Evaluating the Implementation Fidelity of a Pilot Pragmatic Randomized Clinical Trial Comparing Daily-Delivered Meals to Mailed Frozen Meals.

In pragmatic clinical trials (PCTs), the intervention is carried out by participating sites instead of research staff. In this paper, we evaluate study sites' implementation adherence during a pilot PCT of home-delivered meals for older adults with dementia. Participants at three home-delivered meal programs were randomized to receive either (1) meals delivered daily or (2) frozen meals mailed every two weeks; participants' outcomes were tracked for six months. Using the adherence domains from the Framework for Implementation Fidelity, we identified six metrics to assess adherence, with a total possible adherence score ranging from 6 (low adherence) to 18 (high adherence); all three sites scored within the top quartile of adherence. Despite challenges to meal delivery during the COVID-19 pandemic, sites successfully implemented the intervention, justifying a follow-on PCT to test the comparative effectiveness of models of meal delivery on the time to nursing home placement for people living with dementia.

Rolling out PRIDE in All Who Served: Barriers and Facilitators for Sites Implementing an LGBTQ+ Health Education Group for Military Veterans.

BACKGROUND/OBJECTIVE: The Veterans Health Administration (VHA) PRIDE in All Who Served health education group (PRIDE) was developed to improve health equity and access to care for military veterans who are lesbian, gay, bisexual, transgender, queer, and/or other sexual/gender-diverse identities (LGBTQ+). This 10-week program rapidly spread to over 30 VHA facilities in 4 years. Veterans receiving PRIDE experience improved LGBTQ+ identity-related resilience and reductions in suicide attempt likelihood. Despite PRIDE's rapid spread across facilities, information is lacking on implementation determinants. The current study's goal was to clarify determinants of PRIDE group implementation and sustainment. METHODS: A purposive sample of VHA staff (N = 19) with experience delivering or implementing PRIDE completed teleconference interviews January-April 2021. The interview guide was informed by the Consolidated Framework for Implementation Research. Rapid qualitative matrix analysis was completed with methods to ensure rigor (e.g., triangulation and investigator reflexivity). RESULTS: Key barriers and facilitators of PRIDE implementation were heavily related to facility inner setting (what is happening inside the facility), including implementation readiness (e.g., leadership support for LGBTQ+-affirming programming, access to LGBTQ+-affirming care training) and facility culture (e.g., systemic anti-LGBTQ+ stigma). Several implementation process facilitators enhanced engagement at sites, such as a centrally facilitated PRIDE learning collaborative and a formal process of contracting/training for new PRIDE sites. DISCUSSION/CONCLUSION: Although aspects of the outer setting and larger societal influences were mentioned, the majority of factors impacting implementation success were at the VHA facility level and therefore may be more readily addressable through tailored implementation support. The importance of LGBTQ+ equity at the facility level indicates that implementation facilitation should ideally address institutional equity in addition to implementation logistics. Combining effective interventions with attention to local implementation needs will be required before LGBTQ+ veterans in all areas will benefit from PRIDE and other health equity-focused interventions.

Illustrating Resource Needs through Data Visualization: Creation of Life-Space Maps for Rural Veterans with Dementia and their Caregivers.

Rural-dwelling individuals with dementia and their caregivers face unique challenges compared to urban-dwelling peers. Barriers to accessing services and supports are common, and individual resources and informal networks available to support rural families can be difficult to track for providers and healthcare systems outside of the local community. This study uses qualitative data from rural-dwelling dyads, individuals with dementia (n = 12) and informal caregivers (n = 18), to demonstrate how rural patients' daily life needs can be summarized through life-space map visualizations. Thirty semi-structured qualitative interviews were analyzed using a two-step process. First, rapid qualitative analysis was completed to generate daily-life needs of the participants' home and community context. Next, life-space maps were developed to synthesize and visualize dyads' met and unmet needs. Results suggest life-space mapping may offer a pathway for improved needs-based information integration for busy care providers and time-sensitive quality improvement efforts by learning healthcare systems.

Spreading pride in all who served: A health education program to improve access and mental health outcomes for sexual and gender minority veterans.

