Long-Term Care Staff Perspectives on the Care of Persons Living With Dementia During the COVID-19 Pandemic in São Paulo State, Brazil

During the coronavirus disease 2019 (COVID-19) pandemic, the Brazilian long-term care (LTC) sector faced many challenges, which accentuated other common issues experienced by persons living with dementia (PLWD). The current pilot study evaluated staff perspectives regarding the care of institutionalized PLWD during the COVID-19 pandemic. Using an online survey, we collected the perspectives of 24 workers from seven long-term care facilities (LTCFs) located in São Paulo State, Brazil, about the impact of COVID-19 in caring for PLWD. Results highlight concerns about challenges related to following precautionary measures and the negative effects of social distancing on PLWD. Aspects related to workforce and staffing and person-centered care approaches were recognized by staff as important to provide good care for PLWD. Future research is needed to consider how to support LTCFs in achieving a balance between the protection and well-being of PLWD. [Journal of Gerontological Nursing, 49(5), 45-52.].

BARRIERS AND FACILITATORS FOR FOREIGN EDUCATED NURSES TO PROVIDE QUALITY LONG-TERM CARE

Unprecedented registered nursing shortages in long-term care (LTC) threaten the provision of person-centered care for older adults in the United States (US). LTC facilities recruit Foreign Educated Nurses (FENs) to address shortages, which raises concerns about care quality due to cultural, linguistic and communication differences among nurses; yet studies have not thoroughly explored FENs’ perspectives on these issues. The purpose of this study was to advance our understanding of FENs’ professional experiences as they began employment in LTC by exploring factors that inhibit or facilitate their provision of quality care. This qualitative descriptive study used purposive sampling to recruit FENs through professional organizations. Eligible FENs were ≥ 18 years old, worked ≥1 year in LTC, and represented racial and ethnic minority groups from Low and Middle Income Countries. In-depth narrative interviews, ranging from 45–60 minutes, were conducted. Applying content analysis, a priori and inductive coding generated themes. Participants (n=12) interviewed were all married females. Most were 50–59 years old (41.7%), Asian (75.0%), BSN-prepared (58.3%), and reported 31–50 years of nursing experience (50%). Positive facility characteristics, acculturation, effective workplace integration and positive support from colleagues, residents, and their families facilitated the provision of quality care. Conversely, negative facility characteristics, cultural barriers, discrimination and ineffective workplace integration were barriers to providing quality care. FENs highlighted culturally-sensitive strategies such as providing structured mentorship and preceptorship programs that supported them in providing person-centered care. FENs confirmed the need to address racial and anti-immigrant discrimination for achieving more equitable and inclusive workplaces.

IMPACTS OF SOCIAL RELATIONSHIPS ON CO-OCCURRING SYMPTOMS AND FUNCTIONING IN OLDER ADULTS WITH COGNITIVE IMPAIRMENT

Social relationships are crucial for well-being of older adults with cognitive impairment (CI), however, evidence is lacking on how social relationships may influence symptom experience and functioning among those living with CI. This study aimed to identify subgroups of older adults with CI with distinct symptom and functioning profiles and to examine the association between latent class membership and social relationships. The sample included 927 older adults who were screened as having moderate or severe CI from wave 2 of the National Social Life, Health and Aging Project. Symptom (i.e., pain, fatigue, sleep disturbance, depression, anxiety, and stress) and functioning (i.e., instrumental activities of daily living, activities of daily living, and urinary incontinence) variables were used to identify subgroups. Latent profile analyses identified five distinct groups: most (51.7%) belonged to the low-symptom-high-functioning; few (7%) belonged to the high-symptom-low-functioning; while two groups had average symptom burden, one group (25%) had frequent urinary incontinence and normal daily functioning (poor-urinary-functioning), and the other group (5%) had normal urinary functioning and the worst daily functioning (worst-daily-functioning); interestingly, 13% belonged to high-symptom-normal-functioning group. Multinomial logistic regression modeling showed that, among social networks, support, strain, and engagement, members in groups with worse symptom burden and daily functioning were significantly more likely to have social strain, after adjusting for covariates (p-values < 0.01). Only severe CI was associated with worst-daily-functioning (OR = 3.24, p-value = 0.002). Interventions that ameliorate social strain may benefit symptom management and promote independent daily living among older adults with CI.

REJECTION OF CARE AND AGGRESSION AMONG OLDER VETERANS WITH DEMENTIA WITH AND WITHOUT POSTTRAUMATIC STRESS DISORDER

Veterans with co-occurring dementia and posttraumatic stress disorder (PTSD) living in residential long-term care encounter a range of physical and social stimuli, which may trigger trauma-related distress that can be exacerbated and manifested with care rejection and aggression. Yet, it is largely unknown how PTSD influences manifestation of care rejection and aggression in older veterans with dementia. Guided by the need-driven dementia-compromised model, this study examined the moderation effect of PTSD on pathways from background factors, and interpersonal triggers to care rejection and aggression among veterans with dementia with and without co-occurring PTSD. In this secondary analysis study, a multi-group structural equation modeling was conducted using program evaluation data of 315 veterans with dementia from the STAR-VA behavioral intervention implemented in 76 Veterans Health Administration-operated nursing homes. Although no moderation effect of PTSD on the overall model was found, findings revealed distinct patterns of relationships among background factors, interpersonal triggers, and care rejection and aggression between veterans with dementia with and without PTSD. The magnitude of the direct effects of interpersonal triggers on care rejection was greater in veterans with PTSD. Findings on the indirect effect of depression via interpersonal triggers on care rejection and direct effect of functional status on aggression only in veterans with PTSD implies that different mechanisms may underlie distressed behavior depending upon whether or not a veteran has PTSD. This study also underscores the importance of an enhanced focus on trauma-informed care, and individualized multi-component symptom management approach for veterans with dementia and PTSD.

