Nursing students' risk perceptions related to medication administration error: A qualitative study

AIM

The purpose of this study was to explore and describe pre-licensure nursing students' perceptions of risk for medication administration errors in fourth-year baccalaureate student nurses from three campuses at a large central Pennsylvania university.

BACKGROUND

Medication administration errors continue to be a significant safety concern in healthcare settings. Pre-licensure nursing education is a critical time period during which to have an impact on future medication administration practices. Perception of risk influences decision making and behavior, including nursing clinical decision making.

DESIGN

This descriptive, exploratory study involved a qualitative design.

METHODS

A thematic analysis of the qualitative data resulting from 60 individual, in-depth semi-structured interviews was conducted.

RESULTS

The participants offered rich, detailed narratives which revealed the following themes: (1) the nature of risk perceptions, (2) more opportunities to learn, (3) experiences with medication administration error, and (4) intrinsic characteristics influence errors.

CONCLUSIONS

The findings provide a broad description of the nature of student nurse risk perceptions for future medication administration errors. Recommendations for nursing education practice and pedagogy include additional clinical experiences, modified pharmacology curricula and instruction, and expanded simulations involving medication administration error.

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study

BACKGROUND

Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening.

OBJECTIVE

To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA).

DESIGN

Prospective cohort study.

SETTING

Large urban academic medical center and small rural community hospital.

PARTICIPANTS

527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs).

MEASUREMENTS

On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method.

RESULTS

Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%).

LIMITATION

Two sites; limited diversity.

CONCLUSION

An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Caregiving for Persons Living With Dementia in the New Normal: Family Caregiver’s Perspective

Persons living with dementia (PLWD) are at increased risk for COVID-19 and associated poor outcomes, including: incident delirium, hospitalization, severe symptoms, intensive care admission, and even death. PLWD are likely to rely on family caregivers to maintain their health and well-being in the community. Under normal circumstances, caregiving can be stressful and complex, and the COVID-19 pandemic has the potential to change and exacerbate the stresses of family caregiving. As a part of a larger study using descriptive qualitative methodology to explore the family caregiver understanding and experiences related to delirium in caring for a person with dementia, 14 participants (age x̄ =67, SD= 13.8) were asked about the impact of COVID-19 on their caregiving for PLWD. Thematic analysis of the transcribed interviews using Dedoose generated four overarching themes associated with the family caregiver’s perspective of changes in caregiving during the COVID-19 pandemic: 1) Cautious of COVID-19 exposure, 2) We can’t go in, 3) Feeling of isolation for both the PLWD and caregiver, and 4) Six-feet distance. The current study highlights the importance of understanding the needs of PLWD during a pandemic based upon the perspective of their family caregivers and will inform the development of ways to safely incorporate family caregivers in the interdisciplinary care team. Caregivers are integral to the care of PLWD across settings of care and should be partners even during a pandemic. Solutions for care include integrating technology for individualized approaches. Finally, future areas for research will be discussed.

Age-Friendly Care, PA: A Geriatric Workforce Enhancement Program

Age-Friendly Care, PA is co-led by Primary Health Network, the largest Federally Qualified Health Center in Pennsylvania, and Penn State College of Nursing that aims to bring reliable, high-quality, age-friendly care to all older adults living in rural PA. Sponsored by HRSA through its Geriatric Workforce Enhancement Program, Age-Friendly Care, PA utilizes the ECHO, all-teach-all-learn, platform to engage isolated rural providers in incorporating the 4Ms (IHI) into their practice. Age-Friendly Care, PA reaches out directly to rural older adults and their care partners to co-design education and support. We have hosted 28+ events and reached 450+ individuals. Results include tracking and improvement in quality indicators assessed including support for individuals living with dementia and their care partners (NA-66.7%), risk for opioid misuse (NA-78%), high-risk medication management (NA-47.8%), fall-risk management (NA-9.4%), and advanced care planning (NA-8.9%). We will discuss the creation, co-development, implementation, lessons learned, and future of Age-Friendly Care, PA.