Access to effective, replicable services is critical to reduce known mental health disparities for sexual and gender minority or LGBTQ+ veterans (lesbian, gay, bisexual, transgender, queer, questioning, and related identities). This paper examines the impact of a manualized 10-week health education group, called PRIDE in All Who Served on veteran patient experience, protective factors (e.g., identity acceptance), and mental health outcomes (e.g., suicide risk) at 10 Department of Veterans Affairs (VA) facilities. Implementation facilitation strategies (e.g., consultation, staff training) supported adoption at new sites and initial facilitators and barriers are described. Forty-four veterans (M = 47.21 years old) completed outcome surveys before and after the group. Significant improvement in acceptance concerns, identity uncertainty, community involvement, and likelihood of future suicide attempts were observed; other changes in mental health symptoms were not replicated in this sample (e.g., depression, anxiety). Open-ended veteran feedback reflected improved social support and engagement and increased self-understanding as the most frequent themes. At the facility level, Healthcare Equality Index scores (a Human Rights Campaign measure of affirmative care climate) improved from 30% to 90% achieving top-performer/leader status from pre- to postimplementation. Manualized approaches, like PRIDE in All Who Served, that are based on established minority stress models and can be spread for use with diverse LGBTQ+ veterans (e.g., age, race, gender identity, sexual orientation, rurality, housing) are needed. The PRIDE in All Who Served program is an increasingly available resource to VA clinicians advocating for greater health equity within a national healthcare setting. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Paucity of Data on Veterans 65 and Older and Risk of Suicide: A Systematic Review.

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.

A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME).

BACKGROUND AND OBJECTIVES: Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs. RESEARCH DESIGN AND METHODS: Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting. RESULTS: Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention. DISCUSSION AND IMPLICATIONS: CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

A pilot evaluation of sexual and gender minority identity measures in a treatment-engaged military veteran sample.

Sexual and gender minority (SGM) military veterans have endured a history of discriminatory policies and hetero- and cis-sexist-related military culture that can negatively impact identity and mental health. The present pilot evaluation examined measure characteristics of the Lesbian, Gay, and Bisexual Identity Scale (LGBIS) and lesbian, gay, and bisexual positive identity measure (LGB-PIM) in a clinical sample of SGM military veterans in order to assess the potential use of these instruments in understanding identity and mental health in the context of program implementation. A cross-sectional pilot survey of 83 SGM veterans was conducted in 10 veterans affairs sites. Self-report data were collected as part of a quality improvement project across 2018 and 2019. Results showed that the sample was characterized by low internalized prejudice and identity uncertainty, as well as generally high positive aspects of identity (e.g., identity affirmation, authenticity, social justice beliefs). LGB-PIM subscale internal consistency values were acceptable (α range = .89-.92), whereas LGBIS subscale values varied (α range = .51-.87). Acceptance concerns, identity uncertainty, and social justice beliefs distinguished mental health symptom severity levels. Higher identity uncertainty and social justice beliefs were associated with worse symptoms of depression, anxiety, and suicide risk. Preliminary results support further application and study of the LGB-PIM and some LGBIS subscales as possible tools in program development and improvement within military veteran samples. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Pilot Study Comparing Two Measures of Perceived Health Services Access Among Military Veterans With Musculoskeletal Injuries and Mental Health Conditions.

