3 (64.9) | 12.5 (54.5) | 6.3 (43.3) | −0.1 (31.8) | −4.5 (23.9) | 6.2 (43.2) |
Record low °C (°F) | −31.8 (−25.2) | −33.6 (−28.5) | −26.9 (−16.4) | −8.9 (16.0) | −1.1 (30.0) | 5.4 (41.7) | 10.1 (50.2) | 6.1 (43.0) | −2.0 (28.4) | −10.5 (13.1) | −25.8 (−14.4) | −29.9 (−21.8) | −33.6 (−28.5) |
Average mm (inches) | 15 (0.6) | 12 (0.5) | 17 (0.7) | 25 (1.0) | 28 (1.1) | 25 (1.0) | 22 (0.9) | 17 (0.7) | 16 (0.6) | 19 (0.7) | 17 (0.7) | 18 (0.7) | 231 (9.1) |
Average extreme snow depth cm (inches) | 2 (0.8) | 2 (0.8) | 1 (0.4) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (0.4) | 2 (0.8) |
Average rainy days | 8 | 6 | 7 | 11 | 12 | 11 | 10 | 9 | 9 | 9 | 12 | 10 | 114 |
Average snowy days | 14 | 12 | 7 | 0.4 | 0 | 0 | 0 | 0 | 0 | 0 | 6 | 12 | 51 |
Average (%) | 84 | 80 | 73 | 63 | 61 | 58 | 58 | 59 | 66 | 74 | 83 | 86 | 70 |
Mean monthly | 87 | 106 | 163 | 226 | 293 | 316 | 332 | 309 | 252 | 181 | 84 | 58 | 2,407 |
Source 1: Pogoda.ru.net | |||||||||||||
Source 2: NOAA (sun, 1961–1990) |
Astrakhan has five institutions of higher education. Most prominent among these are Astrakhan State Technical University and Astrakhan State University .
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The city is served by Narimanovo Airport named after Soviet Azerbaijani politician Nariman Narimanov . It is managed by OAO Aeroport Astrakhan. After its reconstruction and the building of the international sector, opened in February 2011, Narimanovo Airport is one of the most modern regional airports in Russia. There are direct flights between Astrakhan and Aktau , Istanbul , St. Petersburg and Moscow.
There is also a military airbase nearby ( Astrakhan (air base) ).
Astrakhan is linked by rail to the north ( Volgograd and Moscow), the east ( Atyrau and Kazakhstan ) and the south ( Makhachkala and Baku). There are direct trains to Moscow, Volgograd, Saint Petersburg , Baku , Kyiv , Brest and other towns. Intercity and international buses are available as well. Public local transport is mainly provided by buses and minibuses called marshrutkas . Until 2007 there were also trams, and until 2017 trolleybuses.
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Astrakhan is twinned with:
Privolzhsky District is the name of several various districts in Russia. The name literally means "something near the Volga".
Krasnoyarsky District is the name of several administrative and municipal districts in Russia:
Akhtubinsk is a town and the administrative center of Akhtubinsky District in Astrakhan Oblast, Russia, located on the left bank of the Akhtuba River, 292 kilometers (181 mi) north of Astrakhan, the administrative center of the oblast. Population: 41,853 (2010 Russian census) ; 45,542 ; 50,261 (1989 Soviet census) ; 30,000 (1968).
Znamensk is a closed town in Astrakhan Oblast, Russia. Population: 29,401 (2010 Russian census)
Narimanov is a town and the administrative center of Narimanovsky District in Astrakhan Oblast, Russia, located on the western bank of the Volga River, 48 kilometers (30 mi) northwest from Astrakhan, the administrative center of the oblast. Population: 11,521 (2010 Russian census) ; 11,202 (2002 Census) ; 11,084 (1989 Soviet census) ; 3,400 (1979).