Perspectives Toward Long-Term Care Measurement From Frontline Workers in Brazil

The Brazilian long-term care (LTC) sector remains poorly structured and underdeveloped. COVID-19 did not bring unprecedented focus to the sector just because of the high mortality; it also affected the quality of care. In this pilot study, we evaluated the perspectives toward WE-THRIVE LTC measurements from Brazilian frontline workers in five long-term care facilities. For the four WE-THRIVE domains of LTC measurement (workforce and staffing, person-centered care, organizational context, and care outcomes), respondents used a 4-point Likert scale to rate their importance and answered open-ended questions about how these aspects of care changed since COVID-19. With few exceptions, respondents rated these aspects of LTC as extremely important or very important. Qualitative results highlighted concerns about and impacts of COVID-19, such as challenges related to the isolation of residents. The assessed measurement domains are confirmed to be important by frontline staff in Brazil. Measurement adoption must account for current issues.

Resilience in Relation to Multimorbidity in Older Adults: A Scoping Review

Multimorbidity is widespread, costly, and associated with a range of deleterious symptoms, affecting 70-80 % of older adults. Resilience in late life has been the focus of considerable research to understand differences in vulnerabilities and recovery from stressors relevant to multimorbidity. Despite this, previous reviews have not focused on resilience in relation to multimorbidity in older adults; therefore, this study synthesized relevant literature. The study design was a scoping review following JBI methodology. Searched electronic databases included PubMed, Embase, CINAHL, and PsycINFO. Data were extracted by two independent reviewers and charted using Garrard’s review matrix method. Gough’s weight of evidence criteria were used to appraise quality. Of 468 retrieved studies, 14 met inclusion criteria, primarily from the US, UK, and Canada. Most resilience in multimorbidity frameworks operationalize resilience as dependent on the socio-environmental context of older adults. Resilience was commonly considered a dynamic process, but only one study was longitudinal. Measures were primarily psychological or psycho-social in nature and did not include biological or physical measures of resilience. Quality of life and quality of care were common outcomes; resilience significantly related to these outcomes. Findings indicate both the important relationships of resilience with outcomes of multimorbidity, as well as multiple gaps in our current understanding of resilience in relation to multimorbidity. Results highlight the need for studies with diverse populations across diverse cultures, studies that incorporate multidimensional measures, with attention to physiological or physical properties of resilience, and longitudinal studies that capture the dynamic process of resilience in multimorbidity.

Impacts of Social Capital Factors on Blood Glucose Control and Depressive Symptoms

Social capital, conceptualized as resources arising from social networks, is receiving increased attention for its role in prevention and management of chronic conditions such as diabetes and depression that commonly co-occur. Although social capital has been linked to control of blood glucose and depression, previous research has not considered these two outcomes simultaneously while distinguishing between cognitive (i.e., perceived social support, shared values and trust in community) and structural (i.e., social connectedness and participation) domains. This study examined how these two domains of social capital relate to glucose control and depressive symptoms, and whether physical exercise and care access mediate those relationships, using structural equation modeling. The sample included 3,043 older adults aged 57 and above from wave 2 of the National Social Life, Health and Aging Project. Although a higher level of cognitive social capital was associated with higher levels of physical exercise (b=.38, p<.001), access to care (b=.40, p=.007), lower levels of blood glucose (b=-.43, p<.001) and depressive symptoms (b=-.84, p<.001), a higher level of structural social capital was associated only with a higher level of physical exercise (b=.16, p=.002). The mediating effects of physical exercise and access to care were not significant. Findings suggest that cognitive social capital may have greater influence on blood glucose and depressive symptoms than structural social capital, and therefore have different implications for practice, especially in the context of pandemic-related disruptions to social capital. Future research should examine other mediators and investigate how promotion of cognitive social capital might improve health outcomes.

Perspectives Toward Person-Centered Long-Term Care in China

Health care aides provide direct care for older residents with advanced dementia in long-term care facilities. This study aims to understand care aides’ perceptions of what is ‘good’ care, what is person-centered care, and how to provide person-centered care for older residents with advanced dementia, as preparatory work of the WE-THRIVE consortium’s efforts to develop internationally-relevant common data elements of person-centered dementia care and launch comparative research in LMICs. Semi-structured interviews were conducted with health care aides (N=35) from 2 government-owned and 2 private long-term care facilities in urban China. Directed and conventional content analysis were used, drawing upon core constructs of person-centered dementia care and Nolan’s (2006) senses framework. We found that although care aides were not trained in person-centered care, they did incorporate person-centeredness in their work by tailoring their care to the needs of older residents and facilitating interactions with residents and their peers through communication cues.

