Preferences and Quality of Life in Nursing Home Residents: A Mixed Methods Study.

PURPOSE: Delivery of person-centered care (PCC) is the standard in nursing homes (NHs) and demonstrates a positive impact on resident quality of life (QOL). PCC inherently recognizes and prioritizes resident preferences; however, preferences, and their degree of importance among residents, demonstrate a variable relationship with QOL that remains underexplored. Therefore, the current study examined the association between preferences and QOL among NH residents. METHOD: A mixed methods study incorporating surveys was conducted among 144 residents, with semi-structured follow-up interviews with 11 residents. RESULTS: Findings confirm a variable relationship between resident preferences and QOL. Higher order preferences not captured within the preference assessment may influence QOL. High numbers of unimportant and can't do/no choice preferences were linked to resident acclimatization to the NH. QOL was at risk if care was not consistent with preferences. CONCLUSION: In-depth assessments and robust measures of preferences and QOL should be integrated into care delivery and future research. [Journal of Gerontological Nursing, 50(5), 7-13.].

Policies Shaping Nursing Home Medication Practices: Involving Nurses to Advance Individualized Deprescribing.

Deprescribing is a common practice in the care of older adults, including those living in nursing homes (NHs). Deprescribing represents an individualized approach to optimizing medication use; it considers the risks, benefits, and goals of an individual, and can mitigate the effects of polypharmacy and potentially inappropriate medications. In NH settings, prescribing practices are shaped directly and indirectly by historical and contemporaneous policies at federal, state, and local levels, which have primarily targeted chemical restraints and unnecessary medications. Understanding these policies, their impact, and potentially unintended consequences is essential for gerontological nursing to transition toward individualized practices and approaches to deprescribing. [Journal of Gerontological Nursing, 49(9), 15-20.].

Verbal and Nonverbal Expressions of Persons Living With Dementia as Indicators of Person-Centered Caregiving.

BACKGROUND AND OBJECTIVES: Improved measures capable of capturing the influence of person-centered caregiving by staff in formal care settings on people living with dementia beyond deficit-oriented outcomes such as absence or reduction of symptoms are important for measuring progress toward improvements in well-being. This exploratory ethnographic study aimed to identify verbal and nonverbal expressions evidenced by people living with dementia surrounding person-centered caregiving approaches and to consider their use in informing temporally specific observational measures. RESEARCH DESIGN AND METHODS: This study adopted a microethnographic approach through secondary analysis of 5.3 h of audiovisual observations of people living with dementia (N = 9) in nursing home settings at mealtimes. We observed expressions surrounding person-centered caregiving approaches. A systematic review of audiovisual observations generated codes (observable indicators) of expressions that were characterized at their most discrete and unambiguous level. RESULTS: Drawing from 82 observable verbal and nonverbal expressions by people living with dementia, 14 discrete observable indicators were identified, broadly evidencing shifts in engagement and communication. We found that people living with dementia's expressions served both responsive and initiatory communicative purposes. DISCUSSION AND IMPLICATIONS: Efforts to expand positive outcome measurement for people living with dementia should extend beyond characterizing them as passive respondents toward active participants in their lived experiences. Identified observable indicators can inform efforts to refine and validate measures of expressions among people living with dementia. Further research can extend this inquiry into different contexts and engage input from people living with dementia and caregivers.

The VA Storybook Program: Humanizing Care With Nurse Stories.

The Veterans Affairs (VA) Storybook Program was developed to enhance nurse-patient relationships and satisfaction with care. Personal stories about nurses were distributed to patients on a medical/surgical unit. Quantitative and qualitative evaluation data were collected from patients and nurses to capture patients' descriptions of nurses and perceptions of program value. Results show patients describe nurses differently after reading the storybook. Patients were highly satisfied with the program, and interviews suggest the stories fostered connection and developed an atmosphere of trust. Story programs may be an effective, structured approach to enhancing nurse-patient relationships.

Biopsychosocial characteristics associated with engagement in art making among older adults.

In order to design patient-centered art making interventions for health and well-being, investigators need to understand the population of interest regarding their relationship to engagement in art making activities. This study, therefore, aimed to examine older adults' characteristics that were associated with engagement in art making activities, and to provide practical examples of how to use the identified characteristics. We conducted correlation analyses to evaluate such associations, using cross-sectional survey data from the 2014 Health and Retirement Study (n=731). Female sex, higher education, personality traits, positive attitude toward the arts, and a larger social network size were positively associated with engagement in art making activities (p<.05). Males and those with lower education could be targeted, while the type of art making activity could be tailored based on personality traits for patient-centered art making interventions. Future studies can use this information to empirically study art making interventions for older adults.

