Accuracy and bias of licensed practical nurse and nursing assistant ratings of nursing home residents' pain.

BACKGROUND: This study evaluated the accuracy of licensed practical nurses' (LPN) and nursing assistants' (NA) Minimum Data Set (MDS) pain ratings of nursing home residents and evaluated the bias in pain ratings associated with residents' race, gender, mental status, function, depression, or disruptive behavior. METHODS: Data were obtained on the same day directly from residents, LPNs, and NAs by trained interviewers in two safety-net nursing homes. A total of 252 residents were included in this study: 79% were Black, and 60% were men. MDS items J2a and J2b evaluated pain frequency and pain intensity during the last 7 days (weekly pain frequency and weekly pain intensity). A parallel question evaluated pain intensity on the day of the interview (daily pain intensity). MDS data were obtained for the MDS Cognition Scale, the MDS Activities of Daily Living-Long Form Scale, the MDS Depression Rating Scale, and the MDS Disruptive Behavior Scale. RESULTS: Kappa coefficients documented fair to good resident-LPN (K =.70,.56, and.50) and resident-NA (K =.72,.58, and.60) agreement for weekly pain frequency, weekly pain intensity, and daily pain intensity ratings. LPNs and NAs underestimated residents' weekly pain frequency (p <.001 for LPNs, and p <.001 for NAs), weekly pain intensity (p <.001 for LPNs, and p <.001 for NAs), and daily pain intensity (p <.001 for LPNs, and p =.002 for NAs). LPNs underestimated weekly and daily pain intensity more than NAs did (p =.016 for weekly pain intensity, and p =.035 for daily pain intensity). LPN and NA pain ratings were not biased by resident race, gender, mental status, function, depression, or disruptive behavior. CONCLUSIONS: Results documented that (i) LPNs and NAs underestimated residents' pain frequency and pain intensity, (ii) NAs were more accurate than LPNs for pain intensity, and (iii) resident characteristics did not bias LPN or NA pain ratings.

Stability of performance of activities of daily living using the MDS.

The Minimum Data Set (MDS) requires assessment of performance of activities of daily living (ADLs) by newly admitted nursing home residents over all shifts for a 7-day period, for a total of 21 assessments. This study evaluated within-subject equivalence of multiple assessments of 42 residents' admission MDS ADL performance. Friedman two-way analysis of variance for ranks documented no significant within-subject differences among repeated measurements for all 13 MDS ADL variables. Thus, fewer than 21 assessments may accurately assess ADL performance.

Comprehensive care: the healthcare provider's perspective.

A paradigm shift, or change in worldview, is currently occurring in which clients are being comprehensively viewed within the environmental context. This shift addresses both mind and body in client care and views healthcare providers as part of the environment. Wound care specialists can refine and extend their practice by: a) using concepts from comprehensive care and holistic nursing, b) focusing on the outcome and process of delivering care, and c) caring for themselves in a comprehensive manner. This article describes the author's development as a comprehensive and holistic healthcare provider and the impact of comprehensive care on her practice.

Biobehavioral effects of therapeutic touch.

PURPOSE: To document immediate and short-term biobehavioral effects of therapeutic touch (TT), estimate the magnitude of TT effects, and compare TT effects to placebo responses. DESIGN: A repeated measures, pretest-posttest quasi-experimental design. TT and mimic TT were administered using standardized protocols to 11 adults in a controlled setting. METHODS: Four physiological (total pulse amplitude, blood pressure, pulse, temperature) and three subjective (stress, self-assessment of health, time perception) variables were evaluated over 24 hours. FINDINGS: Total pulse amplitude and time perception decreased significantly immediately after TT intervention, indicating vasoconstriction and time passing "faster," with large and medium effect sizes significantly greater than were placebo responses. Vasodilation, a relaxation response, was expected instead of vasoconstriction. CONCLUSIONS: TT may have adverse and positive outcomes.

Determinants of health-related hardiness among urban older African-American women with chronic illnesses.

A systematic probability sample of 100 community-living older African-American women with chronic illnesses was evaluated during clinic visits to an urban safety-net hospital to explore health and demographic factors predictive of health-related hardiness (HRH). Questionnaires on HRH, function, self-assessed health, morbidity, health behavior, and selected demographics were used for collection of data. Multiple linear regression analyses ascertained that years of education and function explained 20% of the variance in HRH. Findings raise issues regarding validity of HRH prediction models and the cultural appropriateness of current methods of assessing HRH in older African-American women.