Person-Centered Care Post-Pandemic in Rural U.S. Settings: Use of WE-THRIVE Measures

Frontier communities are rural counties that are sparsely populated with limited resources to provide residential long-term care; COVID-19 has heightened these barriers and adversely affected residents, their families and staff. This study describes the feasibility of implementing recommended WE-THRIVE measures in one residential long-term care setting in a frontier community in the rural Midwest, and the capacity for administrative leadership to draw upon results of measures to implement person-centered care post-pandemic. During the COVID-19 pandemic, early efforts to advance person-centered care in the setting were displaced by a focus on infection control and containment. WE-THRIVE measures assess person-centered care following immunization distribution, and are discussed in terms of how to develop a dashboard to ‘de-escalate’ a COVID-19 focus and rebuild momentum towards person-centered care. Particular attention is given to the context of measurement, including data sharing and measurement burden, to inform advancing person-centered long-term care in other frontier communities.

Human Capital and Employment Outcomes Among Foreign Educated and US Nurses Working in Long Term Care

Employing Foreign Educated Nurses (FENs) helps address Registered Nurse (RN) shortages in long-term care (LTC) in the United States (US). However, examination of factors explaining differences in their employment outcomes relative to US Educated Nurses (USENs) is limited. This study uses 2018 National Sample Survey of Registered Nurses data to compare income, work hours, job satisfaction, and human capital, defined as personal characteristics (knowledge, work experience) and behaviors (job mobility), of FENS and USENs working full-time in LTC. A human capital score, consisting of highest nursing education, skill certifications, state licensures, years of experience, multi-state employment history, and multi-lingual status was constructed. Covariates included nurse demographics, direct care role, and ability to practice to full scope. Covariate-adjusted group differences in employment outcomes and human capital were compared using ANCOVA and logistic regression. Mediation analyses explored whether human capital explained FEN vs USEN differences. FENs earned higher hourly wages (p=0.0169), worked fewer hours annually (p=0.0163), and reported greater human capital (p<.0001) compared to USENs. FENs and USENs, however, had similar annual salaries (p=0.3101) and job satisfaction (p=0.1674). Human capital mediated FEN vs USEN effects on hourly wages but not annual work hours. FENs’ higher levels of human capital partially account for FEN vs USEN differences in hourly wages. Application of the human capital concept advanced our ability to examine differences in employment outcomes and highlight aspects of the value that FENs contribute to LTC settings.

Measuring What Matters Across International Long-Term Care Settings

Measuring what matters most to residents, relatives and staff in residential long-term care settings is critical, yet underdeveloped in our predominantly frailty and deficits-focused measurement frameworks. The Worldwide Elements to Harmonize Research in Long-Term Care Living Environments (WE-THRIVE) consortium has previously prioritized measurement concepts in the areas of care outcomes, workforce and staffing, person-centered care, and care context. These concepts include knowing the resident and what matters most to the resident, and outcomes such as quality of life, and personhood. We present findings of our currently recommended measures, including both general population and dementia-specific measures, such as the Person-Centered Care Assessment Tool (PCAT), the Personhood in Dementia Questionnaire (PDQ), and the ICEpop CAPability Measure for Older People (ICECAP-O). We also describe remaining gaps in existing measures that will need to be addressed to fully specify common data elements focused on measuring what matters most to residents, relatives and staff.

Laying Down the Groundwork for an International Measurement Infrastructure

The COVID-19 epidemic has brought to light the significant problems in the long-term care (LTC) sector, specifically the lack of an infrastructure to collect and aggregate data between LTC sectors in different countries. This talk will briefly describe goals of the WE-THRIVE initiative, and focus on exploring the development of “workforce and staffing” common data elements for LTC. We will describe how the subgroup is “laying down the groundwork” within this domain with various methodologies to develop CDEs related to workforce and staffing. The CDEs aim to measure staff retention and turnover, evaluating nursing supervisor effectiveness, and staff training in LTC. Anticipated challenges of this international work will also be highlighted. International research on LTC can valuably inform LTC policy and practice, and the proposed CDEs can facilitate data sharing and aggregation internationally, including low-, middle-, and high-income countries.

Testing cost containment of future healthcare with maintained or improved quality-The COSTCARES project

BACKGROUND

Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross-disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person-centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies.

METHOD

In order to develop and test the roadmap, a COST Action project was initiated: COST-CARES, with 28 participating countries. This paper provides an overview of evidence about the effects of each of the identified enablers. Intersections between the drivers and the enablers are identified as critical for the success of future cost containment, in tandem with maintained or improved quality in healthcare. This will require further exploration through testing.

CONCLUSION

Cost containment of future healthcare, with maintained or improved quality, needs to be addressed through a concerted approach of testing key factors. We propose a framework for test lab design based on these drivers and enablers in different European countries.

