Family Caregivers' Characterization of Conversations Following an ACP Event.

BACKGROUND: Advance care planning (ACP) has been shown to benefit patients and families, yet little is known about how an ACP event impacts communication and conversation about end-of-life treatment wishes and the content of such conversations between patients and family caregivers. OBJECTIVE: To characterize post-ACP conversations regarding medical wishes between seriously ill patients and their family caregivers. PARTICIPANTS: Patients with advanced illness and family caregivers. OUTCOME MEASURED: Post-ACP conversations. DESIGN: As part of a larger randomized controlled trial, dyads consisting of seriously ill patients and their identified family caregiver engaged in ACP and created an advance directive for the patient. Approximately 4 to 6 weeks later, semistructured interviews were conducted with the family caregivers to elucidate the subsequent communications regarding medical wishes. If the dyad did not have any conversations post-ACP, reasons and barriers were explored. RESULTS: The majority of dyads (131/188, 69.7%) had 2 to 3 conversations lasting 3 to 5 minutes each in the weeks immediately following ACP. These conversations most commonly addressed general patient wishes about quality of life and specific medical treatments. The most common reasons for not having conversations were a general discomfort with the topic (13/57, 22.8%) and previously having discussed medical wishes (16/57, 28.1%). CONCLUSION: The ACP events promote conversation regarding quality of life, general wishes at the end of life, and specific medical wishes. Barriers to conversation following ACP were similar to barriers to ACP in general, suggesting that a more intentional focus on addressing these barriers pre- and post-ACP may be necessary to improve communication.

Pilot Study of a Two-Step Delirium Detection Protocol Administered By Certified Nursing Assistants, Physicians, and Registered Nurses.

The feasibility and acceptability of a two-step screening protocol for delirium identification was pilot tested. Step 1, a screening tool, comprises two items: "Please tell me the day of the week," and "Please tell me the months of the year backwards starting with December." If either/both items are incorrect, Step 2, a 3-minute diagnostic assessment, follows. Trained researchers enrolled 24 hospitalized older adults and identified 22% to be delirious after a reference standard assessment. Thereafter, physicians and RNs completed the two-step protocol, whereas certified nursing assistants (CNAs) completed the screener only, on the same patients. All three clinical assessments were successfully completed in 100% of enrolled participants and within the target 2-hour time window in 91%. The screener and two-step protocol achieved high sensitivities and specificities in RNs, CNAs, and physicians. Qualitative information on barriers to and facilitators of implementation was also collected. Nurses and other clinicians can feasibly implement this ultra-brief screener and two-step protocol, which holds promise to improve delirium identification. [Journal of Gerontological Nursing, 44(5), 18-24.].

A Toolkit for Enhancing End-of-Life Care: An Examination of Implementation and Impact.

The purpose of this study was to examine the infusion of a Toolkit for Enhancing End-of-Life Care in prisons, as well as the outcome and impact on the quality of prison end-of-life care. A total of 74 front-line staff and administrators were in attendance across two post-Toolkit-infusion evaluation visits. Applying qualitative analysis, co-researcher outcome findings were related to activities, community outreach and relations, multidisciplinary team, quality improvement approach, and participatory action research team effects. Organizational outcomes included barriers and challenges, cost, organizational features, sphere of influence, readiness (for change), and sustainability.

A Discourse Analysis: One Caregiver's Voice in End-of-Life Care.

Informal family caregivers make a significant contribution to the U.S. health care system, and the need for caregivers will likely increase. Gaining deeper insights into the caregiver experience will provide essential knowledge needed to support the future caregiver workforce delivering care. Discourse analysis is a viable approach in analyzing textual caregiver data that focuses on the end-of-life caregiving experience. The purpose of this study was to conduct an in-depth discourse analytic examination of 13 hours of caregiver interview data, which reveal the multiplicity of shifting stances and perceptions of one caregiver in the midst of end-of-life care, specifically with regard to his perceptions of self (caregiver) and other (care recipient). By isolating a specific but limited set of reference terms used throughout the discourse, we gained systematic glimpses into the mind and perceptions of this single caregiver in relation to his role as caregiver for his terminally ill wife.

Enhancing Care of Aged and Dying Prisoners: Is e-Learning a Feasible Approach?

BACKGROUND: Prisons and jails are facing sharply increased demands in caring for aged and dying inmates. Our Toolkit for Enhancing End-of-life Care in Prisons effectively addressed end-of-life (EOL) care; however, geriatric content was limited, and the product was not formatted for broad dissemination. Prior research adapted best practices in EOL care and aging; but, delivery methods lacked emerging technology-focused learning and interactivity. PURPOSES: Our purposes were to uncover current training approaches and preferences and to ascertain the technological capacity of correctional settings to deliver computer-based and other e-learning training. METHODS: An environmental scan was conducted with 11 participants from U.S. prisons and jails to ensure proper fit, in terms of content and technology capacity, between an envisioned computer-based training product and correctional settings. RESULTS: Environmental scan findings focused on content of training, desirable qualities of training, prominence of "homegrown" products, and feasibility of commercial e-learning. CONCLUSIONS/IMPLICATIONS: This study identified qualities of training programs to adopt and pitfalls to avoid and revealed technology-related issues to be mindful of when designing computer-based training for correctional settings, and participants spontaneously expressed an interest in geriatrics and EOL training using this learning modality as long as training allowed for tailoring of materials.