INTRODUCTION: Service members endure a number of musculoskeletal injuries (MSIs) during service (e.g., ankle sprains and chronic back pain). Musculoskeletal injuries can reduce engagement in physical activity after military service and contribute to a sedentary lifestyle that diminishes physical health and elevates the risk for psychological distress including suicide-related behaviors. Yet, little is known about barriers and facilitators to accessing care in veterans with co-occurring MSI and mental health conditions. The purpose of this study was to pilot two brief measures of barriers and facilitators to rehabilitation and mental health services in military veterans with musculoskeletal and mental health conditions. Self-report tools vary in their response formats in ways that can impact usability, data quality, and completeness. We examine two response styles (i.e., checklist vs. thermometer) for two health services (mental health and rehabilitation) to determine usability, patterns in item endorsement, and veteran preference. MATERIALS AND METHODS: Barriers and facilitators informed by the Fortney Veterans Healthcare Access model were assessed by veterans (n = 31) on the newly developed 22-item, paper-and-pencil scale with separate ratings for mental health and rehabilitation services. All participants completed scales with both response styles and the order of administration was randomized (i.e., either the checklist first or the thermometer-style response first). Data also included self-reported demographics, musculoskeletal and mental health diagnoses, health-related quality of life, physical activity levels, mental health symptoms, suicide risk, and coronavirus disease of 2019 pandemic-related stress. RESULTS: Veterans reported no differences in ease of use across response formats; however, 83.9% (n = 26) preferred the checklist style, with only 3.22% (n = 1) preferring the thermometer format. Checklist items also resulted in less missing data (i.e., range 0.00%-6.45%) than the thermometer-style option (i.e., range 6.45%-61.30%). On the checklist, total number of perceived barriers was low for mental health and rehabilitation services (i.e., M = 1.58 and M = 1.61, respectively). Distance to care and problems related to symptoms were the most frequently identified barriers for both services. Facilitators outnumbered barriers for mental and rehabilitation services, and nearness of the clinic/hospital was the top-rated facilitator for both. On the thermometer, the perceived strength of each mental health (M = 39.37) and rehabilitation (M = 39.81) service barrier was moderate (0-100 scale), while the average perceived strength of each mental health (M = 61.66) and rehabilitation service (M = 61.84) facilitator was higher. Associations between barrier and facilitator scores with mental and physical health indicators were small with exceptions. For instance, suicide attempt likelihood was positively correlated with rehabilitation services barriers; mental health burden was positively associated with both barriers and facilitators. CONCLUSIONS: Results of this pilot comparing two measurement approaches identified actionable next steps. Brief barriers and facilitators checklists were viable for veteran ratings across type of health. The thermometer-based tool captured the perceived strength of barriers and facilitators but yielded problematic rates of missing data in its current form and was not preferred by veterans.

Potentially traumatic events and health among lesbian, gay, bisexual and heterosexual Vietnam veterans: Results from the Vietnam Era Health Retrospective Observational study.

Objectives: To examine differences in potentially traumatic events (PTEs), probable PTSD, and health-related quality of life (HRQoL) between lesbian, gay, and bisexual (LGB) and heterosexual Vietnam Era veterans. Method: Data are from the 2016-2017 Vietnam Era Health Retrospective Observational study survey (n = 18,866; 45% response rate). PTEs were defined using the 10-item Brief Trauma Questionnaire and a dichotomous item about whether respondents witnessed sexual assault during military service. Current probable PTSD was measured with the Primary Care PTSD Screen, and mental and physical HRQoL was assessed with the SF-8™. Multivariable regression analyses were first adjusted for sociodemographic and military-related characteristics, and then with PTEs as a count variable ranging from 0-11. Survey weights accounted for the complex sampling design and nonresponse. Results: Approximately 1.5% of veterans were LGB. Compared to heterosexual veterans, LGB veterans were more likely to report exposure to natural disasters, childhood physical abuse, adulthood physical assault, and sexual assault, and they were less likely to report combat exposure, witnessing someone being seriously injured or killed, or witnessing sexual assault while in the military. Compared to heterosexual veterans, LGB veterans had greater odds of current probable PTSD (adjusted odds ratio [aOR] = 1.50, 95% CI [1.04, 2.16]) and poorer mental HRQoL (B = -1.70, SE = .72, p = .018). PTEs attenuated sexual orientation differences in probable PTSD (aOR = 1.27, 95% CI [.82, 1.97]) and poorer mental HRQoL (B = -1.22, SE = .67, p = .067). Conclusions: Among Vietnam Era veterans, PTEs differ based on sexual orientation, and contribute to LGB veterans' greater prevalence of current probable PTSD and poorer mental HRQoL relative to heterosexual veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Links between Savoring, Rumination, and Sleep-Related Experiences across Adulthood: Implications for Older Adults.

OBJECTIVES: Sleep problems are pervasive, particularly in older adults. Much work examines psychological factors that adversely affect sleep; fewer studies examine those with a positive effect. Savoring is a form of positive repetitive thought that is linked to several aspects of health but has been understudied in relation to sleep. We examined cross-sectional associations of both savoring and rumination with subjective sleep experiences, and assessed if these associations vary by age. METHODS: Adults and older adults (N = 216) ranging from 20-80 years in age (M = 44.9 ± 15.6 years) completed an online survey of validated measures of savoring, rumination, sleep disturbance, and sleep-related impairment. RESULTS: Higher levels of savoring were significantly associated with lower levels of sleep-related impairment but not sleep disturbance in regression analyses. Higher levels of rumination were significantly associated with higher levels of sleep disturbance and sleep-related impairment. Associations of savoring and rumination with sleep-related experiences did not vary by age. CONCLUSIONS: Savoring and rumination are relevant to sleep-related experiences in adults ranging from younger to older. Further investigation of the potential positive impact of savoring on sleep-related experiences is needed. CLINICAL IMPLICATIONS: Engagement in savoring and rumination should be considered when assessing sleep and sleep-related impairment in adults.