Dynamics of Multimorbidity Resilience and Health Outcomes Over Time in Community-Residing Older Adults

Multimorbidity resilience may mitigate the adverse effects of multiple chronic diseases on older adults’ health. Wister et al.’s (2018) multimorbidity resilience index was developed and tested in a cross-sectional sample of older adults in Canada. Building on these findings, we examined the reciprocal relationships of resilience on outcomes to test these potentially mitigating effects in a community-based, U.S. sample of older adults over time. The study sample includes 1,054 older adults from waves 2 and 3 of the National Social Life, Health, and Aging Project (NSHAP) study (Waite et al 2020). Wister et al.’s (2018) index was mapped to NSHAP measures, and reciprocal relationships of multimorbidity resilience and health outcomes over a 5-year period was tested using structural equation modeling (SEM). Results indicated significant effects of multimorbidity resilience on self-rated physical health and pain. Interestingly, a better functional resilience at baseline conferred better self-rated physical health at follow-up, while better psychological resilience predicted lower pain level. By contrast, the influence of health outcomes on any domain of multimorbidity resilience was not detectable at all, supporting the direction of these associations from resilience to outcomes. The study systematically investigated the dynamic hypotheses between multimorbidity resilience and health outcomes. That is, whether they are determinants or consequences, or both. Our findings suggest multimorbidity resilience predicts subsequent 5-year change in health outcomes, especially self-rated physical health and pain level, but not vice versa, strengthening the evidence of the importance of resilience in the health of older adults.

Dyadic Experiences of Living With Cognitive Impairment Through a 3-Year Longitudinal Qualitative Study

The fastest growth of population living with cognitive impairment takes place in China. The estimated prevalence of cognitive impairment among older adults in China is between 13% and 20%. This study focused on persons with cognitive impairment (PWCI) and their spousal care partners to explore how spousal relationships impact dyadic experiences of living with cognitive impairment through a person-centered care lens. We conducted a longitudinal qualitative study of 10 dyads of PWCI and their care partners over three years with three data collection time points. Our findings suggest that the complexity of changing experience of living with cognitive impairment is interpreted in the dynamic nature of their spousal relationship and relationship with others, patterns of communication, daily activities and care during the extended period of cognitive decline. It is crucial to help them nurture the belief that there is a significant meaning in the journey of living with cognitive impairment.

Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process

Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.

Nursing home residents' perspectives on their social relationships

AIMS AND OBJECTIVES

To explore nursing home residents' perspectives on their relationships with other residents, family members and staff.

BACKGROUND

The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility.

DESIGN

Qualitative secondary analysis.

METHODS

We analysed individual and group interviews obtained during "stakeholder engagement sessions" with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed.

RESULTS

Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents' relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship-peer, family and staff-made distinctive contributions residents' psychosocial well-being.

CONCLUSION

Recognising the diverse roles of different actors from residents' social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents' psychosocial well-being.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the need for nursing home staff to understand how residents' social relationships influence residents' psychosocial outcomes. Staff training programmes are needed to support residents' rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships.

MULTIMORBIDITY RESILIENCE IN COMMUNITY-RESIDING OLDER ADULTS: MEASUREMENT AND HEALTH OUTCOMES

Multimorbidity is widespread, costly, and associated with a range of deleterious outcomes; it affects an estimated 67-80% of older adults. This study tests the validity of a multimorbidity resilience index developed in a Canadian sample of older adults by Wister et al., (2018), with a U.S.-based sample, using National Social Life, Health, and Aging Project (NSHAP) data, and draws upon the index to investigate the effects of resilience on outcomes over time. We mapped Wister et al.’s (2018) index to NSHAP measures, and assessed cross-sectional associations with health outcomes, using logistic regression. To assess the effects of resilience on health outcomes over time, we estimated mixed models of the relationships between resilience on outcomes over a 5-year interval. Total resilience was consistently associated with improved outcomes, including pain level (OR=.51, CI .41-.64); reduced utilization (OR=.45, CI .33-.60); improved mental health (OR=9.13, CI 6.20-13.44); self-rated physical health (OR=6.97, CI 4.76 10.19); and sleep quality (OR=3.66, CI 2.76-4.86). Longitudinal model results indicate change in multimorbidity resilience and number of chronic diseases predict (α=.001) pain level and self-rated physical health. Effects were moderated by socio-demographic factors. Our findings validate Wister et al.’s (2018) resilience index in a U.S. sample, supporting the importance of this measure to capture core components of older adults’ capacity to sustain well-being in the context of living with multiple, chronic conditions. Results from the longitudinal models provide beginning insights into the effects of resilience on symptom experience and perceived health over time, highlighting potential levers for change.

SOCIAL NETWORKS, HEALTH, AND WELL-BEING AMONG PEOPLE LIVING WITH DEMENTIA

Although the impact of dementia on the health and well-being of those living with Alzheimer’s Disease and related Disorders (ADRD) and their care partners has been widely studied, less attention has been paid to how the disease impacts individuals within the context of their larger social networks. This symposium presents findings from a series of integrated studies aimed at strengthening measurement of health and well-being among older adults with living with dementia and well-being among members of their social networks. Findings will be presented from five studies: (1) a scoping review of social network measurement in older adults in chronic illness, including dementia, that emphasizes the use of technology in measuring older adults’ social networks; (2) a simulation study to evaluate the feasibility and reliability of sensor technology to measure social interaction among a person living with dementia and others in their immediate surroundings; (3) development of a web-based application that allows older adults to map and activate their social networks; (4) a qualitative analysis of interviews from persons living with dementia, their unpaid caregivers, and paid caregivers from an adult day health program concerning well-being focused outcomes; and (5) a mixed methods analysis of the feasibility of using both traditional and novel measures of health and well-being deployed among networks of people living with dementia. Emerging technologies for measuring social networks health and well-being hold promise for advancing the study of the relationship-based nature of care for people living with dementia.

