Staff Perceptions of Implementing a Person-Centered Communication Tool in the Nursing Home Setting: PAL Cards.

PURPOSE: To understand direct care workers' perceptions of the impact of implementing a person-centered communication tool, Preference for Activity and Leisure (PAL) Cards, into care. METHOD: PAL Cards provide at-a-glance information about a nursing home (NH) resident's background and important preferences for activities and leisure. As a quality improvement project, 11 NHs implemented use of PAL Cards in their communities and provided feedback (N = 91 feedback forms received) on their perceptions of impact of PAL Cards on care communication and delivery. RESULTS: A variety of NH staff members, across disciplines, were a part of PAL Card implementation. The majority of staff (84%) perceived that PAL Cards helped them start a conversation with a resident and 64% indicated that PAL Cards helped them provide care for a resident. CONCLUSION: PAL Cards are an effective tool for communicating information about NH residents' preferences to staff. [Journal of Gerontological Nursing, 50(8), 5-10.].

Preference Importance Ratings among African American and White Nursing Home Residents.

OBJECTIVES: The Preferences for Everyday Living Inventory (PELI-NH) assesses psychosocial preferences of nursing home (NH) residents. This study explored the association of race with importance ratings of self-dominion preferences (i.e., preferences for control). METHODS: PELI-NH interviews were conducted with 250 NH residents. Tests of mean differences compared African American (n = 57) and White (n = 193) residents on demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Stepwise multiple regression accounted first for associations of demographic and clinical attributes then for the unique association of race with total importance of self-dominion preferences to determine whether African American and White residents differ. For between group demographic/clinical differences, interaction effects were tested. RESULTS: African Americans were younger and more functionally impaired. After accounting for the effects of gender (female), age (younger), anxiety (greater), and functional impairment (less) with higher reports of importance of self-dominion preferences, race was significant. There were no significant moderating effects. CONCLUSIONS: African American residents reported greater importance of self-dominion preferences than Whites. CLINICAL IMPLICATIONS: Cultural sensitivity is critical; it may be more important to provide opportunities for autonomous decision-making for African American than for White residents.

Adverse childhood experiences, adult trauma, and depressive symptom trajectories.

OBJECTIVES: Associations among adverse childhood experiences prior to age 18 (ACEs), subjective reports of trauma during Hurricane Sandy, and trajectories of depressive symptoms reported by community-dwelling older people were examined. METHODS: We analyzed 6 waves of data from 5,688 people aged 50-74 recruited in 2006 and followed for 12-years using multilevel mixed effects models. RESULTS: We found that: (1) people who experienced ACEs had trajectories of depressive symptoms in late life that were higher than people not having these experiences, (2) people experiencing two or more ACEs were more likely to report fear and distress when Hurricane Sandy hit than people experiencing either one or no adverse childhood experiences, and (3) while both ACE exposure and peri-traumatic stress were associated with trajectories having higher levels of depressive symptoms, the risk associated with ACEs (especially multiple ACEs) was greater. CONCLUSION: Findings support life course stress theories including the cumulative inequality theory and stress proliferation theory, suggesting that inequalities are manifested over the life course and that people experiencing adversity during childhood are at increased risk of experiencing adversity in late life. By studying the relationship between adverse childhood experiences and response to Hurricane Sandy our findings demonstrate that adverse childhood experiences can alter the way traumatic events in adulthood are experienced. This finding in turn, has important implications for clinical practice, as it identifies a group of people likely to be at risk for adult trauma.

The Prospective Association of Personality Traits and Successful Aging.

We used data (N = 928) from ORANJ BOWL, a six-wave panel of adults (aged 50-74 at baseline) to address the association between personality and successful aging at two points in time, 8 years apart. Regressions examined the associations between Wave 2 neuroticism, extraversion, openness, agreeableness, and conscientiousness and Wave 3 subjective success, functional ability, pain, and chronic conditions. Models tested personality traits independently and then simultaneously, with interactions. Confirmatory analyses used Waves 5/6 data. All traits but openness were individually associated with successful aging at both time points. When testing traits simultaneously, only neuroticism and extraversion were consistently associated with subjective success, with an interaction at Waves 2/3. Neuroticism (Waves 2/3) and conscientiousness (Waves 5/6) were associated with functional ability. Neuroticism was associated with pain (Waves 2/3). Personality was not associated with chronic conditions. These analyses set up future work examining relationships between change in personality and change in successful aging.