Kamyzyak is a town and the administrative center of Kamyzyaksky District in Astrakhan Oblast, Russia, located on the Kamyzyak River, 27 kilometers (17 mi) south of Astrakhan, the administrative center of the oblast. Population: 16,314 (2010 Russian census) ; 16,052 (2002 Census) ; 15,084 (1989 Soviet census) .
Volodarsky District is the name of several administrative and municipal districts in Russia. The districts are generally named after V. Volodarsky, a Russian revolutionary and politician.
Chernoyarsky District is an administrative and municipal district (raion), one of the eleven in Astrakhan Oblast, Russia. It is located in the north of the oblast. The area of the district is 4,217.99 square kilometers (1,628.58 sq mi). Its administrative center is the rural locality of Chyorny Yar. As of the 2010 Census, the total population of the district was 20,220, with the population of Chyorny Yar accounting for 38.5% of that number.
Ikryaninsky District is an administrative and municipal district (raion), one of the eleven in Astrakhan Oblast, Russia. It is located in the south of the oblast. The area of the district is 1,950 square kilometers (750 sq mi). Its administrative center is the rural locality of Ikryanoye. As of the 2010 Census, the total population of the district was 47,759, with the population of Ikryanoye accounting for 21.0% of that number.
Limansky District is an administrative and municipal district (raion), one of the eleven in Astrakhan Oblast, Russia. It is located in the southwest of the oblast. The area of the district is 5,234 square kilometers (2,021 sq mi). Its administrative center is the urban locality of Liman. As of the 2010 Census, the total population of the district was 31,952, with the population of Liman accounting for 28.2% of that number.
Privolzhsky District is an administrative and municipal district (raion), one of the eleven in Astrakhan Oblast, Russia. It is located in the south of the oblast. The area of the district is 840.9 square kilometers (324.7 sq mi). Its administrative center is the rural locality of Nachalovo. Population: 43,647 (2010 Russian census) ; 38,649 ; 38,575 (1989 Soviet census) . The population of Nachalovo accounts for 12.5% of the district's total population.
Volodarsky District is an administrative and municipal district (raion), one of the eleven in Astrakhan Oblast, Russia. It is located in the south of the oblast. The area of the district is 3,883 square kilometers (1,499 sq mi). Its administrative center is the rural locality of Volodarsky. Population: 47,825 (2010 Russian census) ; 47,351 ; 46,638 (1989 Soviet census) . The population of the administrative center accounts for 20.9% of the district's total population.
Yenotayevsky District is an administrative and municipal district (raion), one of the eleven in Astrakhan Oblast, Russia. It is located in the west of the oblast. The area of the district is 6,300 square kilometers (2,400 sq mi). Its administrative center is the rural locality of Yenotayevka. Population: 26,786 (2010 Russian census) ; 27,625 ; 29,093 (1989 Soviet census) . The population of Yenotayevka accounts for 28.4% of the district's total population.
Kharabali is a town and the administrative center of Kharabalinsky District in Astrakhan Oblast, Russia, located on the left bank of the Akhtuba River 142 kilometers (88 mi) northwest of Astrakhan, the administrative center of the oblast. Population: 18,117 (2010 Russian census) ; 18,296 (2002 Census) ; 18,566 (1989 Soviet census) .
Ikryanoye is a rural locality and the administrative center of Ikryaninsky District of Astrakhan Oblast, Russia. Population: 10,036 (2010 Russian census) ; 9,925 (2002 Census) ; 9,629 (1989 Soviet census) .
Krasny Yar is a rural locality and the administrative center of Krasnoyarsky District of Astrakhan Oblast, Russia. Population: 11,824 (2010 Russian census) ; 10,926 (2002 Census) ; 10,875 (1989 Soviet census) .
Nachalovo is a rural locality and the administrative center of Privolzhsky District of Astrakhan Oblast, Russia. Population: 5,451 (2010 Russian census) ; 4,830 (2002 Census) ; 3,922 (1989 Soviet census) .
Volodarsky is a rural locality and the administrative center of Volodarsky District of Astrakhan Oblast, Russia. Population: 10,005 (2010 Russian census) ; 9,553 (2002 Census) ; 9,326 (1989 Soviet census) .
