The aging veteran population: Promoting awareness to influence best practices

The older adult population is the most rapidly growing population in the United States. It is projected that by 2035, the population of adults older than 65 years is expected to be greater than the population of children. The projected number of Veterans age 60 and older is about 11 million. Along with common age-related complex and high-risk chronic medical conditions, care of older adult Veteran requires a holistic approach that focuses on the culture, and subcultures, and unique health care needs resultant of military service. Veterans' health care is often multifocal and complex, requiring an integrated, collaborative, and comprehensive model of care that better facilitates meeting health goals to the degree most realistic and attainable for each older adult Veteran. This highlights the need to promote awareness and provide educational opportunities for engaging in best practices that meet the unique needs of the aging Veteran population.

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.

Avoiding Socialization Pitfalls in Accelerated Second-Degree Nursing Education: The Returning-to-School Syndrome Model

Second-degree students are highly motivated and tend to excel academically. However, nurse educators in accelerated programs face challenges in socializing these students to the nursing role. One pitfall is the hostility that may develop if students perceive a mismatch between their expectations and their new role as baccalaureate nursing (BSN) students in a fast-paced and intense program. This article discusses the applicability of the returning-to-school syndrome model in helping second-degree nursing students maneuver successfully through an accelerated BSN program. This 3-stage model has been previously applied in RN-to-BSN education. Using the model in an accelerated BSN curriculum to identify transition points and offer student support through specific stages can better prepare students to meet the challenges of accelerated education, as well as help nurse educators become more adept at providing resources and implementing supportive strategies at the appropriate time.

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.

Nurse assistant mental models, sensemaking, care actions, and consequences for nursing home residents

In a nursing home case study using observation and interview data, the authors described two mental models that guided certified nurse assistants (CNAs) in resident care. The Golden Rule guided CNAs to respond to residents as they would want someone to do for them. Mother wit guided CNAs to treat residents as they would treat their own children. These mental models engendered self-control and affection but also led to actions such as infantilization and misinterpretations about potentially undiagnosed conditions such as depression or pain. Furthermore, the authors found that CNAs were isolated from clinicians; little resident information was exchanged. They suggest ways to alter CNA mental models to give them a better basis for action and strategies for connecting CNAs and clinical professionals to improve information flow about residents. Study results highlight a critical need for registered nurses (RNs) to be involved in frontline 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.

5 competencies needed by new baccalaureate graduates

As nurse educators prepare new graduates for practice, part of the challenge is to ensure that these nurses are capable of functioning in a broad continuum of care with increased responsibilities. To identify competencies needed by new baccalaureate graduates in today's health care environment and determine whether these competencies fall into particular dimensions, a cross-sectional survey design was used to query 363 nurse administrators from three health care settings. Nurse administrators rated the importance of 45 nursing competencies. Factor analysis was conducted on the competency items, and factor scores were calculated to determine the importance ratings by work setting groups. Findings revealed a simple six-factor competency structure (Health Promotion Competency, Supervision Competency, Interpersonal Communication Competency, Direct Care Competency, Computer Competency, and Caseload Management Competency). MANOVA indicated significant differences in the importance of these competence factors by work setting. The findings are an important beginning for evidence-based decision-making about nursing curriculum reform, both in the classroom and clinical practice areas. The study also provides a foundation for further measurement of nursing competencies.

The impact of work rewards on radiographers' organizational commitment

Organizational commitment is an affective work outcome that has been used to predict work-related behaviors such as turnover, absenteeism and intent-to-leave. There has been little research in organizational commitment for the allied health professions and no empirical studies in the radiologic sciences. The purpose of this study was to examine the predictive value of selected intrinsic and extrinsic work reward variables--involvement, significance, autonomy, general working conditions, supervision and salary--on staff radiographers' organizational commitment. In this study of 600 full-time staff radiographers in North and South Carolina, supervision (for ages 20-37 years) and involvement (for ages 38-66 years) were significant predictors of organizational commitment. The results of the study indicate that healthcare organizations should provide potential supervisors with managerial training, especially for radiographers who move to supervisory positions based on clinical skills and years of experience. In the long run, such programs are much less expensive than costs associated with replacing employees who leave the organization because of low organizational commitment. Also, management strategies and programs to redesign and enhance job tasks may help maintain or increase organizational commitment.