INTEREST GROUP SESSION—SYSTEMS RESEARCH IN LONG TERM CARE: DEVELOPING AN EVIDENCE BASE FOR NURSING HOME STAFFING IN EUROPE AND BEYOND: MANY PATHS TO ONE GOAL?

Despite heterogeneity across countries, nursing homes worldwide have to ensure the delivery of high quality care. At the same time, adequately staffing the homes remains a major concern in most countries. It is a significant challenge to determine the numbers and type of staff as well as staff’s competencies that are necessary to meet the complex needs of nursing home residents. While, especially in the US, research on the relationship between staffing and quality in nursing homes has received considerable attention, the research literature is contradictory. Evidence shows that employing more staff or more registered nurses instead of nurse assistants will not automatically lead to better nursing home quality. This inconsistency of evidence might be explained by a myriad of methodological and theoretical challenges. This symposium aims to provide an international perspective on how researchers from different European countries contribute to the development of an evidence base for nursing home staffing. The first presenter will draw on findings from a realist review conducted in the UK, focusing on the mechanisms (how, why and in what circumstances) under which staff influence care home quality. The second presenter will offer insights into a Swiss study, taking a broader perspective on measuring staffing and quality in nursing homes. The third presenter will present a new instrument to identify staffing ratios in German nursing homes and provide insight into its development process. The fourth presenter will discuss the results of a critical review on the evidence base of a Dutch nursing home staffing guideline.

RELATIONSHIP-CENTERED CARE: ADULT DAY CARE FOR PERSONS LIVING WITH DEMENTIA AND THE SENSES FRAMEWORK

Relationship-centered dementia care (RCDC) has been related to improved quality of residential long-term care for persons living with dementia (PLWD). The senses framework supports accomplishing RCDC, whereby PLWD meet fundamental needs or senses through caregiving relationships. This study explored the application of the senses framework to a non-residential, long-term care setting, and included relationships across formal and informal caregivers. The study design is a qualitative, descriptive study of PLWD (N=3), with matched formal (N=3) and informal (N=3) caregivers in one adult day care setting in North Carolina. Semi-structured individual interviews explored each of the six senses of security, belonging, continuity, purpose, achievement, and significance. Interviews were analyzed using both inductive and deductive thematic analysis. Themes elucidate convergence and divergence of how senses are met or not met across triads of caregiving relationships. Findings inform our understanding of how to integrate the larger social network of PLWD for relationship-centered care.

MHEALTH PROTOTYPE AND PILOT PROTOCOL TO ENHANCE SOCIAL SUPPORT FOR PERSONS LIVING WITH DEMENTIA

An emerging component of mHealth is the use of tailored mobile applications (app) to facilitate self-management of chronic illnesses, including the mapping of social networks to assist adults living with chronic illnesses to help them be able to identify sources of social support. The purpose of this study is to describe a prototype app to support persons living with dementia (PLWD) in the community and their informal caregivers to map social networks and identify sources of emotional, instrumental, informational, and appraisal of social support. Adapting the Network Canvas open-source software and drawing upon a previously-developed mobile application for adults to self-manage chronic illnesses, we share the key specifications, including health care provider output, preliminary end user feedback, and the pilot protocol designed to test the feasibility. Findings illustrate the importance of leveraging social network data in novel ways to enhance self-management and well-being among PLWD and their caregivers

EVALUATING GERIATRIC WORKFORCE DEVELOPMENT NEEDS AMONG HOSPITALS USING NICHE BENCHMARKING DATA

The Nurses Improving Care for Health System Elders (NICHE) program aims to improve geriatric care competencies for improved care quality. A quantitative descriptive design utilizing secondary data analysis was done to evaluate geriatric workforce enhancement efforts in one acute healthcare system. Data were collected using the Geriatric Institutional Assessment Profile (GIAP) from 2008 and 2013. The GIAP measures perceived professional issues (disagreements among staff and families, limited access to geriatric services, vulnerability to legal action, intensity and burden of behavioral problems) on a Likert scale from best=0 to poor=10. Staff perception of the Geriatric Care Environment was scored by the GIAP as: age sensitive care delivery (0-40), institutional values (0-28), resource availability (0-32) and capacity for collaboration (0-12). Higher scores on the Geriatric Care Environment reflected improvements. Independent sample t-tests examined changes in baseline scores. Post-NICHE implementation, compared to peer hospitals by teaching status and bed size in 3 hospitals there were significantly (p<0.05) improved scores for: access to geriatric services (2.79-3.21), burden of behavioral problems (2.40-3.15), aging sensitivity care delivery (26.05-29.53), institutional values (18.85-19.59) and resource availability (19.51-19.97). Peer hospitals had significantly (p<0.05) better scores for: disagreements among staff about treatment of older adults (1.63-1.94) and capacity for collaboration (7.72-7.99). Findings indicate improvement in perceived professional issues and need for improvement in the geriatric care environment and care redesign to progress to becoming an Age-Friendly health system. This was an initial step in a health system to improve care quality through health workforce development.