Volgo-Kaspiysky is an urban-type settlement in Kamyzyaksky District of Astrakhan Oblast, Russia. Population: 2,581 (2010 Russian census) ; 2,674 (2002 Census) ; 3,088 (1989 Soviet census) .
Kirovsky is an urban-type settlement in Kamyzyaksky District of Astrakhan Oblast, Russia. Population: 2,249 (2010 Russian census) ; 2,259 (2002 Census) ; 2,446 (1989 Soviet census) .
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Districts | |
Cities and towns | |
Have you ever visited a new place and felt ‘wow’ about it? For many visitors, it happens at Astrakhan.
Astrakhan may not be as popular as other cities in Russia, but don’t let that fool you. Astrakhan is a smaller but beautiful upcoming tourist destination that is worth a visit. You will be surprised by some of the unique things to do and places you can explore at this hidden destination.
You might wish to revisit it someday again, to take a break and relax at Astrakhan.
If you have plans to visit Russia and are not sure if Astrakhan should be included in your itinerary, keep reading. In this list, we have put together some of the things to do in Astrakhan and around. We have a hunch that if you include this city in your travel plans, you will be thrilled you did so.
Here is the list of things to do in Astrakhan and tourist attractions in city.
Address: Narimanovo Airport Astrakhan, Russia 423520
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Astrakhan , oblast (region), southwestern Russia . It occupies a low-lying area (much of it below sea level) along the lower Volga River and is bordered to the northeast by Kazakhstan . The Volga and its parallel distributary, the Akhtuba River, form the axis of the oblast , ending in a large delta on the Caspian Sea . The majority of the population lives in the delta area around the city of Astrakhan , the administrative centre.
Vegetables and fruit are grown on the fertile fields enriched by the Volga. Fishing is important along the rivers and Caspian shore, but it has suffered from pollution and the falling sea level . A major nature reserve in the delta protects the unique vegetation—including the lotus ( Nelumbium caspicum )—and abundant birdlife—including pelicans and herons . Outside the floodplain and delta is an arid steppe –semidesert region, with sand dunes, saline soils and lakes, and a sparse sage vegetation; it is used only for extensive cattle and sheep raising and large-scale salt extraction at Lake Baskunchak. Area 17,027 square miles (44,100 square km). Pop. (2010) 1.010,073; (2014 est.) 1,016,516.
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At least 65% of the people that live in retirement homes have something to do with mental health such as (what we mostly hear about) Alzheimer's, dementia, Parkinson and many more. These patients require very special and strict care, and sadly but true; many family members cannot provide them with what they need.
Introduction With the growing number of elderly people in need of care, nursing homes and long-term care facilities have become more vital than ever. However, these institutions pose significant health disparities for aging individuals from minority communities, which could lead to a lower quality of life, limited independence, and untimely death.
Nursing homes started as early as the 17th Century. At that time, they were known as poorhouses or almshouses, which first came into existence in the US after the first English settlers, settled in their country. The poorhouses housed the poor elderly, mentally ill people and the orphans since they offered them a place to have shelter and daily ...
Nursing Home Care. citizens that "There is a nursing home in almost every small town.". The populations of these towns are predominately white. In the case of Mason county Illinois, the population lacks diversity with about 97% being white non-Hispanics (US Census, 2017). It would make sense that in a nursing home populations show the lack ...
Fall Rate Reduction in a Nursing Home. Abstract This paper will present a comprehensive quality improvement initiative focusing on minimizing the fall rate among patients in Nursing Home X. This nursing home is for exceptionally skilled nurses in Connecticut. The study will employ a macro-systems analysis to evaluate the facility's mission ...
The COVID-19 pandemic has amplified the impact of nursing home shortcomings with respect to safety, clinical quality, racial and ethnic disparities in care, mental health, and resident well-being. The horrendous death toll for nursing home residents and staff, 15.4% of U.S. deaths by April 2022 ( Centers for Disease Control and Prevention, 2022 ...