Empowering Change Agents in Hierarchical Organizations: Participatory Action Research in Prisons.

Participatory action research (PAR) approaches harness collaborative partnerships to stimulate change in defined communities. The purpose of this article is to illustrate key methodological strategies used in the application of PAR methods in the particularly challenging environment of a hierarchical organization. A study designed to promote sustainable, insider-generated system-level changes in the provision of end-of-life (EOL) care in the restrictive setting of six state prisons is used as an exemplar of the application of three cardinal principles of PAR. First, development of a collaborative network with active partnership between outsider academic researchers and insider co-researchers began with careful attention to understanding the culture and processes of prisons and gaining the support of organizational leadership, using qualitative data gathering and trust-building. During the implementation phase, promoting co-ownership of change in EOL care through the co-construction of knowledge and systems to enhance sustainable change required carefully-orchestrated strategies to maximize the collaborative spirit of the project. Co-researchers were empowered to examine their worlds and capture opportunities for change using new leadership skills role-modeled by the research team. Third, their local knowledge of the barriers inherent in the contextual reality of prisons was translated into achievable system change by production of a toolkit of formalized and well-rehearsed change strategies that collaborative teams were empowered to enact within their hierarchical prison environment. © 2016 Wiley Periodicals, Inc.

"Wish we would have known that!" Communication Breakdown Impedes Person-Centered Care.

PURPOSE: To understand how nursing home staff obtain information needed for implementing person-centered care (PCC) to residents with dementia who exhibit behavioral and psychological symptoms of dementia (BPSD), and how they communicate this information to other staff. Barriers to PCC and information exchange were also explored. DESIGN AND METHODS: Participants were 59 staff from two nursing homes. Focus group methodology captured discussions in eight 1-hr sessions. Sessions were audiotaped and transcribed. Data were analyzed using qualitative content analysis to provide a comprehensive summary of real world context of implementing PCC. RESULTS: To deliver PCC staff identified a need for access to psychosocial/medical history of the resident and knowledge of strategies families used for managing BPSD in the past. However, resident information is not routinely shared with all staff and written documentation systems for communicating resident-specific information do not support the time-pressured work pattern of certified nursing assistants (CNAs). Word-of-mouth was considered more reliable and expedient than educational sessions. CNAs described themselves as visual learners who prefer educational programs addressing individual resident emergent behaviors and programs that are scheduled at dedicated times. IMPLICATIONS: To improve PCC the flow of information exchange requires: inclusion of all staff, particularly CNAs; systems of communication that consider the time and resource constraints of nursing homes; development of educational programs for BPSD that are responsive to staff learning styles; administrative investment in nursing leadership to effect these changes; and reimbursement approaches to encourage culture change investments.

Efficiency of health care in state correctional institutions.

Little is known about the efficiency of health care in correction settings. This article reports an efficiency analysis of health care in state correctional institutions (SCIs) in a single, mid-Atlantic state from 2003 to 2006. A two-stage data envelopment analysis was used to estimate the technical efficiency of prison health care and determine inmate and institutional characteristics that were associated with efficiency. Our output variable was the number of infirmary inpatient days for each year of study. The input variable for the first stage was the sum of personnel medical staff costs and other medical operating costs. SCIs with more white prisoners, older prisoners, and higher proportions of inmates with parole violations were significantly less efficient in their provision of health care than other SCIs. There were no SCI characteristics that were predictive of efficiency. These results suggest that healthcare efficiency in corrections may decline as the prison population continues to age.

Merging person-centered care with translational research to improve the lives of older adults: creating community-based nursing research networks.

Translational research is a leading trend in science with the aim of bridging the research-practice gap to significantly speed the implementation of effective interventions in clinical practice. Integrating the values and preferences of older adults and their families into this process is critical to the success of translational research. Engaging communities in meaningful research is an important part of advancing translational science in which older adults are partners in developing solutions to the health needs of individuals within communities. The current article describes one approach to developing an infrastructure (i.e., community-based nursing research network) to support patient-centered care within translational research. Nurses are uniquely poised and prepared to assume leadership roles in community-based research networks to support a true collaboration among stakeholders that prizes the voices of older adults and integrates them into practice efforts.

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.

Administrators' perspectives on changing practice in end-of-life care in a state prison system.

