Differences in Staff-Resident Care Interactions by Nursing Home Racial Composition: a Preliminary Analysis.

Limited research has examined racial differences in the quality of staff-resident care interactions in long-term care settings. The quality of care interactions can significantly affect resident quality of life and psychological well-being among nursing home residents living with dementia. Limited research has assessed racial or facility differences in the quality of care interactions. The purpose of the present study was to determine if there were differences in the quality of care interactions among nursing home residents with dementia between Maryland nursing home facilities with and without Black residents. It was hypothesized that after controlling for age, cognition, comorbidities, and function, the quality of care interactions would be better in facilities with Black residents versus those in which there were only White residents. Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) intervention study was used and included 276 residents. The results indicated that facilities in Maryland with Black residents had a 0.27 increase (b = 0.27, p < .05) in the quality of care interaction score compared to facilities without Black residents. The findings from this study will be used to inform future interventions to aid in reducing quality of care disparities in nursing home facilities with and without Black nursing home residents. Future work should continue to examine staff, resident, and facility characteristics associated with the quality of care interactions to improve quality of life among all nursing home residents regardless of race or ethnicity.

The Graying of the Cool Pose: Examining Active Care Strategies Among Older African-American Men With Type 2 Diabetes Mellitus.

OBJECTIVES: The influence of masculinity norms on disparate health outcomes has been established in the literature. What is less understood are the specific ways in which African-American men "do health" by engaging in strategies promoting positive health outcomes. This article reframes what has been previously examined through a health deficit perspective by reporting the experiences and positive health maintenance strategies of older, African-American men with type 2 diabetes mellitus (diabetes). METHODS: We employed an intersectional framework to thematically analyze qualitative interviews with African-American male participants (N = 15) in our National Institute on Aging-funded study of diabetes among older adults in Baltimore. Interviews consisted of a modified version of the McGill Illness Narrative Interview, which included discussions of diabetes experiences and self-management strategies. RESULTS: The majority of African-American men in our study link their successful diabetes management to purposeful self-care activities, despite structural and personal limitations. These activities include proactively seeking diabetes education, healthy eating, medication management, and engaging in supportive relationships. DISCUSSION: Active pursuit of a healthy lifestyle often requires redefining Black manhood, defying negative gender stereotypes of what it means to be a Black male. Results are described in the context of the "Cool Pose," a framework for understanding how African-American men and boys cope with systemic racial oppression and the unachievable dominant standards of masculinity in the United States. The results suggest that this framework may be less applicable for older African-American men who promote well-being in the wake of chronic disease as they age.

"How I Can Help Me": Self-Care Priorities and Structural Pressures Among Black Older Adults With Diabetes.

BACKGROUND AND OBJECTIVES: Disparities in type 2 diabetes mellitus (diabetes) represent an ongoing public health challenge. Black older adults are at high risk of diabetes and diabetes' complications. Diet, physical activity, and medication can control these risks, yet disease rates remain elevated. Utilizing an intersectionality framework, we seek to extend understanding of the social dimensions of diabetes through an examination of the diabetes self-care process from the perspective of Black older adults. RESEARCH DESIGN AND METHODS: This project involved a thematic analysis of diabetes illness narrative interviews with Black participants (N = 41) in our National Institute on Aging-funded study of diabetes. In a narrative approach, the participant communicates the significance of actions and events. RESULTS: The findings suggest that diabetes self-care involves interconnected struggles across four domains of care: (1) multimorbidity management, (2) financial well-being, (3) family support, and (4) formal health care. DISCUSSION AND IMPLICATIONS: Black older adult self-care reflects an active process of pursuing meaningful social goals and critical health needs. An intersectional framework, however, reveals the ongoing histories of inequity that shape this process. Further intervention to address the racist policies and practices found in Black older adults' communities and clinical care is needed to make true progress on diabetes disparities.

Understanding the Subjective Experience of Medication Adherence for Older Urban African Americans With Type 2 Diabetes and a History of Illicit Drug Addiction.

OBJECTIVE: African Americans experience high rates of type 2 diabetes mellitus (T2D). Self-management strategies, such as medication adherence, are key to mitigating negative T2D outcomes. This article addresses a gap in the literature by examining the intersections of drug abuse histories and medication adherence among urban, older African Americans with T2D. METHOD: In-depth interview data were collected as part of a larger ethnographic study examining the subjective experience of T2D among urban older adults. Two representative focal cases were selected and thematic analysis performed to illustrate how former illicit drug addicts perceive prescription medication usage. RESULTS: Narratives reveal that participants are displeased about having to take prescription drugs and are making lifestyle changes to reduce medication usage and maintain sobriety. DISCUSSION: Previous drug abuse not only complicates medication adherence but is also a significant part of how older African Americans who are former drug users frame their understanding of T2D more broadly.

Successful Aging Among African American Older Adults With Type 2 Diabetes.

