Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research.

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

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.].

Toward harmonization of strategies for investigating lucidity in AD/ADRD: A preliminary research framework.

Episodes of lucidity (ELs) in Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD), have garnered increasing attention as an important area of research. Efforts to study lucidity suffer from a lack of clear definitional criteria, inconsistent conceptualization, and diverse approaches to operationalizing features of these events. To advance systematic investigation of ELs in AD/ADRD, there is a need for clarity and precision in labeling event attributes, markers, and specific measurement strategies that enable operational harmonization across distinct approaches to investigating the relatively broad and nascent phenomenon. To that end, we propose a preliminary research framework to guide harmonization of approaches to investigating ELs in AD/ADRD. Our goal is to provide an initial schematic that encourages uniform labeling of operational decisions about ELs.

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.

Testing the Reliability and Validity of the Revised Care Plan Checklist for Evidence of Person-Centered Care Approaches for Behavioral and Psychological Symptoms of Distress in Persons With Dementia.

The Checklist for Evidence of Person-Centered Care Approaches for Behavioral and Psychological Symptoms of Distress (BPSD) in Care Plans was developed to assess the person-centeredness of care plans for nursing home residents living with behavioral and psychological symptoms associated with dementia. The purpose of the current study was to evaluate the reliability and validity of a revised version of the Checklist. Data from a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD were used. One hundred seventy-nine care plans for 103 residents were examined. Descriptive statistics, Rasch analysis, and inter-rater reliability were used. The Checklist demonstrated evidence of inter-rater reliability and validity based on model fit and acceptable INFIT and OUTFIT statistics. This study serves as pilot work for future Checklist use and validation efforts on a larger scale. Findings encourage a discourse on the inclusion of BPSD and person-centered approaches in care plans for those living with dementia. [Research in Gerontological Nursing, 15(6), 303-311.].

Nursing Staff Perceptions of Outcomes Related to Honoring Residents' "Risky" Preferences.

Nursing homes (NHs) are challenged to consistently deliver person-centered care (PCC), or care based on residents' values and preferences. NH staff associate certain resident preferences with risk. However, there are limited evidence-based person-centered risk management strategies to assist NH staff with risky resident preferences. The purpose of the current study was to explore NH staff perceptions of health and safety outcomes associated with honoring NH residents' risky preferences to inform intervention development. This descriptive, qualitative study used sequential focus groups and content analysis, revealing that nursing staff perceive negative and positive outcomes for staff and residents when seeking to honor residents' risky preferences. This finding is supported by three themes: Potential Harms to Staff, Potential Harms to Residents, and Positive Shared Outcomes. These results contribute a set of nurse-driven quality of life and quality of care outcomes for NH staff and residents associated with PCC delivery in NHs. [Research in Gerontological Nursing, 15(6), 271-281.].

Person-centered assessment of apathy and resistance to care in people living with dementia: Review of existing measures.

Introduction: The review described in this paper builds upon the Dementia Care Practice Recommendations (DCPR) published by the Alzheimer's Association in 2018 and addresses behavior change and the need for targeted outcome measures that evolve from person-centered frameworks and help evaluate interventions. Apathy and resistance to care (RTC) are two specific behavioral expressions of unmet need or distress exhibited by people living with dementia, which are upsetting to formal and family caregivers and compromise quality of life for people living with dementia. Methods: We conducted literature searches of major databases (PsycInfo, PubMed, EBSCO, CINAHL) for papers examining apathy and RTC constructs in samples of people living with dementia. Reliability and validity coefficients were reviewed and reported, along with examination of whether each measure facilitates contextual understanding of behavior. Results: Three stand-alone measures of RTC and ten measures of apathy were identified and reviewed. The RTC measures demonstrated good psychometric properties but do not include the perspective of the person living with dementia or contextual aspects of the behavior. The identified apathy measures demonstrated fair to good psychometric properties, and although there is greater consideration of context, none adequately include the perspective of the person living with dementia. Discussion: Although reliable and valid measures have been developed to measure apathy and RTC in people living with dementia, there is greater need for conceptually driven measurement of behavior context and for tools that elicit and include the perspective of the person living with dementia.

The Making of Nurse Leaders in the Nursing Home.

Nurse leaders are first and foremost, registered nurses. Nursing leadership is critical for improving the care and quality of life for older adults. Visionary nurse leaders collaborate, motivate, influence, and inspire the achievement of values and goals to improve the quality of life for older adults in long-term care. Professional registered nurses are transformational servant nurse leaders who hold the key to nursing home reform.

Community Goal Setting and Attainment: Organizational Characteristics and Indicators of Staff Adoption.

In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [Journal of Gerontological Nursing, 48(5), 5-12.].

Evaluating implementation strategies to support documentation of veterans' care preferences.

OBJECTIVE: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. DATA SOURCES: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. STUDY DESIGN: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. DATA COLLECTION METHODS: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. PRINCIPAL FINDINGS: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). CONCLUSIONS: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.

