"Just Join Them": Improv and Dementia Care.

Improvisational (improv) theatre skill development holds promise for improving the dementia capability of care partners. In this report, we present analysis of data from an ongoing study on meaningful engagement and quality of life among assisted living (AL) residents with dementia. Using ethnographic methods, we collected data from persons with dementia (n = 59) and their care partners (n = 165) in six diverse AL communities each studied for one year. Building cumulatively on past work and existing literature, we demonstrate the potential benefits of training care partners to use improv skills. We discuss implications, including the need for intervention research.

Understanding Capacity and Optimizing Meaningful Engagement among Persons Living with Dementia.

Meaningful engagement is a key dimension of quality of life among persons living with dementia, yet little is known about how to best to promote it. Guided by grounded theory methods, we present analysis of data collected over a 1-year period in four diverse assisted living (AL) communities as part of the study, "Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia." Our aims are to: (a) learn how meaningful engagement is negotiated among AL residents with dementia and their care partners; and (b) identify how to create these positive encounters. Researchers followed 33 residents and 100 care partners (formal and informal) and used participant observation, resident record review, and semi-structured interviews. Data analysis identified "engagement capacity" as central to the negotiation of meaningful engagement. We conclude that understanding and optimizing the engagement capacities of residents, care partners, care convoys, and settings, are essential to creating and enhancing meaningful engagement among persons living with dementia.

The Impact of COVID-19 on the Person-Centered Care Practices in Nursing Homes.

The COVID-19 pandemic has had a significant impact on long-term care residents, family, and staff. Nursing homes are facing persistent challenges such as staff shortage, lack of personal protective equipment (PPE), and staff experiencing mental health issues including burnout. COVID-19 precautions may have made implementing person-centered care (PCC) in nursing homes more difficult. This report provides a descriptive analysis of perceived COVID-19 impact on the PCC practice in nursing homes. Surveys (N = 379) were collected from 11 nursing homes across Georgia. PCC practice barriers include reduced choice for residents, staff anxiety related to COVID-19 precautions, increased prevalence of short-staffing, and expanded duties for direct care workers. Facilitators for PCC were also present and included staff engagement, the provision of mental health resources, supervisor support, and empowerment of staff. Applied practice and research to address these barriers and expand implementation of facilitators is needed.

"You gotta have your cry": Administrator and direct care worker experiences of death in assisted living.

Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and 38 direct care workers (DCWs) in 7 diverse settings. As assisted living administrators and DCWs experienced resident death, they engaged in a dynamic and individualized process of "managing the normalization of death," which refers to the balance of self-identity and workplace identity. The process of reconciling these opposing contexts in AL involved several individual- and community-level conditions. Administrators and DCWs would benefit from additional resources and training around death. Increasing collaboration with hospice and clarifying policies about death communication would better prepare the workforce to acknowledge the end of life in assisted living.

"I'm not terribly lonely": Advancing the understanding of intimacy among older adults.

BACKGROUND AND OBJECTIVES: Intimacy, a social relationship component, continues to be essential in later life, including for older adults in long-term care such as assisted living. Yet, no previous study has conceptualized how individuals experience intimacy holistically (i.e., broadly defined) and within the context of later life, health decline, and long-term care. The purpose of this analysis was to provide an in-depth understanding of intimacy in the lives of older adults in assisted living. RESEARCH DESIGN AND METHODS: Using grounded theory methods, we analyzed data from the "Convoys of Care" (Kemp, PI: R01AG044368) longitudinal, qualitative research project. Data consisted of 2224 h of participant observation and interviews with 28 assisted living residents (aged 58-96), and their care partners (n = 114) followed over two years from four diverse assisted living communities. RESULTS: Residents' experience with intimacy was a process involving four dimensions: emotional, intellectual, spiritual, and physical. Intimacy occurred in platonic or romantic forms and was dynamic over time alongside residents' intimacy needs. Residents engaged in an ongoing process requiring that they manage their needs while negotiating intimacy opportunities and constraints. DISCUSSION AND IMPLICATIONS: Our findings expand the current conceptualization of intimacy in later life, specifically in the context of long-term care. Findings indicate the need for an approach to long-term care that addresses individuals' intimacy needs and preferences.

"It's Going to be Different for Everyone": Negotiating Quality of Life and Care Priorities Within Care Convoys.

Objective: The overall goal of this analysis was to learn about residents' quality of life and quality of care in assisted living over time and from multiple viewpoints within support networks. Method: This grounded theory analysis examined qualitative data collected from 50 residents and 169 of their care network members followed over two consecutive 2-year periods in 8 diverse settings. Results: Quality involved a dynamic process of "negotiating priorities," which refers to working out what is most important for residents' quality of life and care. Resident and care partner priorities were not always consistent or shared, in part because quality is personal, subjective, dynamic, and situational. Discussion: Communication and collaboration among formal and informal care partners are vital to residents' ability to age in place with a high quality of life and quality care.