OBJECTIVES: Rowe and Kahn's concept of successful aging remains an important model of well-being; additional research is needed, however, to identify how economically and socially disadvantaged older adults experience well-being, including the role of life events. The findings presented here help address this gap by examining the subjective construction of well-being among urban African American adults (age ≥ 50) with Type 2 diabetes. METHOD: As part of the National Institute on Aging-funded Subjective Experience of Diabetes among Urban Older Adults study, ethnographers interviewed African American older adults with diabetes (n = 41) using an adaptation of the McGill Illness Narrative Interview. Data were coded using an inductively derived codebook. Codes related to aging, disease prognosis, and "worldview" were thematically analyzed to identify constructions of well-being. RESULTS: Participants evaluate their well-being through comparisons to the past and to the illnesses of friends and family. Diabetes self-care motivates social engagement and care of others. At times, distrust of medical institutions means well-being also is established through nonadherence to suggested biomedical treatment. DISCUSSION: Hardship and illness in participants' lives frame their diabetes experience and notions of well-being. Providers need to be aware of the social, economic, and political lenses shaping diabetes self-management and subjective well-being.

Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication.

Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.

Promoting and Protecting Against Stigma in Assisted Living and Nursing Homes.

PURPOSE OF THE STUDY: To determine the extent to which structures and processes of care in multilevel settings (independent living, assisted living, and nursing homes) result in stigma in assisted living and nursing homes. DESIGN AND METHODS: Ethnographic in-depth interviews were conducted in 5 multilevel settings with 256 residents, families, and staff members. Qualitative analyses identified the themes that resulted when examining text describing either structures of care or processes of care in relation to 7 codes associated with stigma. RESULTS: Four themes related to structures of care and stigma were identified, including the physical environment, case mix, staff training, and multilevel settings; five themes related to processes of care and stigma, including dining, independence, respect, privacy, and care provision. For each theme, examples were identified illustrating how structures and processes of care can potentially promote or protect against stigma. IMPLICATIONS: In no instance were examples or themes identified that suggested the staff intentionally promoted stigma; on the other hand, there was indication that some structures and processes were intentionally in place to protect against stigma. Perhaps the most important theme is the stigma related to multilevel settings, as it has the potential to reduce individuals' likelihood to seek and accept necessary care. Results suggest specific recommendations to modify care and reduce stigma.

Licensed nurse staffing and health service availability in residential care and assisted living.

OBJECTIVES: To create data-driven typologies of licensed nurse staffing and health services in residential care and assisted living (RC/AL). DESIGN: Cluster analysis was used to describe the patterns of licensed nurse staffing and 47 services and the extent to which these clusters were related. SETTING: RC/AL communities in the United States. PARTICIPANTS: A convenience sample of administrators and healthcare supervisors from 89 RC/AL communities in 22 states. MEASUREMENT: RC/AL characteristics, licensed nurse staffing (total number of hours that registered nurses (RNs) and licensed practical nurses (LPNs) worked), number of hours that contract nurses worked, and availability of 47 services. RESULTS: Analysis revealed four licensed nurse staffing clusters defined according to total number of hours and the type of nurse providing the hours (RN, LPN, or a mix of both). They ranged from no or minimal RN and LPN hours to high nursing hours with a mix of RNs and LPNs. The 47 services clustered into five clusters: basic services; technically complex services; assessments, wound care, and therapies; testing and specialty services; and gastrostomy and intravenous medications. The availability of services was related to the presence of nurses (RNs and LPNs) except for the gastrostomy and intravenous medication services, which were not readily available. CONCLUSION: The amount and skill mix of licensed nurse staffing varies in RC/AL and is related to the types of services available. These findings may have implications for resident care and outcomes. Future work in this area, including extension to include nonnurse direct care workers, is needed.

Physician perspectives on medical care delivery in assisted living.

OBJECTIVES: To describe the provision of medical care in assisted living (AL) as provided by physicians who are especially active in providing care to older adults and AL residents; to identify characteristics associated with physician confidence in AL staff; and to ask physicians a variety of questions about their experience providing care to AL residents and how it compares with providing care in the nursing home and home care settings. DESIGN: Cross-sectional descriptive study. SETTING: AL communities in 27 states. PARTICIPANTS: One hundred sixty-five physicians and administrators of 125 AL settings in which they had patients. MEASUREMENTS: Interviews and questionnaires containing open- and close-ended questions regarding demographics, care arrangements, attitudes, and behaviors in managing medical problems. RESULTS: Most respondents were certified in internal medicine (46%) or family medicine (47%); 32% were certified in geriatrics and 30% in medical directorship. In this select sample, 48% visited the AL setting once a year or less, and 19% visited once a week or more. Mean physician confidence in AL staff was 3.3 (somewhat confident), with greater confidence associated with smaller AL community size, nursing presence, and the physician being the medical director. Qualitative analyses identified differences between settings including lack of vital sign assessment in the home setting, concern about the ability of AL staff to assess and monitor problems, and greater administrative and regulatory requirements in AL than in the other settings. CONCLUSION: Providing medical care for AL residents presents unique challenges and opportunities for physicians. Nursing presence and physician oversight and familiarity and communicating with AL staff who are highly familiar with a given resident and can monitor care may facilitate care.

The Emerging Role of Health Care Supervisors in Assisted Living.

Historically, the assisted living (AL) industry has promoted a social, non-medical model of care. Rising health acuity of residents within AL, however, has brought about the need for providing increased health care services. This article examines the key staff role related to health care provision and oversight in AL, described as the health care supervisor. It briefly describes individuals in this role (N = 90) and presents their perspectives regarding their roles and responsibilities as the health care point person within this non-medical environment. Qualitative analyses identified four themes as integral to this position: administrative functions, supervision of care staff, provision of clinical and direct care, and clinical care coordination and communication. The article concludes with recommendations for AL organizations and practice of the emerging health care supervisor role in AL.