Facilitators and Barriers to Implementation of the EIT-4-BPSD Intervention

This study aimed to explore the perceptions of stakeholders (site champions, administrators, and front-line, social service, and activity staff) regarding the EIT-4-BPSD implementation strategy, including its utility, and the barriers and facilitators to implementation in real-world settings. A process evaluation included qualitative data from focus groups conducted with 93 stakeholders of 21 nursing homes (NHs) that implemented the EIT-4-BPSD strategy. Data were analyzed using a conventional content analysis. Emerging codes were sorted into categories then organized in meaningful clusters based on the domains of the RE-AIM framework. Challenges, facilitators, and contextual factors explain variability in implementation of EIT-4-BPSD strategy among NHs in six key categories: multi-stakeholder engagement, multi-level outcomes, process adaptations, uptake and utility of EIT resources, adoption barriers and facilitators, and future planning. Overall, stakeholders reported that the EIT-4-BPSD strategy can be successfully implemented in NHs and is helpful in improving staffs’ approach to BPSD.

Engagement of Family in a Goal Setting Strategy: Impact Upon 30-Day Hospital Readmissions

Family-centered Function-focused Care (Fam-FFC) works with family caregivers as care partners in the assessment, function-promoting goal setting, implementation, and evaluation of goal attainment during hospitalization and immediate post-acute period. ANCOVA technique examined the preliminary impact of Fam-FFC upon 30-day hospital readmissions and logistic regression tested the association of goal attainment, measured with the Goal Attainment Scale (GAS) with 30-day hospital readmissions. The majority of the patients were Black (50%), female (62%), had a mean age of 81.6 (SD=8.4), mean Barthel Index of 60.29 (SD=27.7), and mean MoCA of 10.67 (SD=7.0). Goals represented six main categories: mobility, cognition, self-care, toileting, sleep, and pain management. Patients in the intervention group had less 30-day hospitalizations (F= 4.6, p=.033) and goal attainment was significantly associated with less recidivism (B=.179, Wald= 2.8 (1), p= .045). FamFFC shows promise in reducing 30-day hospital readmissions; results support the contribution of family engagement and use of GAS

Clinical Research in the Hospital During the Pandemic: What’s Worked and Not Worked?

Under normal conditions, the hospital setting presents multiple challenges to research with persons with dementia and their care partners. This presentation describes the additional barriers posed by the COVID-19 pandemic, as well as the strategies to meet those challenges, in a cluster randomized controlled trial that examines the efficacy of a nurse-family partnership to promote functional recovery of persons with dementia. In response to research restrictions, the research team altered their plan for recruitment, implementation of the intervention, data collection, and analytic approach. This presentation describes these alterations and discusses the plan to meet the aims of the project while meeting the requirements of the Institutional Review Board, accountability to the funder, and university regulations. Modifications in staffing patterns, staff training, and procedures will also be discussed, as well as the study timeline. Finally, strategies to maintain a positive attitude and productivity within the team will be discussed.

Pilot Testing of the UB-CAM Delirium Screening App

Systematic screening improves delirium detection among hospitalized older adults. This poster describes the development and pilot testing of an iOS-based app that incorporates the Ultra-Brief Confusion Assessment Method (UB-CAM), a two-step, delirium detection protocol that combines the UB-2 (2-item screener) and 3D-CAM. Previous work tested a RedCAP-based UB-CAM app in 527 patients with 399 physicians, nurses, and certified nursing assistants (CNAs) showing it can be successfully completed by all three disciplines in 97% of eligible patients in 80 seconds on average with over 85% accuracy relative to a gold standard. To improve accessibility to the clinical setting, our research team now collaborated with a computer scientist to develop and refine an iOS-based UB-CAM app for the iPhone and iPad through iterative “laboratory” testing. The app was piloted by non-clinician, research testers in hospitalized older adults (age x̄ =83, SD= 8.0) with dementia (Clinical Dementia Rating Scale x̄ =1.1, SD= .30); 64% were assessed to be delirium positive. The app demonstrated preliminary efficiency (90 seconds on average), high acceptability (100% satisfaction of users), and reliability (100% inter-rater). This project underscores the need for close collaboration between researchers, clinicians, and computer scientists with iterative testing of bedside-facing apps prior to testing with patients. Next steps include testing effectiveness in a pragmatic trial with clinician users (physicians, nurses, CNAs), integrating the UB-CAM app into the routine hospital care of all older patients. Having rapid, accurate bedside delirium detection has the potential to transform care.