Improving Suicide Risk Detection and Clinical Follow-up after Discharge from Nursing Homes.

Objectives: Suicide Awareness for Veterans Exiting Community Living Centers (SAVE-CLC) is a brief intervention to standardize suicide-risk screening and clinical follow-up after VA nursing home discharge. This paper examines the outcomes of SAVE-CLC compared to care as usual.Methods: A quasi-experimental evaluation was conducted (N = 124) with SAVE-CLC patients (n = 62) matched 1:1 to a pre-implementation comparison group. Data were obtained through VA Corporate Data Warehouse resources and chart reviews. Outcomes examined (within 30/90 days of discharge) included mortality rates, frequency of outpatient mental health visits, emergency department visits, rehospitalizations, depression screens (PHQ-2), and the latency period for outpatient mental health care.Results: A greater portion of SAVE-CLC patients received a depression screen after discharge, n = 42, 67.7% versus n = 8, 12.9%, OR = 14.2 (5.7, 35.3), p < .001. The number of days between discharge and first mental health visit was also substantially shorter for SAVE-CLC patients, M = 8.9, SD = 8.2 versus M = 17.6, SD = 9.1; t = 2.47 (122), p = .02. Significant differences were not observed in emergency department visits, hospitalizations, or mortality.Conclusions: SAVE-CLC is a time-limited intervention for detecting risk and speeding engagement in mental health care in the immediate high-risk post-discharge period.Clinical Implications: Care transitions present an important opportunity for addressing older adults' suicide risk; brief telephone-based interventions like SAVE-CLC may provide needed support to individuals returning home.

Pride in all Who Served: Development, Feasibility, and Initial Efficacy of a Health Education Group For LGBT Veterans.

Many of the more than 1 million military veterans who identify as lesbian, gay, bisexual, and/or transgender (LGBT) have encountered "rejecting experiences in the military" and stigma from prior "Don't Ask Don't Tell" policies. Associated minority stress and social isolation have been linked to a disproportionate risk for depression and suicide, as well as a reluctance to seek medical care at Veterans Health Administration (VHA) facilities. This paper describes feasibility and preliminary outcomes of the newly developed, Pride in All Who Served Health Education Group created to meet the unique needs of sexual and gender minority veterans. The 10-week, closed, health education group (e.g., continuums of identity, military culture) enables open dialogue, fosters social connectedness, and empowers veterans to be more effective self-advocates within the healthcare system. Feedback from formative evaluations (n = 29 LGBT veterans and n = 25 VHA stakeholders) was incorporated before conducting a small scale, non-randomized pilot. Preliminary pre-post surveys (n = 18) show promise (i.e., Cohen's d range ± 0.40 to 1.59) on mental health symptoms (depression/anxiety, suicidal ideation), resilience indicators (identity affirmation, community involvement, problem-focused coping), and willingness to access care within the VA system (satisfaction with VA services, perception of staff competence). Results suggest that the 10-week Pride Group may be an effective tool for addressing minority-related stress in LGBT veterans. A full-scale, randomized clinical trial of this intervention is needed to determine short and long-term impacts on clinical and healthcare access-related outcomes.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Older Veterans following Discharge from VA Nursing Facilities.

Objective: We describe the development and implementation of a telephonic intervention (SAVE-CLC) piloted at three VA sites for Veterans returning to the community from VA nursing facilities (Community Living Centers or "CLCs"). Care transitions present a known period of medical risk for older adults and may pose increased risk for suicide. Veterans discharging from CLCs are at elevated risk compared to age and gender matched controls.Methods: Using a quality improvement approach, input was gathered from key stakeholders to aid in the development of the intervention. Veterans were screened for depressive symptoms and need for additional support by phone.Results: Of the Veterans who received the SAVE-CLC intervention, 87.9% had at least one prior mental health diagnosis, though only 19.7% had an outpatient mental health appointment arranged at CLC discharge. Results suggest that the intervention is feasible across multiple outpatient settings and is generally well-received by Veterans and caregivers, with 97% of those contacted reporting that the telephone calls were helpful.Conclusion: This flexible, telephone-based intervention addresses the unmet need of integrating mental health care into discharge planning during care transitions.Clinical Implications: SAVE-CLC offers a feasible and acceptable solution to suicide risk in older Veterans exiting a CLC.