OBJECTIVE: Sentencing trends have created a demographic shift in prison populations. Greater numbers of inmates are aging and dying in prison, creating a demand for enhanced end-of-life (EOL) care. Changing practice to meet escalating care demands in correction settings is complicated by economic constraints, attitudinal barriers, and organizational features. This study explored perspectives of EOL care held by administrators in a state prison system to reveal challenges to changing practice to meet the needs of inmates suffering advanced illness and dying in prison. DESIGN AND SAMPLE: Qualitative interviews were conducted with 12 administrators from the central office of a state department of corrections. MEASURES: Semi-structured discussion guide. RESULTS: Key influences impacting EOL care services included: local prison culture, treatment versus security focus, case-by-case consideration, public sentiment, budget neutral approaches, and conflicting views of service targets. CONCLUSIONS: These findings revealed the organizational structures, attitudes, and beliefs held by the administrative echelon of a state prison system and were used to guide the derivation of discrete approaches to changing practice in this complex system. Contextual evaluation permitted a much deeper understanding of the influences on changing practice in this hierarchical bureaucracy. This type of preliminary evaluation is crucial to infusing new practice initiatives in complex organizations caring for stigmatized, at-risk populations.

Care and companionship in an isolating environment: inmates attending to dying peers.

The purpose of this study was to examine the values, beliefs, and perceptions of end-of-life (EOL) care held by inmates caring for peers approaching the end of their lives. The study is part of a broader participatory action research project to infuse enhanced EOL care into state prisons. Face-to-face interviews using a semistructured discussion guide were conducted with 17 male prisoners who were providing care for peers with advanced chronic illness and approaching end of life. Qualitative data were analyzed using content and thematic analyses. Key themes were getting involved, living the role, and transforming self through caring for others. As well, contextual features at the organizational, peer, and personal levels were identified, which either facilitated or impeded inmate caregiving. Provision of enhanced EOL care by inmate peers shows promise for improving prison community relations and morale, reducing suffering, and demonstrating care and compassion within the harsh prison environment. This study provides clear evidence that providing compassionate care for dying peers may result in transformative experiences for inmate caregivers. Implications for correctional nursing practice include providing training for inmate caregivers, including them in team meetings, and implementing grief support programs. Also, upholding nursing's code of ethics and watching for predatory behavior are critical.

End-of-life caregiving: challenges faced by older adult women.

In the United States, the number of people older than 60 is expected to triple over the next 50 years, and as the population ages so do family caregivers. Increased levels of depression and low ratings of subjective well-being in caregivers are consistently associated with older age, the spousal relationship, and female caregiver gender. Less well known is the effect care delivery models have on the older adult as his or her spouse approaches the end of life. The purpose of this study was to explore the challenges faced by older adult spousal caregivers providing end-of-life care across different life-limiting illness trajectories in distinctive care delivery models. An instrumental case study using purposive sampling identified the following themes for older spousal caregivers: balancing multiple morbidities; feeling overwhelmed and exhausted; dealing with personal health issues; feeling isolated; and coordinating care. Implications for health care providers are also examined.

Pilot testing of the function focused care intervention on an acute care trauma unit.

The purpose of this pilot study was to test the feasibility and preliminary effectiveness of Function Focused Care for Acute Care (FFC-AC) on acute care trauma nurses. A single group pre/post repeated measure design was used with measurements completed at baseline, 3 and 9 months post implementation of the intervention. FFC-AC was implemented by a function focused care nurse champion and includes 3 components: (I) Environmental and Policy Assessments; (II) Education; and (III) Mentoring and Motivating. The nurses were willing to participate in the study and attend educational sessions. There was evidence that exposure to FFC-AC strengthened beliefs in the benefits of providing this type of care increased the amount of function focused care that nurses provided to patients.

The influence of the culture of care on informal caregivers' experiences.

The environment of care can have a profound impact on caregiving experiences of families caring for loved ones with a life-limiting illness. Care is often delivered through disease-specific specialty clinics that are shaped by the illness trajectory. In this study, the following 3 distinct cultures of care were identified: interdisciplinary, provider dominant, and cooperative network. Each of these cultures was found to express unique values and beliefs through 5 key characteristics: acknowledgment of the certainty of death, role of the formal caregiver, perception of the patient system, focus of the patient visit across the trajectory, and continuum of care across the trajectory.

A model of caregiving through the end of life: seeking normal.

Informal family caregivers provide significant contributions to end-of-life (EOL) care. A theoretical model of the phases and transitions of EOL caregiving was explicated using grounded theory methods to explore the experiences of 46 family caregivers of adults suffering a variety of life-limiting conditions. The derived model describes four phases of caregiving spanning prediagnosis through bereavement. Phases are demarcated by key transitions experienced when the illness progression manifestly challenges the established "steady state" achieved by the caregiver. The basic social process was defined as "seeking normal" as caregivers sought reliable patterns of everyday life while meeting the demands of caregiving. Understanding the progression of EOL caregiving enables clinicians to better support family caregivers as both coproviders and corecipients of care.

End-of-life care and barriers for female inmates.

The number of female inmates is growing, and their average age is increasing. As a result, end-of-life care is situated in a highly restrictive environment with a focus on security rather than comfort. We describe the need for and potential barriers to humane care and provide care strategies that can be useful in a complex organizational system. Frontline workers such as nurses who understand the balance between care and control must promote change in the women's prison system.