Nursing Staff Perceptions of Risk Outcomes in Delivering Preference-Based Person-Centered Care

Effective management of the perceived risks associated with delivering preference-based person-centered care (PBPCC) is historically challenging for nursing home staff. Existing research lacks the granularity needed to guide clinicians who fear negative health and safety outcomes for residents. This study examined direct-care nursing staff perceptions of outcomes associated with delivering PBPCC. Participants (N=27) worked in NHs experiencing 6-12 health citations, were mostly female (85%), and represented diverse ages, race, education, and collective work experience in NHs. Content analysis of verbatim transcripts from 12 focus groups identified an overarching theme of: “person-centered outcomes related to risk engagement”; and sub-themes of: harms to staff (e.g. fear, frustration, guilt); harms to residents (e.g. negative moods and behaviors, physical discomfort); and positive shared outcomes (e.g. building nurse-resident relationships, positive care environment). Implications for risk management that improves quality of care and life outcomes in a post-COVID era will be discussed.

Factors Associated With the Quality of Staff-Resident Interactions in Assisted Living

Care interactions are essential to understand and respond to resident needs in assisted living (AL). The factors that influence care interactions in AL have not been directly examined. In this study, we explored the factors associated with the quality of care interactions in AL. It was hypothesized that resident functional status, agitation, depression, and resistiveness to care as well as facility size and ownership would be significantly associated with the quality of care interactions in AL after controlling for resident demographics (age, gender, marital status), comorbidities, and cognition. To test the hypothesis, we utilized baseline data including 379 residents from the second and third cohorts recruited in a randomized trial titled ‘Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle’. Regression analysis was performed using a stepwise method. The care interactions were mostly positive (mean=6.3; range = 0-7). Resident agitation and facility ownership were significantly associated with care interactions and accounted for 8.2% of the variance. Increased resident agitation was associated with negative or neutral interaction while for-profit ownership was associated with positive interactions. To promote positive care interactions, staff should be educated about strategies to minimize resident agitation (e.g., calm posture and respectful listening) and encouraged to engage with residents using resident-centered care and communication approach. Findings also suggest the need to work towards optimizing care interactions in nonprofit stings. Future research could further explore the impact of facility-level factors (e.g., staffing ratios, staff longevity, and job satisfaction) on care interactions.

The Impact of FFC-AL-EIT on Resident and Setting Outcomes

FFC-AL-EIT was implemented by a Research Nurse Facilitator working with a community champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included four steps: (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function Focused Care Service Plans; and (Step IV) Mentoring and Motivating. A total of 85 communities and 794 residents were included. The age of participants was 89.48 (SD=7.43), the majority was female (N=561, 71%) and white (N=771, 97%). Resident measures, obtained at baseline, four and 12 months, included function, physical activity, and performance of function focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans. Effectiveness was based on less decline in function (p<.001), more function focused care (p=.012) and better environment (p=.032) and policy (p=.003) support for function focused care in treatment sites.