Relationships among types of activity engagement and insomnia symptoms among older adults.

BACKGROUND: An increasing awareness exists that lack of activity engagement is associated with insomnia symptoms. However, the majority of studies have focused on the association between a single type of activity engagement and insomnia symptoms. METHODS: This is a cross-sectional study using secondary data from the Health and Retirement Study examining the relationships among different types of activity engagement and insomnia symptoms among older adults. The sample for this study included 3321 older adults who responded to survey modules on activity engagement and insomnia symptoms in 2016. Activity engagement was measured using items for three types of activities (i.e., social, cognitive, and physical) validated in this study. Insomnia symptoms were measured using four items (i.e., difficulty of falling asleep, waking up during the night, waking up too early, and feeling rested). Independent t-tests were conducted to identify the differences in insomnia symptoms according to activity engagement level. Regressions were conducted to examine the associations among three types of activity engagement and insomnia symptoms after adjusting for covariates such as demographics, chronic disease, activities of daily living difficulty, cognitive function, sleep disorder, loneliness, and caregiving. RESULTS: The respondents in the high-level social, cognitive, and physical activity engagement groups were found to show fewer insomnia symptoms. Furthermore, higher social (ß = - 0.04, p = 0.040) and cognitive (ß = - 0.06, p = 0.007) activity engagements were associated with fewer insomnia symptoms even after adjusting for other types of activity engagement and all covariates. CONCLUSIONS: This study suggests that older adults with higher social and cognitive activity engagements may be likely to have fewer insomnia symptoms. Based on these results, future research is needed to develop multi-component intervention programs that can encourage older adults to engage in these activities.

Implementing Coordinated Specialty Care for First Episode Psychosis: A Review of Barriers and Solutions.

Specialized early interventions (SEI) for individuals diagnosed with a first episode of psychosis (FEP) are effective treatment modalities (Azrin et al. in Psychiatr Ann 45(11):548, https://doi.org/10.3928/00485713-20151103-05 , 2015). SEI offered immediately or shortly following a first episode improves functional and clinical outcomes for those individuals with, and at risk for, serious mental illness (SMI; Correll et al. in JAMA Psychiatry 75(6):555-565, https://doi.org/10.1001/jamapsychiatry.2018.0623 , 2018). In the United States, SEI programs referred to as Coordinated Specialty Care (CSC), have been utilized to provide a beneficial, team-based, multi-component method of treating FEP. However, despite the success, CSC programming is still met with considerable challenges. This article reviews existing CSC literature to identify and explore relevant barriers to successful implementation of CSC. Identified barriers include stigma, cultural competence, disengagement, measurement and evaluation, workforce development, implementation in rural areas, and financial stability. The ongoing efforts to address these barriers are described and areas for continued improvements are discussed.

The My Life, My Story Program: Sustained Impact of Veterans' Personal Narratives on Healthcare Providers 5 Years After Implementation.

Patient-centered care promotes positive patient, staff, and organizational outcomes. Communication is one critical element of patient-centered care. Establishing a patient-provider relationship in which a patient feels comfortable sharing their goals, preferences, and values is important to support patient-centered care and positive health outcomes. The My Life, My Story (MLMS) program was developed in 2013 to elicit and share Veterans' life stories with their healthcare providers. Life stories become part of the Veteran's chart so providers can access, read, and utilize as appropriate. To evaluate the program's sustained value and impact 5 years after implementation, healthcare staff were recruited to complete a short survey with closed and open-ended items. Descriptive statistics were used to analyze the quantitative survey responses and thematic analysis was used to analyze qualitative responses. Approximately 94% of staff indicated they had read MLMS notes and over 86% agreed or strongly agreed that reading the notes was a good use of their clinical time and helped them provide better treatment or care. Staff also described making more personalized decisions about the plan of treatment or care delivery after knowing the Veteran better from their story. Our findings suggest the MLMS program has been well sustained over time, and the use of patient stories in healthcare may be a valuable, practical, and sustainable tool to support the delivery of patient-centered care.

Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis.

INTRODUCTION: Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers' perceptions of the intervention. MATERIALS AND METHODS: This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs. RESULTS: We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences. CONCLUSION: Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.

