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.

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.].

Delirium superimposed on dementia in post-acute care: Nurse documentation of symptoms and interventions.

Delirium superimposed on dementia (DSD) is common in older adults being discharged to post-acute care settings (PAC). Nurse documentation remains poorly understood. Aims were to describe nurse documentation and to determine associations in a secondary data analysis of a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve For DSD). Just under 75% of the sample had at least one symptom of delirium documented by the nursing staff, while 25.9% had none despite being CAM positive by expert adjudication. Only 32% had an intervention documented. Number of documented interventions were significantly associated with number of documented symptoms. There is a need for research and innovation related to nurse documentation and communication of DSD symptoms and interventions in an efficient and accurate manner to impact care for vulnerable older adults in these settings.

Using Appreciative Inquiry to Optimize a Person-Centered Care Training Program for Clinical Champions in Rural Critical Access Hospitals.

Person-centered care (PCC) involves shared decision-making between the individual and provider and is widely recognized as the gold standard of care. However, not all organizations have successfully implemented PCC, especially those in rural settings with limited resources. Implementation strategies, such as clinical champions, are key to PCC uptake. The purpose of the current article is to illustrate how Appreciative Inquiry, a strengths-based framework for transformational change, can be used to optimize a successful PCC champion training program. Appreciative Inquiry employs the quality improvement processes of (a) define, (b) discover, (c) dream, (d) design, and (e) deliver/destiny. Using Appreciative Inquiry, we were able to identify three new long-term goals and add supporting features to an existing champion training program. The methods developed herein could be implemented by researchers and evidence-based practice councils to improve the care of older adults in any care setting to make it more person-centered. [Journal of Gerontological Nursing, 47(8), 7-12.].

Use of an expert panel to identify domains and indicators of delirium severity.

PURPOSE: Our purpose was to create a content domain framework for delirium severity to inform item development for a new instrument to measure delirium severity. METHODS: We used an established, multi-stage instrument development process during which expert panelists discussed best approaches to measure delirium severity and identified related content domains. We conducted this work as part of the Better ASsessment of ILlness (BASIL) study, a prospective, observational study aimed at developing and testing measures of delirium severity. Our interdisciplinary expert panel consisted of twelve national delirium experts and four expert members of the core research group. Over a one-month period, experts participated in two rounds of review. RESULTS: Experts recommended that the construct of delirium severity should reflect both the phenomena and the impact of delirium to create an accurate, patient-centered instrument useful to interdisciplinary clinicians and family caregivers. Final content domains were Cognitive, Level of consciousness, Inattention, Psychiatric-Behavioral, Emotional dysregulation, Psychomotor features, and Functional. Themes debated by experts included reconciling clinical geriatrics and psychiatric content, mapping symptoms to one specific domain, and accurate capture of unclear clinical presentations. CONCLUSIONS: We believe this work represents the first application of instrument development science to delirium. The identified content domains are inclusive of various, wide-ranging domains of delirium severity and are reflective of a consistent framework that relates delirium severity to potential clinical outcomes. Our content domain framework provides a foundation for development of delirium severity instruments that can help improve care and quality of life for patients with delirium.

Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings.

The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

A Tailored Intervention for PAP Adherence: The SCIP-PA Trial.

OBJECTIVE/BACKGROUND: Positive airway pressure (PAP) is highly efficacious treatment but nonadherence is prevalent with little improvement over the last 15 years. Tailored interventions show promise for promoting adherence to other treatments. The study objective was to examine feasibility and acceptability of a tailored intervention to promote PAP adherence. PARTICIPANTS: The convenience sample met inclusion criteria: newly diagnosed OSA; treatment-naïve; ≥ 18 years. EXCLUSION CRITERIA: previous obstructive sleep apnea (OSA) diagnosis and treatment; new psychiatric diagnosis; use of oxygen/bilevel PAP; secondary sleep disorder. Adults (n = 118) were randomized to tailored intervention (TI; n = 61) or usual care (UC; n = 57); application of a priori exclusion criteria resulted in 30 participants per assignment who were middle-aged (51.3 ± 11.1 years) adults (70% male) with severe OSA (apnea hypopnea index [AHI], 35.9 ± 25.2). METHODS: Randomized, double-blind, single-site pilot controlled trial. A multiphased tailored intervention targeting social cognitive perceptions of OSA-PAP treatment was delivered at four intervals. Descriptive analysis, group differences, and self-efficacy change scores by t-test, and thematic analysis of acceptability data are reported. RESULTS: One-week PAP use among TI was 35 min greater than UC condition (p = 0.20; Cohen's d = 0.336). Treatment use decreased at 1 month and 3 months (NS). Per-protocol delivery of face-to-face intervention delivery was 100% but lower for telephone intervention delivery. Personalized approach was valued by participants. CONCLUSIONS: A tailored intervention approach is acceptable to participants and feasibly implemented in a clinical sleep center setting. The intervention effect size at 1 week is consistent with other educational PAP adherence interventions but was not sustained; further pilot testing is warranted to address pilot RCT limitations.

