Exit interview-consultation for research validation and dissemination

Dissemination of research findings to practice and maintenance of rigor and validity in qualitative research are continuing challenges for nurse researchers. Using three nursing home case studies as examples, this article describes how exit interview-consultation was used as (a) a validation strategy and (b) a rapid research dissemination tool that is particularly useful for nursing systems research. Through an exit interview-consultation method, researchers validated inferences made from qualitative and quantitative data collected in three comprehensive nursing home case studies that examined nursing management practices. This exit interview-consultation strategy extends the traditional member-check approach by providing confirmation at the individual and organizational level. The study examined how using the exit interview-consultation strategy can potentially assist nursing home organizations to increase their capacity for improving operations. Benefits from research participation are often indirect; this study's results suggest that exit interview-consultation can provide direct and immediate benefits to organizations and individuals.

Connection, Regulation, and Care Plan Innovation

We describe how connections among nursing home staff impact the care planning process using a complexity science framework. We completed six-month case studies of four nursing homes. Field observations (n = 274), shadowing encounters (n = 69), and in-depth interviews (n = 122) of 390 staff at all levels were conducted. Qualitative analysis produced a conceptual/thematic description and complexity science concepts were used to produce conceptual insights. We observed that greater levels of staff connection were associated with higher care plan specificity and innovation. Connection of the frontline nursing staff was crucial for (1) implementation of the formal care plan and (2) spontaneous informal care planning responsive to changing resident needs. Although regulations could theoretically improve cognitive diversity and information flow in care planning, we observed instances of regulatory oversight resulting in less specific care plans and abandonment of an effective care planning process. Interventions which improve staff connectedness may improve resident outcomes.

MDS coordinator relationships and nursing home care processes

This study describes how Minimum Data Set (MDS) coordinators' relationship patterns influence nursing home care processes. MDS coordinators interact with nursing home staff to coordinate resident assessment and care planning, but little is known about how they enact this role or influence particular care processes beyond paper compliance. Guided by complexity science and using two nursing home case studies, the authors describe MDS coordinators' relationship patterns by assessing the extent to which they used and fostered good connections, new information flow, and cognitive diversity. MDS coordinators at one site fostered new information flow, good connections, and cognitive diversity, which positively influenced assessment and care planning, whereas those at the other site did little to foster these three relationship parameters, with little influence on care processes. This study revealed that MDS coordinators are an important new source of capacity for the nursing home industry to improve quality of care.

Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical "chain of command" between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

"The Golden Rule": Only a starting point for quality care

The Golden Rule guides people to choose for others what they would choose for themselves. The Golden Rule is often described as 'putting yourself in someone else's shoes', or 'Do unto others as you would have them do unto you'(Baumrin 2004). The viewpoint held in the Golden Rule is noted in all the major world religions and cultures, suggesting that this may be an important moral truth (Cunningham 1998). The Golden Rule underlies acts of kindness, caring, and altruism that go above and beyond "business as usual" or "usual care" (Huang, 2005). As such, this heuristic or 'rule of thumb' has universal appeal and helps guide our behaviors toward the welfare of others. So why question the Golden Rule? Unless used mindfully, any heuristic can be overly-simplistic and lead to unintended, negative consequences.A heuristic is a rule of thumb that people use to simplify potentially overwhelming or complex events. These rules of thumb are largely unconscious, and occur irrespective of training and educational level (Gilovich, Griffin & Kahneman 2002). Rules of thumb, such as the Golden Rule, allow a person to reduce a complex situation to something manageable-e.g., 'when in doubt, do what I would want done'. Because it is a simplifying tool, however, the Golden Rule may lead to inappropriate actions because important factors may be overlooked.In this article we describe "The Golden Rule" as used by administrators, supervisors, charge nurses, and CNAs in case studies of four nursing homes. By describing use of this rule-of-thumb, we aim to challenge nurses in nursing homes to: 1) be mindful of their use of "The Golden Rule" and its impact on staff and residents; and 2) help staff members think through how and why "The Golden Rule" may impact their relationships with staff and residents.

Urinary incontinence strategies for frail elderly women

Among the majority of frail older women, urinary incontinence has not been adequately assessed or treated, with resultant negative impact on quality of life. An assessment and intervention model based on type of incontinence, evidence-based interventions, and the influence of patient preference and capacity to carry out interventions are described.

Complexity Theory: A Long-Term Care Specialty Practice Exemplar for the Education of Advanced Practice Nurses

This clinical exemplar highlights how an academic clinical practice supported gerontological nursing students as they learned evidence-based approaches to managing complex geriatric syndromes in long-term care. Urinary incontinence (UI), which occurs in more than two thirds of nursing home residents, was the focus of the faculty practice. Advanced practice nursing skills developed by students included advanced physical assessment and diagnostic reasoning techniques, critical appraisal of the scientific evidence for UI management, and the ability to teach evidence-based approaches to UI care to bedside nursing staff. Outcomes of the practice for the facilities included improved detection of urinary retention, reduced wetness rates, and strengthened systems of care for UI. Student outcomes included an increased sense of self-efficacy in management of UI and other complex geriatric problems. Complexity theory guides a discussion of how curriculum design and research-based practices can be implemented to enhance both student and facility outcomes.

Promoting social continence: products and devices in the management of urinary incontinence

Urinary incontinence (UI) is a prevalent problem occurring in men and women across the lifespan. Technologic innovations have provided individuals with incontinence and caregivers with an array of options for achieving social continence. Even when UI cannot be completely cured, it can always be managed with products, skin care regimens, occlusive or drainage devices and toileting equipment to ensure optimal skin integrity, odorless urine containment, social independence, comfort, and freedom of movement. Various products, devices, and equipment available to help incontinent individuals preserve independence and quality of life and manage incontinence are described.

Bladder management in adult care homes. Review of a program in North Carolina

In North Carolina there are approximately 34,000 residents in adult care homes (ACHs). Approximately 40% of these residents have urinary incontinence, and others require assistance with toileting. High prevalence of cognitive impairment, few licensed staff, and low staff-to-resident ratios in ACHs make behavioral techniques used in community-dwelling populations and toileting programs used in nursing homes inappropriate for these residents. This program was implemented using a two-level approach (facility and individual resident) and uses an education consultation approach for implementation.

In their own words: nursing assistants' perceptions of barriers to implementation of prompted voiding in long-term care

Prompted voiding is an effective intervention for the improvement of continence in long-term care. This study investigated certified nursing assistants' (CNAs) perceptions of incontinence etiologies, as well as perceived barriers to prompted voiding implementation. A questionnaire was administered to CNAs in 23 long-term care facilities. Data analysis was conducted using descriptive statistics and correspondence analysis. CNAs perceived prompted voiding as helpful; however, inadequate staffing, workload, and turnover/absenteeism hindered implementation. CNA recommendations for long-term success included increased staff, staff support, improved communication, ongoing education, and alternative delivery models of care.

Assessment of urinary incontinence

1. In the past, nursing practice toward incontinence has focused on urine containment and skin protection rather than on proactive treatment-oriented therapeutic care. 2. Accurate assessment and diagnosis of urinary incontinence determine the success of treatment. 3. Efforts directed at early identification, appropriate assessment and treatment, and linkage to community agencies should be initiated by the nurse.