The Relationship Between Pain, Function, Behavioral, and Psychological Symptoms of Dementia and Quality of Life.

BACKGROUND: This study evaluated the association between age, sex, comorbidities, cognition, and administration of opioids with pain and the impact of all of these variables plus function, agitation, resistiveness to care, and depression on quality of life among residents in nursing home with severe dementia. DESIGN: This was a descriptive study using baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia implementation study. METHODS: Model testing was done using structural equation modeling. The sample included 553 residents from 55 nursing homes with a mean age of 83.88 (standard deviation = 10.44) and mean Brief Interview of Mental Status of 4.30 (standard deviation = 3.50). RESULTS: There were significant associations showing those who were older, male, had fewer comorbidities, better cognition, and were black were more likely to have pain. Pain, in combination with the demographic and descriptive variables, explained 32% of the variance in function, 75% of the variance in depression, 88% of the variance in agitation, 98% of the variance in resistiveness to care, and 92% of the variance in quality of life. The model however did not show a good fit to the data. SETTING: The study was done in 55 nursing homes in Maryland and Pennsylvania. PARTICIPANTS/SUBJECTS: A total of 553 residents were included in the study. CONCLUSIONS: The model did not have a good fit with the data which likely was due to the lack of variance in outcomes. The hypothesized paths, with the exception of opioid use, were significant.

Gender Differences in Disease, Function, and Behavioral Symptoms in Residents with Dementia.

The purpose of this study was to consider gender differences in depressive symptoms, agitation, resistiveness to care, physical function, and use of psychotropic medications in older adults with moderate to severe dementia in nursing homes. Sixty-seven nursing homes and 889 residents from two states were included. The majority of the participants were female (n = 640, 72%) and White (n = 618, 70%) with a mean age of 86.58 years (SD = 10.31). Differences by gender with regard to age, physical function, depressive symptoms, agitation/aggression, and resistiveness to care were tested using multivariate analysis of variance. Older females with moderate to severe dementia present with more depressive symptoms (anxiety, sadness, and somatic complaints) than males. Males present with more aggressive behavior and are more likely to receive anticonvulsants. Caregivers should focus on preventing and managing depressive symptoms including anxiety, sadness, and somatic complaints among older females and aggressive behavior in older males with dementia.

12-month trajectory and predictors of affect balance in nursing home residents living with dementia.

Objectives:Emotional expressions in late-stage dementia have traditionally been studied within a deficit paradigm. Moving the narrative of the dementia trajectory from a solely negative pathological experience to one that acknowledges the potential for positive experiences aligns with international recommendations for living well with dementia. The purpose of this study was to extend prior research by examining the pattern of well-being using affect balance, the ratio of positive to negative affect, in nursing home residents living with dementia over 12 months and its association to factors that could potentially influence resident well-being.Method:This study was a secondary analysis of baseline, 4 and 12-month data from a pragmatic clinical trial. A total of 536 residents with moderate to severe cognitive impairments from 55 nursing homes were included in the multivariable linear mixed model regression analyses.Results:Resident function, the number of registered nurse hours devoted to care in the facility, and the quality of staff interaction predicted higher affect balance over time after controlling for other variables.Conclusion:The findings provide support for the utility of affect balance as a meaningful outcome measure of well-being for persons living with dementia. In addition, results point to specific interventions (i.e. maintaining/improving resident function, providing adequate nurse staffing levels, and improving staff communications skills) that can serve as the focus for both research and practice to help residents live well with dementia. Clinicaltrials.gov (NCT03014570).

Racial Disparities in Care Interactions and Clinical Outcomes in Black Versus White Nursing Home Residents With Dementia.

BACKGROUND: With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised. PURPOSE: The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months. METHODS: This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included. RESULTS: Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department. CONCLUSIONS: Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions.

Reliability and Validity of the Cornell Scale for Depression in Dementia and Invariance Between Black Versus White Residents in Nursing Homes.

OBJECTIVES: The purpose of this study was to expand on prior work testing invariance on several depression measures in community-based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia. DESIGN: This was a descriptive measurement study. SETTING AND PARTICIPANTS: This was a secondary data analysis using baseline data from 2 studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from 2 states and 889 residents were recruited. The mean age of the participants was 86.58 (SD 10.31) and most were women (72%) and White (70%). METHODS: This was a descriptive study, and a Rasch analysis was done to establish reliability based on internal consistency and evidence of differential item functioning (DIF) across races. Validity was based on item fit and model testing with structural equation modeling to compare models between White and Black participants. RESULTS: There was evidence of internal consistency (alpha coefficient of 0.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Black individuals. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants. CONCLUSIONS AND IMPLICATIONS: The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further, the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives.

BACKGROUND: Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders' perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings. METHODS: EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. RESULTS: The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning. CONCLUSION: Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success. TRIAL REGISTRATION: The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov ( NCT03014570 ) January 9, 2017.