Pilot Testing of the Promoting Positive Care Interactions (PPCI) in Assisted Living Study During a Pandemic

The purpose of this study was to test the feasibility and preliminary efficacy of Promoting Positive Care Interactions (PPCI)—a four step intervention designed to establish positive care interactions between staff and residents with cognitive impairment or dementia in Assisted Living (AL). Initially designed as a traditional on-site intervention, PPCI was later transformed to be conducted remotely through webinar and virtual meetings due to challenges related to onsite engagement in AL during the COVID-19 pandemic. Additionally, the study adopted shorter timeline, a single group pretest-posttest design, and limited recruitment to staff only; 17 care staff were recruited, and data was collected via online surveys and interviews. PPCI was successfully implemented as intended with considerable stakeholder engagement. Findings demonstrated feasibility and promising staff adoption of PPCI. Continued research is needed to optimize the quality of care interactions in AL and evaluate whether online approach to staff training can change staff behavior.

Cultural Appropriateness of an Intervention to Promote Functional Recovery From Hospitalization: Caregiver Views

The Fam-FFC model includes caregiver education and care pathway to promote physical function, wellbeing, and cognition. The Ecological Model (EM) provided a framework to assess the cultural appropriateness of the Fam-FFC intervention, through interviews with family caregivers, patients, and nurse champions, and focus groups with staff. Findings are described within the eight dimensions of the EM: 1 ) language: perceptions of the dyads’ comfort level with intervention information; (2) persons: representation of dyads’ ethnic /racial group within the nurse champions’ ethnicity/race; (3) metaphors: use of cultural terms equivalent to those used by participants; (4) content: integration of participants’ values, customs, and traditions in the intervention; (5) concepts: congruence of caregiving concepts with cultural norms; (6) goals: congruence of the intervention goals with participants’ cultural norms and goals; 7) methods: the culturally appropriateness of the delivery of the intervention; and (8) context: alignment of the intervention with the participant’s socio-community context.

Examining Caregiver-Resident Communication and Apathy in Dementia in Nursing Homes During the COVID-19 Pandemic

This presentation shares lessons learned from conducting a study examining the impact of staff caregivers’ communication approach on apathy in residents with dementia in nursing homes. Due to COVID-19 restrictions, this study had to be paused and required major revisions to continue, which resulted in significant delays and increased expenses. Additionally, this study required in-person data collection and video recordings to capture staff caregivers’ communication with residents with dementia during caregiving activities. However, due to the pandemic, nursing home residents’ daily routines have been significantly changed, making it challenging to capture the nature of caregiver-resident interactions. Furthermore, using masks created unforeseen barriers for capturing communication between staff caregivers and residents including difficulties in identifying residents’ facial expressions, which are a vital component of assessing apathy. The presentation describes approaches to communication with founders, collaborators, and clinical sites and discusses strategies to recruit participants and conduct data collection.

Reliability and Validity of the Cornell Scale for Depression in Dementia and Invariance Between Black Versus White Residents in Nursing Homes

OBJECTIVES

The purpose of this study was to expand on prior work testing invariance on several depression measures in community-based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia.

DESIGN

This was a descriptive measurement study.

SETTING AND PARTICIPANTS

This was a secondary data analysis using baseline data from 2 studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from 2 states and 889 residents were recruited. The mean age of the participants was 86.58 (SD 10.31) and most were women (72%) and White (70%).

METHODS

This was a descriptive study, and a Rasch analysis was done to establish reliability based on internal consistency and evidence of differential item functioning (DIF) across races. Validity was based on item fit and model testing with structural equation modeling to compare models between White and Black participants.

RESULTS

There was evidence of internal consistency (alpha coefficient of 0.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Black individuals. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants.

CONCLUSIONS AND IMPLICATIONS

The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further, the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

Implementation of the Evidence Integration Triangle for behavioral and psychological symptoms of dementia (EIT-4-BPSD) in care communities

BACKGROUND

Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches.

PURPOSE

This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD.

METHODS

About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model.

FINDINGS

There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation.

DISCUSSION

EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided.

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives

BACKGROUND

Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders' perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings.

METHODS

EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.