The experience of living-dying in a nursing home: self-reports of black and white older adults.

PURPOSE: The purpose of this study was to describe and compare the experiences, needs, priorities, and concerns reported by black and white nursing home residents during the living-dying interval. The living-dying interval is defined as the time between the knowledge of one's impending death and death itself. DESIGN: This qualitative study was part of a larger ethnographic project. Residents participated in from one to four individual, in-depth, semi-structured, audiotaped interviews. SETTING: Residents lived in two large county-financed nursing homes that have historically provided care to indigent black and white older adults. PARTICIPANTS: Purposive sampling was used to identify eight black and five white residents with terminal cancer diagnoses who could serve as rich resources about the experience of living-dying in a nursing home. MEASURES: Residents were asked open-ended questions about how things have been and what would make things better; what comforts them and would make them more comfortable; what dying means to them; and what things are important for nursing staff to know. RESULTS: Verbatim transcripts of the interviews were coded using QRS NUD-IST software. Codes were placed in categories, categories were reviewed for common and different concepts, themes, and patterns, and a conceptual model was developed. The model identified six care needs: (1) day-to-day living; (2) inadequate pain relief for black residents; (3) difficulty chewing and swallowing; (4) importance of religious activities; (5) giving care to others; and (6) appreciation of respectful and prompt care. Residents validated all components of the conceptual model. CONCLUSION: Black and white terminally ill residents focused on the quality of living rather than on dying, and black residents may be undertreated for pain. Important care needs for pain and religion are not routinely addressed by the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) triggers.

Accuracy of nurse aides' functional health assessments of nursing home residents.

BACKGROUND: Nurse aides provide assessments of nursing home residents' functional health for use in care planning and quality assurance. Nurse practitioner assessments can serve as a standard for analysis of nurse aides' accuracy. This study compared nurse aide to nurse practitioner assessments of nursing home residents' functional health with regard to possible bias and extent of correlation. METHODS: Nurse aides' accuracy in assessing nursing home residents' activities of daily living was evaluated by comparisons to assessments performed by a master's-prepared nurse practitioner using four functional assessment instruments: the Barthel Index, the Katz Index of Activities of Daily Living, the Multidimensional Observation Scale for Elderly Subjects, and the Scaled Outcome Criteria. Data were collected in a 159-bed nonprofit nursing home licensed for skilled and intermediate care. Residents had a wide variety of functional and cognitive abilities and disabilities. Ninety-six nursing home residents provided data for the study. Functional health assessments by 24 nurse aides, each assessing 4 different nursing home residents, were compared to those of 1 nurse practitioner. Statistical analysis of accuracy used paired samples t-tests and Pearson product moment correlation coefficients. RESULTS: Nurse aide assessments and nurse practitioner assessments were highly correlated. Most functional health assessments evidenced no significant nurse aide bias. When bias was present it usually resulted from nurse aides electing more optimistic choices when using an assessment instrument that offered fewer response levels for rating residents. CONCLUSIONS: Nurse aides can accurately use well-calibrated instruments to assess nursing home residents' functional health. Demonstration of assessment accuracy in nurse aides, who provide the majority of direct care for nursing home residents, documented a valuable clinical resource for planning and evaluating resident care.

Health status gender differences of newly admitted black nursing home residents.

OBJECTIVES: To investigate gender differences in health status of newly admitted black nursing home residents on the day following admission. DESIGN: Descriptive and comparative cross-sectional study of black residents drawn from a larger prospective longitudinal study on health and functional status of new nursing home residents interviewed on the first full day after admission. SETTING: Eight southern nursing homes: three not-for-profit, three for-profit, one county government-operated, and one federal government-operated. Homes ranged in size from 110 to 575 beds and were licensed for skilled and intermediate care. PARTICIPANTS: Black nursing home residents (N = 224) aged 60 years and older as admitted sequentially to nursing homes. MEASUREMENTS: Health status was assessed by the Short Portable Mental Status Questionnaire, as a measure of mental status, and the Scaled Outcome Criteria, as a measure of ability to perform activities of daily living (ADLs). Morbidity was assessed by the number of medical diagnoses, number of prescribed medications, and the medical diagnoses of hip fracture, dementia, and cancer. Resident classification data assessed the source of entry to the nursing home, payer source, and level of care required. Demographic data assessed included age, education, marital status, and number of living children. RESULTS: Both black men (n = 126) and women (n = 98) newly admitted to the nursing home had health and social deficits. Moreover, women, although not significantly different from men in average age, were more impaired in six of eight ADLs, including grooming, dressing, feeding, ambulating, transferring, and defecating. Women were also less likely to be married. No gender differences were found for five other health status variables, four other demographic variables, five resident classification variables, or five measures of morbidity. CONCLUSION: These data on southern black nursing home residents provide evidence that among older black nursing home residents, women have greater care needs than men. Findings illustrate the need to consider gender in planning nursing home care of black older residents, black women may be at greater risk for health status alterations and require more frequent health status monitoring and intervention.