Social justice advocacy in mental health services: Consumer, community, training, and policy perspectives.

This article addresses important aspects of and strategies for social justice advocacy in mental health care across consumer, community, educational, and policy domains. Social justice advocacy is intentional and sustained action intended to influence public policy outcomes, with and/or on behalf of a vulnerable individual, group, community, or the public at large. The paper presents a series of policy and advocacy levels of change, which may be used to promote social justice among individuals with mental health disorders with an emphasis on how psychologists can be valuable in these efforts. These social justice advocacy approaches are presented in a 3-level bio/socioecological framework at the micro, meso, and macro levels based on Bronfenbrenner's theoretical model. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Exploring Patterns in Preferences for Daily Care and Activities Among Nursing Home Residents.

Nursing homes have shifted from task-focused to person-centered care (PCC) environments. Understanding resident preferences for daily care and activities is fundamental to PCC. Examining resident similarities based on preferences may be useful for group or community-wide PCC planning. The aims of the current study were to group residents according to similarities in preferences and determine the factors that predict membership in these groups. A latent class analysis of resident preferences using data from the Minimum Data Set (N = 244,718) was conducted. Resident function, depression, cognitive impairment, and sociodemographics were used as predictors of class membership. The four-class model showed residents cluster around overall interest or disinterest in having choices about daily care and activities or specific interest in either care or activity preferences. Race and ethnicity, cognitive impairment, and depression predicted class membership. Findings suggest that residents can be grouped by preferences and knowledge of resident group membership could help direct efforts to systematically meet resident preferences. [Journal of Gerontological Nursing, 45(8), 7-13.].

Exploring Variation in Certified Nursing Assistant Assignments From the Perspective of Nursing Home Residents: A Comparison of Adopters and Nonadopters of Consistent Assignment.

Objective: To describe and compare certified nursing assistant (CNA) staffing between adopter and nonadopters of consistent assignment. Data sources: One month of preexisting CNA assignment and scheduling sheets from a purposive sample of 30 homes. Study design: A descriptive comparative study was conducted to calculate and compare numbers of CNAs assigned per resident across homes. Data extraction: Resident names and CNA assignments were abstracted from assignment records and entered into the Advancing Excellence consistent assignment tool to calculate numbers of CNAs assigned per resident. Principal findings: Both variation and overlap existed in the number of CNAs per resident within and between homes. Adopters assigned significantly fewer CNAs per resident. Conclusion: Research is needed to determine how assignment variations affect resident perceptions of quality.

Nursing home resident relationship types: What supports close relationships with peers & staff?

AIMS AND OBJECTIVES: To describe from the nursing home resident perspective (a) the types and dimensions of relationships residents develop with others in the nursing home and (b) the conditions that influence the development of close relationships. BACKGROUND: Close relationships are considered the fundamental building block of person-centred care. Prior studies have examined the various types of relationships residents develop with peers and staff, but few have focused specifically on articulating the characteristics and dimensions of a close relationship or the factors that can support or detract from their development. DESIGN: Grounded theory. METHODS: Fifteen cognitively intact residents from two nursing homes were recruited for one-on-one, unstructured interviews. Interview questions started broadly and became more focused as the study progressed. Data were analysed using open, axial and selective coding. RESULTS: Residents described developing a range of relationships with peers and staff (adversarial, utilitarian, and friendly). Residents used "friendly" to describe many different types of relationships including acquaintanceships, casual friendships and close friendships. Few residents had close relationships with peers or staff. Several conditions promoted development of positive and friendly relationships. Physical proximity and access to peers with similar interests, who could communicate clearly, fostered friendly peer relationships. Spending noncare time, providing little extras, treating residents as special and responding positively to care requests fostered friendly staff relationships. CONCLUSIONS: Findings add new evidence regarding nuances in resident relationships and demonstrate how development of close relationships may be limited in practice. Careful assessment of resident relationship needs and goals may be critical to setting appropriate social goals. RELEVANCE TO CLINICAL PRACTICE: Nurses can be intentional about resident placements in the facility to promote social interactions and keep social goals in mind when making medical or staffing decisions to prevent interruption of important relationships.

Impact of Hospital Context on Transitioning Patients From Hospital to Skilled Nursing Facility: A Grounded Theory Study.