Pain Patterns and Treatment Among Nursing Home Residents With Moderate-Severe Cognitive Impairment.

OBJECTIVES: To examine the frequency and severity of pain and use of pain therapies among long-term care residents with moderate to severe dementia and to explore the factors associated with increased pain severity. DESIGN: Prospective individual data were collected over 1 to 3 days for each participant. SETTING: Sixteen long-term care facilities in Alabama, Georgia, Pennsylvania, and New Jersey. PARTICIPANTS: Residents with moderate to severe cognitive impairment residing in a long-term care facility for at least 7 days were enrolled (N = 205). Residents were 47% female, predominantly white (69%), and 84 years old, on average (SD = 10 years). MEASUREMENTS: A comprehensive pain assessment protocol was used to evaluate pain severity and characteristics through medical record review, interviews with nursing home staff, physical examinations, as well as pain observation tools (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale and Pain Intensity Measure for Persons With Dementia). Known correlates were also assessed (agitation, depression, and sleep). RESULTS: Experts' pain evaluations indicated that residents' usual pain was mild (mean = 1.6/10), and most experienced only intermittent pain (70%). However, 45% of residents experienced moderate to severe worst pain. Of residents, 90% received a pain therapy, with acetaminophen (87%) and opioids (32%) commonly utilized. Only 3% had a nondrug therapy documented in the medical record. The only resident characteristic that was significantly associated with pain severity was receipt of an opioid in the past week. CONCLUSION: Using a comprehensive pain assessment protocol, we found that most nursing home residents with moderate to severe dementia had mild usual, intermittent pain and the vast majority received at least one pain therapy in the previous week. Although these findings reflect improvements in pain management compared with older studies, there is still room for improvement in that 45% of the sample experienced moderate to severe pain at some point in the previous week. J Am Geriatr Soc 68:794-802, 2020.

Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes.

PURPOSE: The Mobilization-Observation-Behavior-Intensity-Dementia (MOBID) Pain Scale is an observational tool in which raters estimate pain intensity on a 0-10 scale following five standardized movements. The tool has been shown to be valid and reliable in northern European samples and could be useful in the United States (US) for research and clinical purposes. The goal of this study was to examine the validity and reliability of the MOBID among English-speaking nursing home residents in the US. DESIGN: Cross-sectional study. SETTINGS: Sixteen nursing homes in Pennsylvania, New Jersey, Georgia and Alabama. PARTICIPANTS: One hundred thirty-eight older adults with dementia and moderate to severe cognitive impairment. METHODS: Validity was evaluated using Spearman correlations between the MOBID overall pain intensity score and 1) an expert clinician's pain intensity rating (ECPIR), 2) nursing staff surrogate pain intensity ratings, and 3) known correlates of pain. We assessed internal consistency by Cronbach's alpha. RESULTS: MOBID overall scores were significantly associated with expert clinician's rating of current and worst pain in the past week (rho = 0.54, and 0.57; p < .001, respectively). Statistically significant associations also were found between the MOBID overall score and nursing staff current and worst pain intensity ratings as well as the Cornell Scale for Depression in Dementia (rho = 0.29; p < .001). Internal consistency was acceptable (α = 0.83). CONCLUSIONS AND CLINICAL IMPLICATIONS: Result of this study support the use of the MOBID in English-speaking staff and residents in the US. Findings also suggest that the tool can be completed by trained, nonclinical staff.

Use of the Montreal Cognitive Assessment (MoCA) in a Rural Outreach Program for Military Veterans.

The Montreal Cognitive Assessment (MoCA) is a free, easily accessible screener ideal for rural areas where resources are limited. We examined administration and scoring by Veteran Community Outreach Health Workers (VCOHWs); compared positive screening rates using two cutoff scores; and examined predictors of education-adjusted scores in N = 168 rural military Veterans from the Alabama Veteran Rural Health Initiative. Accuracy of administration (95 percent) and scoring (68 percent) was calculated and recommendations are offered. Higher than expected rates of positive screens were observed (40 percent using 24/30 cutoff) in this relatively young (M = 55 years) community-dwelling sample. Age, education, and race but not subjective health predicted differences in domain and total education-adjusted scores on multivariate and univariate tests. This study advances social science research in rural communities by being the first to: (1) examine MoCA scores in a rural, Deep South U.S. sample; and (2) report fidelity administration data for VCOHWs.