Advancing Long-Term Care Science Through Using Common Data Elements: Candidate Measures for Care Outcomes of Personhood, Well-Being, and Quality of Life

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Person-Centered Incontinence Care in Residential Care Facilities for Older Adults With Cognitive Decline: Feasibility and Preliminary Effects on Quality of Life and Quality of Care

The current study operationalized, assessed, and evaluated the feasibility and preliminary effects of implementing a person-centered approach to incontinence care for older adults with cognitive decline in residential care facilities (RCFs) in Sweden. Twenty health care workers were purposively sampled from two intervention RCFs. Process outcome was measured as number of assessments conducted for incontinence management. Impact outcome measures were quality of life, basal assessment of incontinence, incontinence actions taken, and personally chosen incontinence aids. A usual care control group RCF was matched by resident case-mix and geographic region. Introduction of a person-centered approach showed an increase in residents' quality of life in the intervention group compared to baseline and the control group. A positive effect was found on the number of urinary incontinence assessments conducted (p < 0.05). In addition, the number of person-centered caring actions (e.g., toilet assistance) was significantly higher during and 6 months after implementation of the person-centered approach. Implementing a person-centered approach in clinical practice focused on incontinence care, quality of care, and quality of life is supported for RCF residents. [Journal of Gerontological Nursing, 44(11), 10-19.].

Advancing International Research on Long-Term Care: Using Adaptive Leadership to Build Consensus on International Measurement Priorities and Common Data Elements

International research on long-term care (LTC) can valuably inform LTC policy and practice, but limited transnational collection of data on key LTC issues restricts the contributions of international LTC research. This special collection of Gerontology and Geriatric Medicine helps close the gap between the status quo and the potential for international LTC research by cultivating a transnational common ground of internationally prioritized measurement concepts and sowing the seeds of international LTC common data elements. The articles in this special collection address both adaptive and technical challenges to international LTC measurement, build on and complement existing LTC measurement systems, and provide diverse international perspectives on the measurement of LTC across four overarching domains: LTC contexts, workforce and staffing, person-centered care, and care outcomes. From large transnational teams of scholars specifying the meanings of central LTC concepts, to smaller subnational research teams testing new measures of person-centered care across diverse local LTC settings, contributors spark new insights and point in new directions for a LTC measurement infrastructure supportive of person-centered care and lifelong thriving.

Person-directed care planning in nursing homes: A scoping review

AIM

Federal regulations require nursing homes in the United States to support residents in directing their own care rather than having their care plans developed for them without their engagement, but knowledge of person-directed approaches to care planning in nursing homes is limited. The purpose of this study was to advance understanding of person-directed care planning (PDCP).

METHODS

A multidisciplinary research team conducted a scoping review on individual and family involvement in care planning, including literature from a variety of care contexts. Search results were systematically screened to identify literature that addressed individual or family involvement in care planning as a primary concern, and then analysed using thematic content analysis.

RESULTS

Several themes were identified, including definitions of the concept of PDCP, essential elements of PDCP, barriers, facilitators and outcomes. The concept of PDCP is informed by multiple disciplines, including humanist philosophy, disability rights and end-of-life care. Essential elements of PDCP include knowing the person, integrating the person's goals in care planning and updating care plans as individuals' needs or preferences change. Limited time for care planning in nursing homes hinders PDCP. Facilitators include regulatory mandates and humanist social trends. Outcomes of PDCP were found to be positive (e.g., increased independence), but were inconsistently assessed across studies.

CONCLUSION

This study offers pragmatic information that can support PDCP within nursing homes and insights for policy reform that may more effectively support PDCP.

IMPLICATIONS FOR PRACTICE

These findings can be used to guide implementation of PDCP.

Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial

IMPORTANCE

New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls.

OBJECTIVE

To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS).

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls.

INTERVENTIONS

CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program.

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate.

RESULTS

Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration.

CONCLUSIONS AND RELEVANCE

An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00636675.

Study of Individualization and Bias in Nursing Home Fall Prevention Practices

OBJECTIVES

Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias.

DESIGN

Randomized factorial clinical vignette survey.

SETTING

Sixteen nursing homes in North Carolina.

PARTICIPANTS

Nursing, rehabilitation, and social services staff (n = 433).

MEASUREMENTS

Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories.

RESULTS

Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1).

CONCLUSION

Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.

Health-related quality of life in older depressed psychogeriatric patients: one year follow-up

Background

Knowledge about long-term change in health related quality of life (HQoL) among older adults after hospitalization for treatment of depression has clinical relevance. The aim was firstly to describe the change of HQoL one year after admission for treatment of depression, secondly to explore if improved HQoL was associated with remission of depression at follow-up and lastly to study how HQoL in patients with remission from depression were compared to a reference group of older persons without depression.