Randomised clinical trial: Efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care.

OBJECTIVES: The purpose of this study was to test the efficacy of MOUTh (Managing Oral Hygiene Using Threat Reduction), a nonpharmacologic, relationship-based intervention vs. control on 2 primary outcomes for nursing home (NH) residents with dementia who resisted mouth care: (i) reduction in the occurrence and intensity of care-resistant behaviours (CRBs) and (ii) improvement in oral health. Two secondary outcomes were also examined: (i) the duration of mouth care and (ii) the completion of oral hygiene activities. BACKGROUND: Persons with dementia who exhibit CRBs are at risk for inadequate mouth care and subsequent systemic illnesses. MATERIALS AND METHODS: The study used a randomised repeated measures design. Recruitment occurred in 9 nursing homes that varied in size, ownership, reimbursement patterns and location. One hundred and one nursing home residents with dementia were randomised at the individual level to experimental (n = 55) or control groups (n = 46). One hundred participants provided data for the analyses. RESULTS: Compared to the control group, persons in the experimental group had twice the odds of allowing mouth care and completing oral hygiene activities; they also allowed longer duration of mouth care (d = 0.56), but showed only small reductions in the intensity of CRBs (d = 0.16) and small differential improvements in oral health (d = 0.18). CONCLUSION: The data suggest that this intervention facilitates mouth care among persons with dementia. The management of refusal behaviour may be a clinically more realistic approach than reducing or eradicating refusals.

When study participants are vulnerable: getting and keeping the right team.

BACKGROUND: Research assistants (RAs) are critical members of all research teams. When a study involves vulnerable populations, it is particularly important to have the right team members. AIM: To describe the motivations, personal characteristics and team characteristics that promoted the job satisfaction of RAs who worked on two multi-year, randomised clinical trials involving older adults with dementia. DISCUSSION: A survey was conducted with 41 community members who worked as RAs for up to five years. Measures included demographics, work engagement, personality and characteristics of effective teams, as well as open-ended questions about respondents' experiences of the study. Quantitative analyses and coding of open-ended responses were used to summarise results. Almost all the RAs surveyed joined the team because of previous experiences of interacting with cognitively impaired older people. The RA respondents scored higher in 'dedication to work', 'extraversion', 'agreeableness' and 'conscientiousness' than average. An important aspect of their job satisfaction was team culture, including positive interpersonal interaction and the development of supportive team relationships. CONCLUSION: A positive work culture provides RAs with an opportunity to work with a study population that they are personally driven to help, and promotes motivation and satisfaction in team members. IMPLICATIONS FOR PRACTICE: Results from this study can guide the recruitment, screening and retention of team members for studies that include vulnerable populations.

Implementing Nurse-Facilitated Person-Centered Care Approaches for Patients With Delirium Superimposed on Dementia in the Acute Care Setting.

Little is understood about the use of person-centered care (PCC) for individuals with delirium superimposed on dementia (DSD), especially in the acute care setting. As part of a larger clinical trial, the purpose of the current exploratory study was to describe examples and qualitatively derived themes of nurse-facilitated PCC for hospitalized older adults with dementia and delirium. A total of 750 delirium rounds were analyzed across three diverse acute care sites. Qualitative derived themes of PCC included: (a) Knowing the Patient's Baseline; (b) Knowing the Patient's Interests and Values; (c) Enhancing Sensory Abilities to Communicate; (d) Individualizing Cognitive Stimulation; and (e) Enhancing Behavioral Approaches to Comfort and Sleep. Barriers included failure to see the patient as an individual and lack of time. Principles of PCC were effectively used, demonstrating the potential for PCC to ease the burden of DSD for all members of the health care team. [Journal of Gerontological Nursing, 43(12), 21-28.].