Person-Centered Care in Nursing Homes: Potential of Complementary and Alternative Approaches and Their Challenges.

A person-centered approach to care shifts the mind-set of care partners from a traditional medical model to a social model in managing chronic conditions. Using a qualitative descriptive approach, this study examines the barriers and facilitators to the implementation of person-centered care (PCC) and how the integration of complementary and alternative approaches (CAA) has the potential to improve residents' quality of life in nursing homes (NHs). Findings indicate that NHs offer a wide range of engagement activities, but these activities are not purposefully integrated into a person-centered plan of care. Factors such as turnover, "working short," supervisor support, and rising resident care needs make it challenging to implement PCC in NHs. This knowledge of the landscape of activities will help us identify and improve strategies for supporting residents at a deeper, more meaningful level. CAA has the potential to be therapeutic for residents if integrated into collaborative approaches to care.

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living.

Assisted living (AL) communities are long-term care settings where people live, work, and visit, and where social relationships and care, including end-of-life care, are negotiated. Assisted living is fraught with uncertainty and conflict about values, especially given residents' cognitive and physical frailty. These value-laden issues have implications for both resident and care partners' experiences. Yet, almost no research has examined ethics in this complex care environment. In this article, we draw on and synthesize existing theory, research, and practice knowledge to offer a conceptual model and discuss case examples that highlight everyday ethical issues in AL. We conceptualize the moral decision-making process and hence the moral landscape of AL, as influenced by a myriad of multi-level factors that shape interpersonal encounters and decision-making involving residents and their care partners, which ultimately shape individuals' actions and experiences in the setting. We conclude by discussing implications for research, policy, and practice.

Meaningful Engagement Among Assisted Living Residents With Dementia: Successful Approaches.

Meaningful engagement is an important dimension of quality of life and care for persons living with dementia, including the growing number who reside in assisted living communities. This report presents preliminary findings from an ongoing qualitative study aimed at identifying best care practices to create and maintain meaningful engagement among persons with dementia. Over a 1-year period, we conducted interviews, residents' record review, and participant observations in four diverse care communities. Our analysis identified four approaches that successfully promote meaningful engagement: (a) knowing the person, (b) connecting with and meeting people where they are, (c) being in the moment, and (d) viewing all encounters as opportunity. Incorporation of these approaches in care routines and adoption by all care partners can promote meaningful engagement, including during crises such as COVID-19.

Constructing Recovery Narratives: Experiences and Expectations Following Spinal Cord Injury.

PURPOSE: This study aimed to explore how married individuals construct narratives following spinal cord injury (SCI). DESIGN: Prospective qualitative study. METHODS: Eighteen married people with SCI were recruited during inpatient hospitalization. In-depth interviews were conducted at approximately 1, 4, and 7 months post-SCI. Interviews were analyzed using thematic analysis. FINDINGS: Participants constructed three primary narrative types (optimistic, anxious, and stability) about their trajectories following SCI, focusing on their expectations about recovery and their past and current experiences with their spouse, peers, and health professionals. These narrative types are the foundation for understanding how people make sense of the rehabilitation experience in relation to others. CONCLUSIONS: Findings provide an initial understanding of how expectations of life with SCI as well as social interactions in the healthcare setting influence experiences of injury and recovery. CLINICAL RELEVANCE: Findings can inform future interventions during SCI rehabilitation to ease transitions and decrease anxiety following SCI.

Complexity of care: Stressors and strengths among low-income mother-daughter dyads.

Research on informal care for older adults tends to consider middle- and upper-class individuals. Consequently, less is known about caregiving among low-income families. We present findings from an exploratory qualitative study of low-income African American mothers (n = 5) and their caregiving daughters (n = 5). Guided by a feminist framework, we consider how individual, familial, and societal factors contribute to the intersectional complexities of caregiving. Despite the unavailability of formal resources, we found the 10 women positive in their outlook. Furthermore, this study contributes to a growing body of research that identifies both negative and positive aspects of caregiving among an underrepresented population.

Negotiating the Lack of Intimacy in Assisted Living: Resident Desires, Barriers, and Strategies.

