RNs in nursing homes-It is not always about the numbers.

The compelling evidence that higher RN to resident ratios improve health outcomes in nursing homes underscores the necessity of implementing evidence-based RN nursing home staffing standards. However, there are other dimensions to RN staffing in nursing homes beyond the numbers or hours per resident day (HPRD) that influence the quality of care. Without attending to a broader focus on nurse staffing, the benefits of increased RN staffing levels will not be achieved. This article outlines how RN HPRD can be maximized by magnifying the RN's scope of practice and attending to how nursing care is organized and delivered in nursing homes using a nursing practice model framework. This framework addresses the accountability of the RN and the RN's role in supporting and facilitating: (1) collective decision-making among the nursing staff about the care of residents and the work environment, (2) continuity of information among care providers, and (3) ensuring residents have continuity with the care providers assigned to their care. Attention to the RN's expertise in gerontological nursing and leadership capacity further leverages the RN's ability to influence the quality of care for nursing homes residents.

Self-identified culturally related stressors that influence self-care in older adults with multiple chronic conditions: A qualitative study.

AIM: To identify culturally related stressors that influence self-care in Chinese older adults with multiple chronic conditions. BACKGROUND: Effective self-care can improve health outcomes for chronic conditions, but implementing self-care is challenging. Individuals with multiple chronic conditions face even more self-care complexity than those with single chronic conditions, generating additional stressors. Although stressors have been found to negatively influence self-care in multiple chronic conditions, the role of culture in generating stressors has been neglected. DESIGN: This paper reports on the qualitative component of a larger mixed-methods study. Two free-response items in a survey were used to identify culturally related stressors that influence self-care. This report adhered to the SRQR guideline checklist. METHODS: Data were collected between January and April 2022. One hundred and thirty-eight free text responses asking participants to identify stressors that influenced their self-care effectiveness were analysed sequentially using deductive content analysis and thematic analysis. RESULTS: Findings from deductive content analysis largely confirmed published work in Western literature on stressors complicating self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. CONCLUSION: Chinese older adults with multiple chronic conditions identified a wide range of stressors that impacted their day-to-day self-care. This study provided valuable insights into culturally related stressors in older adults with multiple chronic conditions. Findings deepened our knowledge of cultural influences on the success of self-care in older adults with multiple chronic conditions, suggesting the potential for reaching populations across different cultures and regions. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Stressors that might influence self-care ability are important for nurses to assess in people with multiple chronic conditions. The design of self-care interventions should take a culturally tailored intergenerational family-centred approach to help mitigate the impact of stressors and ultimately improve patient outcomes. IMPACT: What problem did the study address? Stressors documented in older adults with MCCs have all been generated from research with Western populations. China is now home to the largest population of older people in the world. Understanding the influence of culturally relevant stressors on self-care in Chinese older adults with MCCs is lacking. What were the main findings? Findings from deductive content analysis largely confirmed published work in Western literature on stressors that complicated self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors in older adults with MCCs in China: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. Where and on whom will the research have an impact? The research will have an impact on guiding nurses' assessment of culturally relevant stressors' impact on self-care for older adults with MCCs. In addition, findings could inform research and policy development to aim at mitigating the impact of culturally based stressors on self-care. REPORTING METHOD: This study adhered to the Standards for Reporting Qualitative Research (SRQR) guideline checklist. PATIENT OR PUBLIC CONTRIBUTION: During the member-checking process, the validation of findings for accuracy was carried out by 10 participants, who also found resonance between these findings and their own experiences.

Devaluing Incarcerated Populations: Deprioritizing Incarcerated Populations for COVID-19 Vaccination.

The COVID-19 pandemic has highlighted the need for increased attention to measures in place to protect the health of incarcerated populations. Correctional facilities saw massive COVID-19 outbreaks and correctional nurses have been at the forefront of efforts to control COVID-19 in correctional facilities. Before vaccines were widely available, the National Academies of Science, Engineering, and Medicine developed a framework to guide equitable COVID-19 vaccine allocation. This study assessed the use of the framework by reviewing 15 state COVID-19 vaccination plans to identify how incarcerated populations were prioritized. Thirteen initial plans could be located. Ten of these plans placed incarcerated persons in Phases 1 and 2, while 1 state placed them in Phase 3. However, subsequent versions of the plans revealed that 8 states had deprioritized incarcerated populations by no longer considering them as a unique population. The framework was developed to promote equity, however, incarcerated persons were often dis-included as a high-risk population for vaccine prioritization, prolonging their risk of COVID-19. Engaging in the opportunity to influence both policy and practice, and promote the ethical consideration of incarcerated populations may help to address both the structural (prison) challenges and larger political structures that impacted vaccine availability and ability to provide the best care possible to this high-risk population.