Revising the Resistiveness to Care Scale.

BACKGROUND AND PURPOSE: The Resistiveness to Care Scale for Dementia of the Alzheimer's Type was developed to quantify care-resistant behavior. The purpose of this article is to explain how the instrument was modified and tested in two clinical studies that examined interventions to improve the oral hygiene of persons with dementia who resist care. METHODS: After pilot testing, the revised instrument (RTC-r) was used in 7 facilities (N = 83 residents). Systematic training procedures were implemented to preserve reliability. RESULTS: Clinical validity was confirmed throughout the pilot and interventional studies. Reliability was assessed using inter-rater reliability, which ranged from 0.87 (p < .001) to 1.0 (p < .001) across 2,328 mouth care observations. CONCLUSIONS: The RTC-r validly and reliably measures care-resistant behavior in persons with dementia.

Measuring agreement between healthcare survey instruments using mutual information.

BACKGROUND: Healthcare researchers often use multiple healthcare survey instruments to examine a particular patient symptom. The use of multiple instruments can pose some interesting research questions, such as whether the outcomes produced by the different instruments are in agreement. We tackle this problem using information theory, focusing on mutual information to compare outcomes from multiple healthcare survey instruments. METHODS: We review existing methods of measuring agreement/disagreement between the instruments and suggest a procedure that utilizes mutual information to quantitatively measure the amount of information shared by outcomes from multiple healthcare survey instruments. We also include worked examples to explain the approach. RESULTS: As a case study, we employ the suggested procedure to analyze multiple healthcare survey instruments used for detecting delirium superimposed on dementia (DSD) in community-dwelling older adults. In addition, several examples are used to assess the mutual information technique in comparison with other measures, such as odds ratio and Cohen's kappa. CONCLUSIONS: Analysis of mutual information can be useful in explaining agreement/disagreement between multiple instruments. The suggested approach provides new insights into and potential improvements for the application of healthcare survey instruments.

Maturation of the MOUTh Intervention: From Reducing Threat to Relationship-Centered Care.

The purpose of the current article is to describe a personalized practice originally conceived as a way to prevent and minimize care-resistant behavior to provide mouth care to older adults with dementia. The original intervention, Managing Oral Hygiene Using Threat Reduction Strategies (MOUTh), matured during the clinical trial study into a relationship-centered intervention, with emphasis on developing strategies that support residents' behavioral health and staff involved in care. Relationships that were initially pragmatic (i.e., focused on the task of completing mouth care) developed into more personal and responsive relationships that involved deeper engagement between mouth care providers and nursing home (NH) residents. Mouth care was accomplished and completed in a manner enjoyable to NH residents and mouth care providers. The MOUTh intervention may also concurrently affirm the dignity and personhood of the care recipient because of its emphasis on connecting with older adults.

What it takes: perspectives from developing nurse scientists.

The need for nurse scientists has never been greater, given the complexity of health problems facing our world and the rising cost of providing care to prevent and treat them. The development of nurse researchers is critical to preserve and advance the scientific foundation of the discipline. In this article, two successful doctoral students present their personal views about the cognitive and behavioral transformation they experienced during their program of study, highlighting what they believe to be important resources that enhance doctoral education and sharing how they overcame the challenges encountered. The framework of transformational leadership is used to highlight important aspects of their development as nurse scientists. Action steps for attracting a greater number of nurses to a career in science are recommended.

Gender differences in factors associated with delirium severity in older adults with dementia.

The purpose of this descriptive correlational study was to explore potential gender differences in the relationship of dementia severity, age, APOE status, cognitive reserve and co-morbidity (two potentially modifiable factors), to delirium severity in older adults. Baseline data from an ongoing clinical trial and a Poisson regression procedure were used in the analyses. Participants were 148 elderly individuals with dementia and delirium admitted to post-acute care. In women, delirium severity was related to dementia severity (p=0.002) and co-morbidity moderated that effect (p=0.03). In men, education was marginally associated with delirium severity (p=0.06). Implications for research are discussed.