Background: Twenty-five percentage of patients who are transferred from hospital settings to skilled nursing facilities (SNFs) are rehospitalized within 30 days. One significant factor in poorly executed transitions is the discharge process used by hospital providers. Objective: The objective of this study was to examine how health care providers in hospitals transition care from hospital to SNF, what actions they took based on their understanding of transitioning care, and what conditions influence provider behavior. Design: Qualitative study using grounded dimensional analysis. Participants: Purposive sample of 64 hospital providers (15 physicians, 31 registered nurses, 8 health unit coordinators, 6 case managers, 4 hospital administrators) from 3 hospitals in Wisconsin. Approach: Open, axial, and selective coding and constant comparative analysis was used to identify variability and complexity across transitional care practices and model construction to explain transitions from hospital to SNF. Key Results: Participants described their health care systems as being Integrated or Fragmented. The goal of transition in Integrated Systems was to create a patient-centered approach by soliciting feedback from other disciplines, being accountable for care provided, and bridging care after discharge. In contrast, the goal in Fragmented Systems was to move patients out quickly, resulting in providers working within silos with little thought as to whether or not the next setting could provide for patient care needs. In Fragmented Systems, providers achieved their goal by rushing to complete the discharge plan, ending care at discharge, and limiting access to information postdischarge. Conclusions: Whether a hospital system is Integrated or Fragmented impacts the transitional care process. Future research should address system level contextual factors when designing interventions to improve transitional care.

Self-management assessment in multiple chronic conditions: A narrative review of literature.

OBJECTIVES: Effective self-management in individuals with multiple chronic conditions is necessary to optimize health outcomes. Self-management in multiple chronic conditions involves an iterative process prioritizing multiple changing needs/conditions. However, self-management in multiple chronic conditions has been assessed with instruments designed to assess self-management of a single chronic illness. The instruments may not address the complexity of self-management in multiple chronic conditions. Thus, this review aimed to examine how self-management has been operationalized in the context of multiple chronic conditions. DESIGN: A narrative review method was used. DATA SOURCE: The online databases, Pubmed, CINAHL Plus, and PsycInfo, were searched. The search was conducted of the database from January 2006 through November 2017. REVIEW METHODS: Peer-reviewed research articles which operationalized self-management in adults with at least two or more chronic illnesses were selected for review. Two reviewers read full text of selected articles and extracted data regarding operational definitions of self-management and instruments used to assess self-management. Operational definitions were categorized to conceptualize how self-management has been assessed. RESULTS: A total of seven peer-reviewed research articles were selected for inclusion. This review found that self-management has been assessed through prerequisites of self-management and behaviors involved in self-management. Prerequisites of self-management included attitude, self-efficacy, perceived ability, and knowledge. Behaviors included an individual's engagement in self-management such as health-related behaviors, health service use, and medication adherence. CONCLUSIONS: This review revealed that current literature does not operationalize self-management in multiple chronic conditions as a process, indicating incomplete assessments of self-management. To obtain a more comprehensive understanding of self-management in multiple chronic conditions, future studies should consider self-management as an iterative process in addition to prerequisites for self-management and behaviors. Such studies will inform the development of patient-centered self-management interventions for individuals with multiple chronic conditions.

Important Care and Activity Preferences in a Nationally Representative Sample of Nursing Home Residents.

OBJECTIVES: Person-centered care (PCC), which considers nursing home resident preferences in care delivery, has been linked to important outcomes such as improved quality of life, resident satisfaction with care, and mood and reduced behavioral symptoms for residents with dementia. Delivery of PCC fundamentally relies on knowledge of resident preferences. The Minimum Data Set (MDS) 3.0 Preference Assessment Tool (PAT) is a standardized, abbreviated assessment that facilitates systematic examination of preferences from a population of nursing home residents. However, it is unknown how well the PAT discriminates preferences across residents or items. The purpose of this study was to use MDS 3.0 PAT data to describe (1) overall resident preferences, (2) variation in preferences across items, and (3) variation in preferences across residents. DATA: Data from admission MDS assessments between October 1, 2011 and December 31, 2011 were used for this study. SAMPLE: A nationally representative sample of 244,718 residents over the age of 65 years who were able to complete the resident interview version of preference, cognition, and depression assessments were included. MEASUREMENTS: Importance ratings of 16 daily care and activity preferences were the primary outcome measures. Resident factors including function (MDS Activities of Daily Living-Long Form), depression (Patient Health Questionnaire-9), cognitive impairment (Brief Interview for Mental Status), and sociodemographics (age, race, sex, and marital status) were used as predictors of important preferences. ANALYSIS: Overall preferences were examined using descriptive statistics. Proportional differences tests were used to describe variation across items. Logistic regression was used to describe variation in preferences across residents. RESULTS: The majority of residents rated all 16 preferences important. However, there was variation across items and residents. Involvement of family in care and individualizing daily care and activities were rated important by the largest proportion of residents. Several resident factors including cognitive impairment, depression, sex, and race were significant predictors of preferences. CONCLUSIONS: Findings demonstrate the PAT captures variation in preferences across items and residents. Residents with possible depression and cognitive impairment were less likely to rate preferences important than residents without those conditions. Non-Caucasian and male residents reported some preferences differently than Caucasian and female residents. Additional assessment and care planning may be important for these residents. More research is needed to determine the factors that influence preferences and the ways to incorporate them into care.