Psychometric Evaluation of a Pain Intensity Measure for Persons with Dementia.

OBJECTIVE: The goal of this study was to conduct initial psychometric analyses of a seven-item pain intensity measure for persons with dementia (PIMD) that was developed using items from existing pain observational measures. DESIGN AND METHODS: We evaluated validity by examining associations with an expert clinician's pain intensity rating (ECPIR) and an established pain observation tool (Mobilization Observation Behaviour Intensity Dementia [MOBID]). We also examined correlations between the PIMD and known correlates of pain: depression, sleep disturbances, agitation, painful diagnoses, and caregiver pain reports. We examined the differences between PIMD scores for "at rest" and "during movement" observations. We assessed reliability by calculating Cronbach's alpha and estimating inter-rater reliability using intraclass correlations (ICCs). Finally, we examined whether six additional "recent changes in behavior" items improved the PIMD's ability to predict expert clinicians' pain ratings. SETTING: Sixteen nursing homes located in Alabama, Georgia, Pennsylvania, and New Jersey. PARTICIPANTS: One hundred ninety residents with moderate to severe cognitive impairment, mean age of 84 years, 49.5% female, and 70% white. RESULTS: PIMD during movement scores were highly correlated with the ECPIR and overall MOBID scores. As expected, there were large differences between at rest and during movement PIMD scores. Associations of PIMD with known correlates of pain were generally low and statistically nonsignificant. Internal consistency was supported with a Cronbach alpha of 0.72 and an inter-rater ICC of 0.82 for during movement PIMD scores. CONCLUSIONS: Initial evaluation of the PIMD supports its validity and reliability. Additional testing is needed to evaluate the tool's sensitivity to changes in pain intensity.

Developing a Pain Intensity Measure for Persons with Dementia: Initial Construction and Testing.

OBJECTIVE: The goal of this study was to identify a limited set of pain indicators that were most predicive of physical pain. We began with 140 items culled from existing pain observation tools and used a modified Delphi approach followed by statistical analyses to reduce the item pool. METHODS: Through the Delphi Method, we created a candidate item set of behavioral indicators. Next, trained staff observed nursing home residents and rated the items on scales of behavior intensity and frequency. We evaluated associations among the items and expert clinicians' assessment of pain intensity. SETTING: Four government-owned nursing homes and 12 community nursing homes in Alabama and Southeastern Pennsylvania. PARTICIPANTS: Ninety-five residents (mean age = 84.9 years) with moderate to severe cognitive impairment. RESULTS: Using the least absolute shrinkage and selection operator model, we identified seven items that best predicted clinicians' evaluations of pain intensity. These items were rigid/stiff body or body parts, bracing, complaining, expressive eyes, grimacing, frowning, and sighing. We also found that a model based on ratings of frequency of behaviors did not have better predictive ability than a model based on ratings of intensity of behaviors. CONCLUSIONS: We used two complementary approaches-expert opinion and statistical analysis-to reduce a large pool of behavioral indicators to a parsimonious set of items to predict pain intensity in persons with dementia. Future studies are needed to examine the psychometric properties of this scale, which is called the Pain Intensity Measure for Persons with Dementia.

Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention.

Adults who complete an advance directive (AD) are not consistently offered information about the risks, benefits, or alternatives (RBA) of the life-sustaining medical procedures addressed on standardized forms. The current article describes a new patient-centered nurse-supported advance care planning (NSACP) intervention focused on providing information about RBA of life-sustaining procedures. Fifty participants (mean age = 50.26 years) at a Veterans Affairs medical center were randomized to the NSACP intervention or a comparison condition. Before randomization, 78% (n = 39) expressed interest in RBA information. Of participants in the NSACP group, 94% (n = 30) completed an AD. Participants who received NSACP made more decisions to decline life-sustaining treatment than those who were randomized to the comparison group. Promising feasibility data include brevity (mean = 46 minutes), high patient satisfaction, participant retention, and treatment fidelity. The NSACP holds promise as a brief, educational intervention to support patients in completing an AD. [Journal of Gerontological Nursing, 44(7), 31-42.].

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship.

Purpose of Study: To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods: In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results: The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications: The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.