RESULTS

The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning.

CONCLUSION

Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success.

TRIAL REGISTRATION

The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov ( NCT03014570 ) January 9, 2017.

Event-Specific Emotional Expression of Persons Living With Dementia in Long-term Care: A 6 Months Follow-up Study

This longitudinal study aimed to explore the event-specific emotional expressions of persons living with dementia in long-term care during a 6-month period with repeated observations. Emotional expressions at three specific events (mealtime, personal care, and social activity) were videotaped at the beginning, month 3, and month 6. Thirty participants were enrolled, and nine observations were made for each participant. Mixed-effect models were used for statistical analysis. The type of care events, the person who provides care, and the facility type were associated with emotional expressions. Specifically, personal care, interaction with non-nursing providers, and facility type were associated with positive emotional expressions. Negative emotional expressions were related to personal care, interaction with family or volunteer, and facility type. This study provides a better understanding of event-specific emotional expressions and knowledge to support the development of emotion-oriented intervention programs to improve the psychological well-being of persons living with dementia.

Evaluation of the Caregiver Preparedness Scale in African American and White Caregivers of Persons With Dementia During Post-Hospitalization Transition

BACKGROUND AND PURPOSE

The Preparedness for Caregiving Scale (PCS) is a widely used instrument to measure caregiver preparedness. The purpose was to evaluate the PCS in African American and White caregivers of patients with dementia upon discharge from the hospital.

METHODS

Factor structure, measurement invariance, and predictive validity of the PCS were assessed in a sample of 292 family caregivers/patient dyads.

RESULTS

One-factor structure of the PCS and measurement invariance by race was fully supported. Predicative validity revealed significant association between the PCS and anxiety (β = -.41, t = -7.61(287), p < .001), depression (β = -.44, t = -8.39(287), p < .001), and strain (β = -.48, t = -9.29(287), p < .001).

CONCLUSION

The PCS is a valid and meaningful tool to measure preparedness in African American and White family caregivers of persons with dementia during post-hospitalization transition.

The Impact of Cognitive impairment on Clinical Symptoms, Physical Activity and Care Interactions among Residents in Assisted Living Settings

The purpose of this study was to describe differences in pain, behavioral symptoms, quality of staff-resident interactions, participation in function focused care and physical activity among residents with and without cognitive impairment in assisted living. This was a secondary data analysis using baseline data from an ongoing trial testing Function Focused Care for Assisted Living using the Evidence Integration Triangle (FFC-AL-EIT). A total of 550 residents were recruited from 59 communities. The average age of participants was 89.30 (SD = 7.63), the majority were white (98%), female (69%), had evidence of cognitive impairment (75%), and 5.16 (SD = 1.86) comorbidities. Those with cognitive impairment had more pain, were more sedentary and less likely to engage in function focused care activities. Addressing pain and implementing interventions for those with cognitive impairment to participate in function focused care may help optimize function and physical activity in assisted living residents.

Function-Focused Goal Attainment and Discharge Outcomes in Hospitalized Persons With Dementia

Hospitalized persons with dementia are at higher risk for functional decline and cognitive loss related to delirium. Family-centered, function-focused care (Fam-FFC) engages the family care partner in education and active participation in function-focused goal setting, implementation, and evaluation to support delirium prevention and abatement and return to baseline physical function. The purpose of the current study was to examine the association of function-focused goal attainment with two discharge outcomes, return to baseline physical function and delirium severity at discharge, in hospitalized persons with dementia. In the ongoing Fam-FFC clinical trial, the majority of goals (N = 433) developed by 134 care partner/patient dyads and nurses address mobility, cognitive stimulation, and self-care. Regression techniques demonstrated that goal attainment was significantly associated with return to baseline function (B = 0.826, Wald = 4.17 [1], p = 0.041) and lower delirium severity at discharge (B = 0.175, t = 2.239, p = 0.027). Results support the contribution of family engagement in promoting functional recovery of hospitalized persons with dementia. [Journal of Gerontological Nursing, 47(9), 13-20.].