Admission health status differences of black and white indigent nursing home residents.

OBJECTIVE: To compare the health status of newly admitted lower socioeconomic status (SES) southern black (n = 81) and white (n = 53) nursing home residents. DESIGN: The study data were part of a larger prospective study on the health of newly admitted nursing home residents. SETTING: A 575-bed, government-funded nursing home providing care for indigent residents in a large southern city. PARTICIPANTS: Newly admitted black and white nursing home residents aged 60 and older. MEASUREMENTS: Mental status was measured using the Short Portable Mental Status Questionnaire, activities of daily living by Scaled Outcome Criteria, and medical status by medical diagnoses and medications. MAIN RESULTS: Blacks entering the nursing home were more cognitively and functionally impaired and had 3.7 years less education than white residents, but average age was not significantly different for black and white residents. CONCLUSIONS: Many common health status measures showed no significant black-white differences for institutionalized older adults when region and SES were constants. However, mental status, self-care activities, and marital status were significantly different. These findings indicate a possible impact of lifelong poverty or low educational attainment on the increased disability of indigent black older adults. Black residents in our study had less spousal support to remain in the community.

Black and white female nursing home residents: does health status differ?

BACKGROUND: There will be greater numbers of Black female nursing home residents in the future, but past emphasis has been on the study of Black older adults in the community. The purpose of this study was to assess the health status stability of newly admitted female nursing home residents and to analyze Black-White differences in health status and health status stability. METHODS: Health status (mental status, activities of daily living [ADLs], self-reported mood, self-reported health) of Black (n = 98) and White (n = 260) female nursing home residents was evaluated during their first two weeks of residence. Time, race, and their interaction effects on health status were analyzed using repeated measures multivariate analysis of variance. RESULTS: All health status data showed stability or improvement, but there were significant race differences in both health status and health status stability. Black female residents had worse mental status and worse ADLs, and reported less alert mood, less tired mood, and better health. Race differences in stability were evident for hygiene, dressing, ambulation, and transferring ADLs: Black female residents were less likely to show improvements over time. CONCLUSION: Black female residents are an at-risk population for special care needs in nursing homes.

Staff evaluation of nursing home residents' competence.

Nursing home staff members frequently screen residents for competence, but the ability to assess competence has received limited attention. This study compared staff members' competence assessments with residents' (N = 100) mental status, measured by the Short Portable Mental Status Questionnaire (SPMSQ), and examined information used by staff to evaluate residents' competence. Staffers' evaluation of competence was significantly correlated with resident SPMSQ score. Staffers used information about orientation, alertness, and verbal function, with little consideration of decision making ability and mental status.

Predictors of patient-perceived quality.

Larrabee's model of quality proposes a relationship between quality and value. This study tested the relationship by identifying predictors of patient-perceived quality for nursing care. Data were obtained from interviews and records of 199 adult patients. Candidate predictors of patient-perceived quality included patient goal achievement, nurse-perceived quality, and nurse goal achievement. Candidate predictors also included seven demographic, seven financial, six illness, and six hospital variables. Predictors of both patient-perceived quality global and patient-perceived quality total were pain severity on exit interview, clinic referral, unit, and patient goal achievement. Medicare nonrecipient was a predictor of patient-perceived quality global. Worry score on admission was a predictor of patient-perceived quality total. The results support the relationship between quality and value and between quality and beneficence postulated by Larrabee's model of quality. Additional investigation of these relationships in other populations and using other operationalizations of the model concepts is needed to provide further support for the model. This model is potentially useful for investigating quality in diverse cultures because the operationalization of the model concepts can be designed to reflect local, regional, or national values.