Despite continuity in the desire for sex and partnership, many older adults experience a lack of intimacy in late life. The use of assisted living is a complicating factor for understanding issues of partnership, sex, and intimacy for older adults. Using in-depth interviews with 23 assisted living residents and grounded theory methods, we examined how residents negotiate a lack of intimacy in assisted living. The process of negotiation entailed three factors: desire, barriers, and strategies. Although some residents continued to desire intimacy, there was a marked absence of dating or intimacy in our study sites. Findings highlight unique barriers to acting on desire and the strategies residents used as aligning actions between desire and barriers. This research expands previous studies of sexuality and older adults by examining the complex ways in which they balanced desire and barriers through the use of strategies within the assisted living environment.

Resisting ethnic inequities in advanced breast cancer: a call to action.

Maori women with advanced breast cancer are less than half as likely as their Pakeha counterparts to reach the five-year survival mark. We argue that this inequity is unacceptable. We trace the inequity back to i) inadequate screening and risk assessment, ii) lack of support for patient navigation, iii) failure to offer accessible state-of-the-art treatments, and iv) delays in receiving life-prolonging care. We posit that each of these factors is a site of institutional racism and privilege as they cause Maori women to experience significantly worse outcomes than non-Maori. In the active pursuit of justice, cancer survivors, women living with cancer and their supporters across the country have been engaging in passionate advocacy to address inequities. As the Ministry of Health develops a new cancer control plan, in this viewpoint opinion piece, we seek to amplify these distressing inequities and offer evidence-based recommendations to improve the quality of care and ultimately survival rates. Breast cancer inequities are modifiable. We recommend prioritising breast cancer screening and risk assessments for Maori women, reducing treatment delays, providing Maori-centered patient navigation, increasing funding for treatments and drugs to align with the OECD standard of care, and holding health providers accountable for ethnic inequities. We call on policy makers drafting the new cancer control strategy, and those working across the cancer continuum, to take action to improve breast cancer outcomes so Maori women will gain valuable life-years.

Maneuvering Together, Apart, and at Odds: Residents' Care Convoys in Assisted Living.

Objectives: Frail and disabled individuals such as assisted living residents are embedded in "care convoys" comprised of paid and unpaid caregivers. We sought to learn how care convoys are configured and function in assisted living and understand how and why they vary and with what resident and caregiver outcomes. Method: We analyzed data from a qualitative study involving formal in-depth interviews, participant observation and informal interviewing, and record review. We prospectively studied 28 residents and 114 care convoy members drawn from four diverse assisted living communities over 2 years. Results: Care convoys involved family and friends who operated individually or shared responsibility, assisted living staff, and multiple external care workers. Residents and convoy members engaged in processes of "maneuvering together, apart, and at odds" as they negotiated the care landscape routinely and during health crises. Based on consensus levels, and the quality of collaboration and communication, we identified three main convoy types: cohesive, fragmented, and discordant. Discussion: Care convoys clearly shape care experiences and outcomes. Identifying strategies for establishing effective communication and collaboration practices and promoting convoy member consensus, particularly over time, is essential to the creation and maintenance of successful and supportive care partnerships.

"That Is So Common Everyday . . . Everywhere You Go": Sexual Harassment of Workers in Assisted Living.

In assisted living (AL) facilities, workers are intimately involved in the lives of residents. Existing research on AL demonstrates the imbalance of this environment, which is a personal home for the residents and a workplace for staff. Using observational and interview data collected from six AL facilities, this grounded theory project analyzes how AL staff define, understand, and negotiate sexual comments, joking, and physical touch. We developed a conceptual model to describe how such harassment was perceived, experienced by AL workers, and how they responded. Sexualized behavior or harassment was experienced by workers of every status. We found that words and actions were contextualized based on resident and worker characteristics and the behavior. Staff members refused to engage residents, redirected them, or reframed the words and gestures to get the job done. Reporting the incidents was less common. We conclude by discussing implications for policy and research.

Teaching dementia care to physical therapy doctoral students: A multimodal experiential learning approach.

As the population aged 65 and older grows, it becomes imperative for health care providers to expand their knowledge regarding geriatric conditions and concerns. Dementia is a devastating degenerative disease process that is affecting millions of individuals in the United States, with significant economic and emotional burden on family and caregivers. The need for further dementia education in physical therapy school is essential to improve attitudes and treatment that affect patient outcomes and quality of care. This physical therapy program implemented a 12-hour multimodal experiential learning module designed to educate their students on the challenges associated with dementia to increase knowledge and confidence when treating these patients. The results of this study showed statistically significant improvements in overall confidence and knowledge of treating patients with dementia. The study finds the addition of experiential learning to traditional didactic coursework improves students' reported confidence in working with patients with dementia and understanding the challenges associated with treating patients with dementia.

Understanding Sexual Freedom and Autonomy in Assisted Living: Discourse of Residents' Rights Among Staff and Administrators.