Recruiting and Retaining Dyads of Hospitalized Persons with Dementia and Family Caregivers

Persons with dementia have high rates of hospitalization, and along with their caregivers commonly experience negative hospital outcomes. The recruitment and retention of acutely ill older adults with dementia and caregivers can pose a challenge to investigators and threaten the validity of findings. The challenges encountered in an ongoing cluster randomized clinical trial in dyads of hospitalized persons with dementia and family care partners are described. The trial tests the efficacy of a nurse-family partnership model that aims to improve the following: (a) the physical and cognitive recovery in hospitalized persons with dementia, and (b) caregiver preparedness and anxiety. Strategies that address challenges include careful preplanning and preparation with the hospital site, strong communication with dyads and between team members, and honoring preferences and needs related to communication.

Testing the Implementation of Function-focused Care in Assisted Living Settings

OBJECTIVES

The purpose of this study was to evaluate the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention.

DESIGN

FFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents.

INTERVENTION

FFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function-Focused Care Service Plans; and (Step IV) Mentoring and Motivating.

SETTING AND PARTICIPANTS

The age of participants was 89.48 years [standard deviation (SD) = 7.43], and the majority were female (n = 561; 71%) and white (n = 771; 97%).

METHODS

Resident measures, obtained at baseline, 4, and 12 months, included function, physical activity, and performance of function-focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans.

RESULTS

Reach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (P < .001), more function-focused care (P = .012) and better environment (P = .032) and policy (P = .003) support for function-focused care in treatment sites. Adoption was supported with 10.00 (SD = 2.00) monthly meetings held, 77% of settings engaged in study activities as or more than expected, and direct care workers providing function-focused care (63% to 68% at 4 months and 90% at 12 months). The intervention was implemented as intended, and education was received based on a mean knowledge test score of 88% correct. Evidence of maintenance from 12 to 18 months was noted in treatment site environments (P = .35) and policies continuing to support function-focused care (P = .28)].

CONCLUSIONS AND IMPLICATIONS

The Evidence Integration Triangle is an effective implementation approach for assisted living. Future work should continue to consider innovative approaches for measuring RE-AIM outcomes.

Using Appreciative Inquiry to Optimize a Person-Centered Care Training Program for Clinical Champions in Rural Critical Access Hospitals

Person-centered care (PCC) involves shared decision-making between the individual and provider and is widely recognized as the gold standard of care. However, not all organizations have successfully implemented PCC, especially those in rural settings with limited resources. Implementation strategies, such as clinical champions, are key to PCC uptake. The purpose of the current article is to illustrate how Appreciative Inquiry, a strengths-based framework for transformational change, can be used to optimize a successful PCC champion training program. Appreciative Inquiry employs the quality improvement processes of (a) define, (b) discover, (c) dream, (d) design, and (e) deliver/destiny. Using Appreciative Inquiry, we were able to identify three new long-term goals and add supporting features to an existing champion training program. The methods developed herein could be implemented by researchers and evidence-based practice councils to improve the care of older adults in any care setting to make it more person-centered. [Journal of Gerontological Nursing, 47(8), 7-12.].

Reliability and Validity Testing of the Quantified Quality of Interaction Schedule

BACKGROUND AND PURPOSE

The purpose of this study was to test the reliability and validity of the Quality of Interactions Schedule (QuIS) using a quantification scoring approach.

METHODS

Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study was used.

RESULTS

A total of 553 residents participated. There was evidence of inter-rater reliability with Kappa scores of .86 to 1.00 and internal consistency based on the Rasch analysis (item reliability of .98). There was some support for validity based on item fit and hypothesis testing as resistiveness to care was significantly associated with total QuIS scores.

CONCLUSION

This study supports the use of the quantified QuIS to evaluate the quality of interactions over time and to test interventions to improve interactions.