Perceptions of the Role of Living Alone in Providing Services to Patients With Cognitive Impairment.

Importance: The potential role of living alone in either facilitating or hampering access to and use of services for older adults with cognitive impairment is largely unknown. Specifically, it is critical to understand directly from health care and social services professionals how living alone creates barriers to the access and use of supportive health care and social services for racially and ethnically diverse patients with cognitive impairment. Objective: To identify the potential role of living alone in the access and use of health care and social services for diverse patients with cognitive impairment by investigating professionals' perceptions of caring for such patients who live alone in comparison with counterparts living with others. Design, Setting, and Participants: This qualitative study of 76 clinicians, social workers, and other professionals used semistructured interviews conducted between February 8, 2021, and June 8, 2022, with purposively sampled professionals providing services to diverse patients with cognitive impairment in Michigan, California, and Texas. Main Outcomes and Measures: Clinicians, social workers, and other professionals compared serving patients with cognitive impairment and living alone vs counterparts living with others. An inductive content analysis was used to analyze the interview transcripts. Results: A total of 76 professionals were interviewed (mean [SD] age, 49.3 [12.7] years); 59 were female (77.6%), 8 were Black or African American (11%), and 35 were White (46%). Participants included physicians, nurses, social workers, and home-care aides, for a total of 20 professions. Participants elucidated specific factors that made serving older adults living alone with cognitive impairment more challenging than serving counterparts living with others (eg, lacking an advocate, incomplete medical history, requiring difficult interventions), as well as factors associated with increased concerns when caring for older adults living alone with cognitive impairment, such as isolation and a crisis-dominated health care system. Participants also identified reasons for systematic unmet needs of older adults living alone with cognitive impairment for essential health care and social services, including policies limiting access and use to public home-care aides. Conclusions and Relevance: In this qualitative study of professionals' perspectives, findings suggest that living alone is a social determinant of health among patients with cognitive impairment owing to substantial barriers in access to services. Results raised considerable concerns about safety because the US health care system is not well equipped to address the unique needs of older adults living alone with cognitive impairment.

A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models.

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

Relationship between health care interactions and care partner burden.

INTRODUCTION: Older adults often rely on care partners, such as family and friends, to assist with their health-related needs associated with aging. Care partner burden is associated with higher rehospitalization rates and poorer health outcomes for older adults. This study examines the relationship between 3 types of health care interactions and care partner burden. METHOD: Secondary data analyses using cross-sectional data from the 2017 National Study of Caregiving were conducted. A total of 2,313 care partners (representing approximately 21.2 million) of living Medicare beneficiaries age 65 and older were included in the analyses. Multivariable logistic regression analyses were used to determine the relationship between health care interactions and care partner burden. RESULTS: Care partners with burden were significantly more likely to be female (p = .049); white (p = .011); and a spouse, adult child, or grandchild of the older adult (p < .001). Logistic regression analyses showed that making medical appointments (Adjusted Odds Ratio [AOR] = 1.53, 95% CI: 1.13-2.07) and coordinating care between providers (AOR = 1.72, 95% CI: 1.27-2.32) were significantly associated with care partner burden. DISCUSSION: Care partners of older adults who helped make medical appointments or coordinated care between providers were significantly more likely to report burden compared to those who did not assist with these health care interactions. It is essential that health care systems and providers determine ways to make health care interactions less burdensome for care partners. Care delivery approaches that align with family systems thinking may help reduce care partner burden by strengthening health care interactions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Intersections of Structural Racism and Ageism in the Time of COVID-19: A Call to Action for Gerontological Nursing Science.