Method

This study had the one year follow-up information of 108 older patients (≥60 years), all hospitalized for depression at baseline, and a reference sample of 106 community-living older adults (≥60 years) without depression. HQoL was measured using the EuroQol Group’s EQ-5D Index and a visual analog scale (EQ-VAS). Depression and remission were diagnosed according to ICD-10. Socio-demographic variables (age, gender, and education), depressive symptom score (Montgomery-Aasberg Depression Rating Scale), cognitive functioning (Mini Mental State Examination scale), instrumental activities of daily living (the Lawton and Brody’s Instrumental Activities of Daily Living Scale), and poor general physical health (General Medical Health Rating) were included as covariates.

Results

HQoL had improved at follow-up for the total group of depressed patients, as indicated by better scores on the EQ-5D Index and EQ-VAS. In the multivariate linear regression model, improved EQ-5D Index and EQ-VAS was significantly better in those with remission of depression and those with better baseline physical health. In adjusted analyses, the HQoL in patients with remission from depression at follow-up did not differ from the HQoL in a reference group without depression.

Conclusion

Older hospital patients with depression who experienced remission one year after admission gained HQoL and their HQoL was comparable with the HQoL in a reference group of older adults without depression when adjusting for differences in socio-demographics and health conditions.

Severity of Neuropsychiatric Symptoms in Nursing Home Residents

We aimed at assessing time shift in the severity of neuropsychiatric symptoms (NPS) in nursing home residents between 2004/2005 and 2010/2011 and associations between NPS and socio-demographic variables, physical health status, dementia severity, and the use of psychotropic drugs. The Neuropsychiatric Inventory Nursing Home Version was used in 2004/2005 (n = 1,163) and 2010/2011 (n = 1,858). Linear mixed model analysis was applied. There was no time shift in the severity of apathy, psychosis, and affective symptoms, but agitation did exhibit a time shift. Agitation was less severe in 2010/2011 than in 2004/2005 in residents with a Clinical Dementia Rating (CDR) sum of boxes score ≤4, and more severe in residents with a CDR sum of boxes score >16. Higher CDR sum of boxes scores and use of psychotropic medication were associated with more severe apathy, agitation, psychosis, and affective symptoms. Poor physical health was associated with more severe apathy, psychosis, and affective symptoms. Women had more severe agitation and less severe affective symptoms than men. A longer stay in a nursing home was associated with more severe agitation and less severe affective symptoms. In conclusion, agitation was less severe in 2010/2011 than in 2004/2005 among nursing home residents with a milder degree of dementia, and more severe in residents with severe dementia.

Comprehensive Care Plan Development Using Resident Assessment Instrument Framework: Past, Present, and Future Practices

Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed within the context of the comprehensive interdisciplinary assessment framework-the Resident Assessment Instrument (RAI). Consistent compliance with this requirement has been difficult to achieve. To improve the quality of CCP development within this framework, an increased understanding of complex factors contributing to inconsistent compliance is required. In this commentary, we examine the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse staffing; empirical evidence of the CCP's efficacy; and the limitations of extant standards of practices in CCP development. Because of the registered nurse's educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized. Recommendations for evidence-based micro and macro level practice changes with the potential to improve the quality of CCP development and regulatory compliance are presented. Suggestions for future research are given.

Evaluation of Cueing Innovation for Pressure Ulcer Prevention Using Staff Focus Groups

The purpose of the manuscript is to describe long-term care (LTC) staff perceptions of a music cueing intervention designed to improve staff integration of pressure ulcer (PrU) prevention guidelines regarding consistent and regular movement of LTC residents a minimum of every two hours. The Diffusion of Innovation (DOI) model guided staff interviews about their perceptions of the intervention's characteristics, outcomes, and sustainability.

METHODS

This was a qualitative, observational study of staff perceptions of the PrU prevention intervention conducted in Midwestern U.S. LTC facilities (N = 45 staff members). One focus group was held in each of eight intervention facilities using a semi-structured interview protocol. Transcripts were analyzed using thematic content analysis, and summaries for each category were compared across groups.

RESULTS

The a priori codes (observability, trialability, compatibility, relative advantage and complexity) described the innovation characteristics, and the sixth code, sustainability, was identified in the data. Within each code, two themes emerged as a positive or negative response regarding characteristics of the innovation. Moreover, within the sustainability code, a third theme emerged that was labeled "brainstormed ideas", focusing on strategies for improving the innovation.

IMPLICATIONS

Cueing LTC staff using music offers a sustainable potential to improve PrU prevention practices, to increase resident movement, which can subsequently lead to a reduction in PrUs.

Non-nutritive sucking for preterm infants in Egypt

OBJECTIVE

To assess how non-nutritive sucking (NNS) using a pacifier affected physiological and behavioral outcomes of preterm infants.

DESIGN

Short-term longitudinal, experimental design.

SETTING

The study took place at the neonatal intensive care unit at Al-Mansoura, Egypt.

METHODS

Forty-seven preterm infants were divided into intervention and control groups. Preterm infants in the intervention group received NNS during nasogastric tube feeding while infants in the control group never received NNS. During 10 days, behavioral responses were videotaped and physiological responses were monitored.

RESULTS

Significantly higher oxygen saturation occurred during and after nasogastric feeding for the intervention infants as compared to the control group. No significant group differences occurred in heart rate. The NNS group showed an accelerated transition to nipple feeding and had better weight gain and earlier discharge.