Predicting outcomes of nursing home residents: death and discharge home.

The purpose of this study was to document prevalence, identify leading indicators, and develop and assess prediction models for nursing home resident outcomes (death, discharge home). New residents (N = 647) in eight nursing homes were evaluated on admission and 3 and 6 months later. Predictor variables tested included 14 health status variables, 5 demographic variables, and 6 other resident and nursing home variables. A cancer diagnosis was the most important risk factor for death at 3 months (OR = 8.0) and 6 months (OR = 10.8). A first nursing home admission was the most important risk factor for discharge to home at 3 months (OR = 9.5) and 6 months (OR = 13.9). Not having a dementia diagnosis was the second most important risk factor for discharge to home at 3 months (OR = 5.8) and 6 months (OR = 4.2). All prediction models demonstrated useful potential for clinical application.

Stability and improvement of health after nursing home admission.

This prospective study investigated stability of residents' mental status, function (activities of daily living), and mood during the first and second week following nursing home admission. New residents (N = 647) in eight urban nursing homes were assessed three times. Mental status was measured using the Short Portable Mental Status Questionnaire, function was measured using Scaled Outcome Criteria, and mood was measured using the Mood Adjective Checklist. A repeated measures multivariate analysis of variance, controlling for admission from hospital and readmission to the nursing home, documented stable mental status during the first and second week of nursing home residence. Hygiene, grooming, dressing, and transferring improved, whereas feeding, ambulation, urination, and defecation were stable. Tired and depressed mood adjectives improved, and angry, cheerful, afraid, lonely, and alert mood adjectives were stable. Residents admitted from a hospital had lower mental status and function scores, and readmitted residents had lower urination scores.

Prevalence and predictors of regularly scheduled prescription medications of newly admitted nursing home residents.

OBJECTIVE: The purpose of this study was to identify the prevalence and predictors of commonly prescribed regularly scheduled medications. DESIGN: Data were collected on the first day following nursing home admission in this non-experimental study. SETTING: A stratified, proportional probability sample of eight nursing homes in a large Mid-South city participated in this study. PARTICIPANTS: A consecutive sample of 574 new and readmitted nursing home residents who did not refuse participation. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Data were collected on regularly scheduled prescription medications and resident and nursing home characteristics. RESULTS: Residents without a diagnosis of dementia were more likely to receive cardiovascular medications (Odds Ratio = 2.34; 95% CI = 1.56-3.49), and white residents were more likely to receive cardiovascular medications (Odds Ratio = 1.74; 95% CI = 1.19-2.53) or central nervous system medications (Odds Ratio = 1.72; 95% CI = 1.18-2.51). Older residents were less likely to receive central nervous system medications (Odds Ratio = 0.97 per year; 95% CI = 0.96-0.99), and females were more likely to receive cardiovascular medications (Odds Ratio = 1.89; 95% CI = 1.30-2.75). CONCLUSIONS: Resident characteristics were the most important predictors for cardiovascular and central nervous system medication prescriptions of new and readmitted nursing home residents.

Meta-analysis for the refinement of gerontological nursing research and theory.

A meta-analysis review of literature addresses concerns such as inclusion and exclusion criteria for articles in the meta-analysis and seeks potentially biasing effects of sample size and characteristics, measurement of variables, type of design, and analytic techniques. Whereas the narrative review of literature provides direction by identifying potential variables and relationships of concern, meta-analysis quantifies those relationships by integrating findings and providing explicit direction for research, practice, and theory development. Despite its strengths for quantitatively integrating study results, meta-analysis is time consuming, labor intensive, and may omit other sources such as case studies, historical and qualitative research, and clinical decision making.

Meta-analysis techniques.

The three elements of meta-analysis include exact specification of sources from which primary studies are identified; transformation of primary study findings to a common metric; and statistical analysis of primary study findings. Meta-analysis has several drawbacks, such as dependence on the quality of the reporting of primary analysis findings; dependence on sufficient numbers of eligible studies to justify statistical analysis; a lack of a universal common metric; and a lack of expert agreement about the best form of statistical analysis. As researchers become more familiar with meta-analysis, two effects will be seen: an increased use of meta-analysis elements in all review of literature, and increased attention to reporting important details of research in scientific journals.