The health consequences of systemic racism and ageism have received growing attention as the coronavirus disease 2019 pandemic has illuminated long-standing inadequacies and injustices that are structurally engrained in our health systems. The current State of the Science Commentary addresses the intersecting influences of systemic racism and ageism, and other "-isms" that conspire to create disparate health outcomes for older adults from historically excluded and marginalized backgrounds. We focus specifically on the long-term care sector as a representative microcosm of structural inequities, while recognizing that these unjust barriers to health are widespread, endemic, and pervasive. We present a call to action for gerontological nursing science to engage deeply and robustly in these realities, and the ethical and scientific imperative they present to ensure that all older adults encounter just conditions for maximizing their health and well-being. [Research in Gerontological Nursing, 15(1), 6-13.].

Surgeons' mental models of surgical site infection: Insights into adherence with complex prevention bundles.

Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than "pay-for-performance" models.

The Pathways of Nurse Turnover in Long-term Care Hospitals / 한국직업건강간호학회지

Background@#This study explores the pathways of nurse turnover in long-term care hospitals (LTCHs) and its underlying conditions in Korea. Although the factors of staying or leaving of nurses in LTCHs have been reported, few studies have examined the trajectory and conditions of nurses staying in and leaving LTCHs. @*Methods@#A qualitative study design with a grounded theory approach was conducted. Data were collected in one-to-one interviews. Purposive and theoretical sampling led to the inclusion of 20 registered nurses from 15 LTCHs in South Korea. @*Results@#Seeking work-life balance was the core category of the nurses' turnover pathway. The consequences of the nurses' turnover pathway were categorized into three groups: thriving, surviving, and leaving. Thriving nurses found meaning in their work, fostered good relationships, and saw opportunities for growth. Surviving nurses were enduring their jobs in LTCHs, having a work-life balance, and supportive nursing leaders. Leaving group nurses wished to leave LTCHs due to a lack of professional growth, unappealing work, continued conflict, and social stigma. @*Conclusion@#This study provided the trajectory and conditions for nurses to enter, stay, move, or leave. Understanding the pathways for staying or leaving can be used as a strategy for successful retention of registered nurses in LTCHs.

Expert nurse response to workforce recommendations made by The Coronavirus Commission For Safety And Quality In Nursing Homes.

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents' care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.

A Call to the CMS: Mandate Adequate Professional Nurse Staffing in Nursing Homes.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

Assisted Living: Optimal Person-Environment Fit.

Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].

"Everything Is Greyscaled": Immigrant Women's Experiences of Postpartum Distress.

Postpartum distress increases the risk of developing mental disorders over a woman's lifespan. Although immigrant women experience a high rate of postpartum depression, we know very little about the psychosocial experiences of postpartum distress in immigrant populations. No theories have been developed to account for the intersection of cultural and maternal transitions or the relationship of this dual transition to postpartum distress. Therefore, this study aims to generate a conceptual model for describing immigrant women's experience of and social-psychological responses to postpartum distress. This study uses grounded theory to conduct and analyze interviews with 22 Chinese immigrant women who experienced postpartum distress. During their dual transitions, participants encountered many losses significant to their psychological self. The conceptual model of greyscaling and reviving the psychological self provides pathways to respond to these losses, assesses the pathways' impact on experiencing distress, and offers strategies that resolve distress.

"Hopes and wishes": Goals of high-need, high-cost older patients and their caregivers.

OBJECTIVE: Integration of patient-identified goals is a critical element of shared decision-making and patient-provider communication. There is limited information on the goals of patients with multiple medical conditions and high healthcare utilization. We aimed to identify and categorize the goals described by "high-need, high-cost" (HNHC) older patients and their caregivers. METHODS: Using conventional content analysis, we used data from interviews conducted with 17 HNHC older patients (mean age 72.5 years) and 4 caregivers. RESULTS: HNHC older patients and their caregivers used language such as "hopes, wishes, and wants" to describe their goals, which fell into eight categories: alleviating discomfort, having autonomy and control, decreasing treatment burden, maintaining physical functioning and engagement, leaving a legacy, extending life, having satisfying and effective relationships, and experiencing security. CONCLUSION: Our results contribute to knowledge of goals of HNHC patients and provides guidance for improving the patient-provider relationship and communication between HNHC older patients and their healthcare providers. PRACTICE IMPLICATIONS: Our findings can inform provider efforts to assess patient goals and engage high-need, high-cost older patients in shared decision-making. Further, this study contributes to an improved understanding of HNHC older patients to support continued development of effective care models for this population.