CONCLUSION

Non-nutritive sucking was found to improve physiological and behavioral responses of preterm infants.

Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework

PURPOSE OF THE STUDY

To describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care.

DESIGN AND METHODS

The study design was a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of 3 nursing homes. We conducted 7 focus groups of licensed and unlicensed nursing staff, medical care providers, and administrators. Questions explored perceptions of facilitators and barriers to culture change. Using a template organizing style of analysis with immersion/crystallization, themes of barriers and facilitators were coded for adaptive challenges and leadership.

RESULTS

Six key themes emerged, including relationships, standards and expectations, motivation and vision, workload, respect of personhood, and physical environment. Within each theme, participants identified barriers that were adaptive challenges and facilitators that were examples of adaptive leadership. Commonly identified challenges were how to provide person-directed care in the context of extant rules or policies or how to develop staff motivated to provide person-directed care.

IMPLICATIONS

Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.

CONNECT for better fall prevention in nursing homes: results from a pilot intervention study

OBJECTIVES

To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS).

DESIGN

Cluster randomized trial.

SETTING

Community (n=4) and Veterans Affairs (VA) NHs (n=4).

PARTICIPANTS

Staff in any role with resident contact (n=497).

INTERVENTION

NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback.

MEASUREMENTS

NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning.

RESULTS

Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20).

CONCLUSION

CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.

Connecting the learners: improving uptake of a nursing home educational program by focusing on staff interactions

PURPOSE OF THE STUDY

The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone.

DESIGN AND METHODS

Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities.

RESULTS

Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls.

IMPLICATIONS

CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.

Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: a multiple case study

After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.

Top nurse-management staffing collapse and care quality in nursing homes

Director of nursing turnover is linked to staff turnover and poor quality of care in nursing homes; however the mechanisms of these relationships are unknown. Using a complexity science framework, we examined how nurse management turnover impacts system capacity to produce high quality care. This study is a longitudinal case analysis of a nursing home (n = 97 staff) with 400% director of nursing turnover during the study time period. Data included 100 interviews, observations and documents collected over 9 months and were analyzed using immersion and content analysis. Turnover events at all staff levels were nonlinear, socially mediated and contributed to dramatic care deficits. Federal mandated, quality assurance mechanisms failed to ensure resident safety. High multilevel turnover should be elevated to a sentinel event for regulators. Suggestions to magnify positive emergence in extreme conditions and to improve quality are provided.

Studying the clinical encounter with the Adaptive Leadership framework

In this paper we discuss the concept of leadership as a personal capability, not contingent on one's position in a hierarchy. This type of leadership allows us to reframe both the care-giving and organizational roles of nurses and other front-line clinical staff. Little research has been done to explore what leadership means at the point of care, particularly in reference to the relationship between health care practitioners and patients and their family caregivers. The Adaptive Leadership framework, based on complexity science theory, provides a useful lens to explore practitioners' leadership behaviors at the point of care. This framework proposes that there are two broad categories of challenges that patients face: technical and adaptive. Whereas technical challenges are addressed with technical solutions that are delivered by practitioners, adaptive challenges require the patient (or family member) to adjust to a new situation and to do the work of adapting, learning, and behavior change. Adaptive leadership is the work that practitioners do to mobilize and support patients to do the adaptive work. The purpose of this paper is to describe this framework and demonstrate its application to nursing research. We demonstrate the framework's utility with five exemplars of nursing research problems that range from the individual to the system levels. The framework has the potential to guide researchers to ask new questions and to gain new insights into how practitioners interact with patients at the point of care to increase the patient's ability to tackle challenging problems and improve their own health care outcomes. It is a potentially powerful framework for developing and testing a new generation of interventions to address complex issues by harnessing and learning about the adaptive capabilities of patients within their life contexts.

CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes

Background

Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.

Methods/design

Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.

Discussion

By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.

Trial Registration

ClinicalTrials.gov: NCT00636675

Regulation and mindful resident care in nursing homes

Regulatory oversight is intended to improve the health outcomes of nursing home residents, yet evidence suggests that regulations can inhibit mindful staff behaviors that are associated with effective care. We explored the influence of regulations on mindful staff behavior as it relates to resident health outcomes, and offer a theoretical explanation of why regulations sometimes enhance mindfulness and other times inhibit it. We analyzed data from an in-depth, multiple-case study including field notes, interviews, and documents collected in eight nursing homes. We completed a conceptual/thematic description using the concept of mindfulness to reframe the observations. Shared facility mission strongly impacted staff perceptions of the purpose and utility of regulations. In facilities with a resident-centered culture, regulations increased mindful behavior, whereas in facilities with a cost-focused culture, regulations reduced mindful care practices. When managers emphasized the punitive aspects of regulation we observed a decrease in mindful practices in all facilities.

Barriers to and facilitators of clinical practice guideline use in nursing homes

OBJECTIVES

To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).

DESIGN

Qualitative analysis.

SETTING

Four randomly selected community nursing homes.

PARTICIPANTS

NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).

MEASUREMENTS

Interviews (n=35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.

RESULTS

None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were "checklists" to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.

CONCLUSION

Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.