Implementation of daily chlorhexidine bathing to reduce colonization by multidrug-resistant organisms in a critical care unit.

BACKGROUND: Colonized patients are a reservoir for transmission of multidrug-resistant organisms (MDROs). Not many studies have examined the effectiveness of daily chlorhexidine gluconate (CHG) bathing under routine care conditions. We present a descriptive analysis of the trends of MDRO colonization following implementation of daily CHG bathing under routine clinical conditions in an intensive care unit (ICU). METHODS: From May 2010-January 2011, we screened patients admitted to a 24-bed ICU for and methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and fluoroquinolone-resistant gram-negative bacilli (FQRGNB). We calculated and plotted monthly incidence and prevalence of colonization of these MDROs. RESULTS: Prevalence decreased in the immediate aftermath of daily CHG bathing implementation and generally remained at that level throughout the observation period. We observed low rates of incidence of MDRO colonization with VRE>FQRGNB>MRSA. Monthly prevalence of colonization and incidence for the composite of MRSA, VRE, and/or FQRGNB was 1.9%-27.9% and 0-1.1/100 patient-days, respectively. CONCLUSIONS: Following the implementation of daily CHG bathing, the incidence of MDROs remained low and constant over time, whereas the prevalence decreased immediately after the implementation.

Analysis of Multidrug-Resistant Organism Susceptibility to Chlorhexidine Under Usual Clinical Care.

Increasing use of daily chlorhexidine gluconate (CHG) bathing can potentially lead to selection for organisms with reduced susceptibility to CHG, limiting the utility of CHG. We examined reduced susceptibility to CHG of fluoroquinolone-resistant gram-negative bacilli and methicillin-resistant Staphylococcus. No evidence suggested reduced susceptibility to CHG. Infect Control Hosp Epidemiol 2017;38:729-731.

Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences.

BACKGROUND: Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital. METHODS: We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made. RESULTS: Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers. CONCLUSIONS: Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.

Transitions From Hospitals to Skilled Nursing Facilities for Persons With Dementia: A Challenging Convergence of Patient and System-Level Needs.

Purpose of the Study: To describe skilled nursing facility (SNF) nurses' perspectives on the experiences and needs of persons with dementia (PwD) during hospital-to-SNF transitions and to identify factors related to the quality of these transitions. Design and Methods: Grounded dimensional analysis study using individual and focus group interviews with nurses (N = 40) from 11 SNFs. Results: Hospital-to-SNF transitions were largely described as distressing for PwD and their caregivers and dominated by dementia-related behavioral symptoms that were perceived as being purposely under-communicated by hospital personnel in discharge communications. SNF nurses described PwD as having unique transitional care needs, which primarily involved needing additional discharge preplanning to enable preparation of a tailored behavioral/social care plan and physical environment prior to transfer. SNF nurses identified inaccurate/limited hospital discharge communication regarding behavioral symptoms, short discharge timeframes, and limited nursing control over SNF admission decisions as factors that contributed to poorer-quality transitions producing increased risk for resident harm, rehospitalization, and negative resident/caregiver experiences. Engaged caregivers throughout the transition and the presence of high-quality discharge communication were identified as factors that improved the quality of transitions for PwD. Implications: Findings from this study provide important insight into factors that may influence transitional care quality during this highly vulnerable transition. Additional research is needed to explore the association between these factors and transitional care outcomes such as rehospitalization and caregiver stress. Future work should also explore strategies to improve inter-setting communication and care coordination for PwD exhibiting challenging behavioral symptoms.