OBJECTIVES: In contrast to nursing homes, assisted living (AL) facilities emphasize independence and autonomy as part of their mission. However, we do not know to what extent this extends to sexual freedom and autonomy. METHOD: Using grounded theory methodology and symbolic interactionism, we examine how staff and administrators in AL facilities discuss residents' rights to sexual freedom and how this influences the environment of AL. RESULTS: Staff and administrators engage in a contradictory discourse of residents' rights that simultaneously affirms the philosophy of AL while behaving in ways that create an environment of surveillance and undermine those rights. DISCUSSION: A discourse of residents' rights masks a significant conflict between autonomy and protection in regards to sexual freedom in AL.

Exposing the Backstage: Critical Reflections on a Longitudinal Qualitative Study of Residents' Care Networks in Assisted Living.

In this article, we analyze the research experiences associated with a longitudinal qualitative study of residents' care networks in assisted living. Using data from researcher meetings, field notes, and memos, we critically examine our design and decision making and accompanying methodological implications. We focus on one complete wave of data collection involving 28 residents and 114 care network members in four diverse settings followed for 2 years. We identify study features that make our research innovative, but that also represent significant challenges. They include the focus and topic; settings and participants; scope and design complexity; nature, modes, frequency, and duration of data collection; and analytic approach. Each feature has methodological implications, including benefits and challenges pertaining to recruitment, retention, data collection, quality, and management, research team work, researcher roles, ethics, and dissemination. Our analysis demonstrates the value of our approach and of reflecting on and sharing methodological processes for cumulative knowledge building.

Knock-down of transcript abundance of a family of Kunitz proteinase inhibitor genes in white clover (Trifolium repens) reveals a redundancy and diversity of gene function.

The transcriptional regulation of four phylogenetically distinct members of a family of Kunitz proteinase inhibitor (KPI) genes isolated from white clover (Trifolium repens; designated Tr-KPI1, Tr-KPI2, Tr-KPI4 and Tr-KPI5) has been investigated to determine their wider functional role. The four genes displayed differential transcription during seed germination, and in different tissues of the mature plant, and transcription was also ontogenetically regulated. Heterologous over-expression of Tr-KPI1, Tr-KPI2, Tr-KPI4 and Tr-KPI5 in Nicotiana tabacum retarded larval growth of the herbivore Spodoptera litura, and an increase in the transcription of the pathogenesis-related genes PR1 and PR4 was observed in the Tr-KPI1 and Tr-KPI4 over-expressing lines. RNA interference (RNAi) knock-down lines in white clover displayed significantly altered vegetative growth phenotypes with inhibition of shoot growth and a stimulation of root growth, while knock-down of Tr-KPI1, Tr-KPI2 and Tr-KPI5 transcript abundance also retarded larval growth of S. litura. Examination of these RNAi lines revealed constitutive stress-associated phenotypes as well as altered transcription of cellular signalling genes. These results reveal a functional redundancy across members of the KPI gene family. Further, the regulation of transcription of at least one member of the family, Tr-KPI2, may occupy a central role in the maintenance of a cellular homeostasis.

Responses of 9 lepidopteran species to Bacillus thuringiensis: How useful is phylogenetic relatedness for selecting surrogate species for nontarget arthropod risk assessment?

To evaluate phylogenetic relatedness as a proxy for susceptibility to Bacillus thuringiensis (Bt) when selecting species to act as surrogates for others in prerelease testing, we examined the responses of 11 laboratory-reared lepidopteran colonies, comprising members of 2 families, 5 genera, and 9 species, to a commercial Bt preparation. Survival, pupal mass, and timing of pupation and adult emergence of 2 noctuids (Spodoptera litura and Helicoverpa armigera) and 7 tortricids (Cnephasia jactatana, Ctenopseustis obliquana, Ctenopseustis herana,Planotortrix octo, Planotortrix notophaea,Planotortrix excessana [2 different laboratory colonies], and Epiphyas postvittana [2 colonies]) were examined after feeding first instar larvae with artificial diet containing 5 µL/100 mL Dipel ES (Bt subsp. kurstaki). Bt caused significant larval mortality in all species except S. litura, in which only pupation was delayed compared with untreated controls. Neither of the noctuid species tested would act as a suitable surrogate for the other in tests of Bt impacts on survival. With the exception of the 2 colonies of E. postvittana, which differed from each other not only in their responses to Bt but also in their development times when not treated with Bt, species within each tortricid genus had similar responses to Bt and thus could act as surrogates for each other. Members of different genera within this family could represent each other only if relatively coarse measurement endpoints (e.g., toxic or not) were considered adequate for assessing risks to nontarget species in the field.