Vox is a general interest news site for the 21st century. Its mission: to help everyone understand our complicated world, so that we can all help shape it. In text, video and audio, our reporters ...
Start Broad. When writing essays entirely about why you want to pursue nursing, try to start from a broad interest, then slowly work your way to telling specific personal stories and goals. When first thinking about your general interest in nursing, ask yourself what attracts you to the work of being a nurse. This can lead to powerful potential ...
Nursing home residents are not a homogeneous group. Accordingly, a wide range of needs and wishes are reported in the literature, assigned to various topics. This underscores the need for tailored and person-centered approaches to ensure long-term well-being and quality of life in the nursing home care setting.
Nursing Home essays We found 9 samples on this topic All samples on this topic. Trending Abuse and Neglect in Nursing Homes. Words · 727. Pages · 3. Rating · 4.8/5. The Body Nursing home negligence and abuse may take the form of financial abuse, physical abuse of emotional abuse or neglect. As such, abuse entails the infliction of injury ...
But it also exposed many weaknesses, foremost among them being chronic nurse understaffing in hospitals, nursing homes and schools. More nurses died of job-related Covid than any other type of ...
Essay About Working In A Nursing Home. 799 Words4 Pages. A life changing challenge I had was working in the nursing home. In high school, my senior year, I signed up to be in the CNA program, where you could get your CNA license. In the beginning of the year, we learned how to do different activities to take care of someone in need.
Just last year, the for-profit nursing home Princeton Care Center's abrupt and chaotic 24-hour shutdown disrupted, displaced, and, in some cases, traumatized the lives of 72 nursing home ...
This guide contains links to library materials and web resources to assist you with your Nursing Philosophy paper. It also includes tutorials and a template to help you with writing your paper in APA citation style. If your professor provided you with documents that contradict those on this guide, please defer to your professor's.
More than 900,000 people with Alzheimer's or other types of dementia reside in nursing homes and assisted living centers. Many of the most seriously impaired live in the roughly 5,000 facilities ...
President Joe Biden vowed more than two years ago to improve care for the nation's 1.2 million nursing home residents after decades of complaints about neglect and abuse. His administration's ...
One of Iowa's largest nursing home operators, Care Initiatives of West Des Moines, is facing at least 10 wrongful death lawsuits. The lawsuits, all filed in state court over the past 18 months ...
Public Meeting Notice Board of Registration of Nursing Home Administrators meeting — August 16, 2024 Friday, August 16, 2024 at 10:00 a.m. Posted: August 12, 2024 9:10 a.m.
Mr Capstick was a resident at a care home when a nurse fractured his ribs giving him CPR. 22 hrs ago. Cumbria. 6 days ago. Nursing union concern over students unable to find work.
LL Flooring files bankruptcy, will close 94 stores. Here's where they are. The home improvement retailer, formerly known as Lumber Liquidators, is closing nearly 100 stores while 300 will remain open.
Astrakhan is in the Volga Delta, which is rich in sturgeon and exotic plants. The fertile area formerly contained the capitals of Khazaria and the Golden Horde.Astrakhan was first mentioned by travelers in the early 13th century as Xacitarxan. Tamerlane burnt it to the ground in 1395 during his war with the Golden Horde.From 1459 to 1556, Xacitarxan was the capital of Astrakhan Khanate by the ...
Things to do in Astrakhan: Discover the top tourist attractions in Astrakhan for your next trip. From must-see landmarks to off-the-beaten-path gems. Plan your visit to with our handy list and make the most of your time in this exciting destination
Astrakhan, oblast (region), southwestern Russia.It occupies a low-lying area (much of it below sea level) along the lower Volga River and is bordered to the northeast by Kazakhstan.The Volga and its parallel distributary, the Akhtuba River, form the axis of the oblast, ending in a large delta on the Caspian Sea.The majority of the population lives in the delta area around the city of Astrakhan ...