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.].

Emotion-focused communication training online: Development and evaluation of acceptability.

Emotion-focused communication can improve the delivery of care for long-term care recipients, especially individuals' living with dementia. The purpose of this manuscript is to describe the process of translating the Emotion-Focused Communication Training (EFCT) for long-term care staff from an in-person workshop to an online program and evaluate its acceptability and impact on knowledge of emotion-focused communication and perceived self-efficacy for utilizing emotion-focused communication. The online course was developed following the ADDIE (Analysis, Design, Development, Implementation, Evaluation) Model. The program teaches participants to better identify and manage their own emotions and others' emotions in care. Pre- and post-training t-test comparisons on data collected from 247 caregivers across disciplines in long-term care (direct care workers, life-enrichment/activities staff, health care providers, case managers, health educators, students, administrators, ombudsmen, dietary, housekeeping, or maintenance staff, human resources employees, family care partners, and others) indicated a significant increase in level of knowledge of emotion-focused communication and confidence in applying the learned knowledge and skills in care (increased self-efficacy). Participants also reported high levels of program acceptability. Overall, findings indicate the benefits of translating an in-person training opportunity for caregivers into an interactive online experience; implications for caregivers and care recipients are discussed.

The impact of nursing home residents' characteristics on ratings of importance of autonomy preferences in daily care over time.

Objective: Nursing home (NH) residents' preferences for everyday living are the foundation for delivering individualized care. Yet, work has not examined the impact of demographic and clinical characteristics of NH residents on the stability of their preferences over time.Method: This study examined the rate of change in reports of importance of 27 autonomy-related everyday preferences from the Preferences for Everyday Living Inventory over 3-months and the demographic and clinical characteristics associated with change for nursing home residents (N = 255). Descriptive frequencies and tests of mean difference were utilized to examine differences between individuals reporting change in importance over time compared to those that did not report change.Results: Autonomy preferences in daily care remained stable over 3-months for the majority of residents. For residents that did report change on autonomy preferences, no systematic associations of demographic or clinical characteristics were found to be associated with change. Rather, change was associated with differential characteristics based on the preference.Conclusion: This study indicates that knowing a person's demographic or clinical characteristics in care will not uniformly inform a caretaker's understanding of the individual's reports of importance for autonomy related preferences over time. Future work should explore the role of care environment on change in preference ratings over time.

Person-Centered Care Plans for Nursing Home Residents With Behavioral and Psychological Symptoms of Dementia.

Little literature exists examining the development and implementation of person-centered care (PCC) plans focused on behavioral and psychological symptoms of dementia (BPSD). The current study aimed to describe BPSD documented in nursing home (NH) residents' care plans, the types of approaches staff document in addressing those symptoms, and whether resident and/or facility characteristics are associated with documentation of PCC approaches. The sample included 553 residents from 55 NHs in two East Coast states. Resistiveness to care (44.9%), agitation (42.2%), and aggression (42%) were most frequently documented in care plans. PCC approaches were documented in care plans in 21.3% to 62.7% of cases depending on BPSD type. Resident (e.g., younger age, lower functional ability, lower cognitive ability, longer length of stay, male gender) and facility (e.g., less certified nursing assistant staffing hours, greater percentage of residents taking antipsychotic medications, non-profit status) characteristics were associated with increased odds of PCC approaches being documented. Optimal PCC planning is discussed, and a sample PCC plan is provided. [Journal of Gerontological Nursing, 46(11), 17-27.].

Adult Children Living With Aging Parents: The Association Between Income and Parental Affect.

This study examined the moderating effect of parental income on the association between parent-child coresidence and parental affect. Secondary analysis was conducted with data from the ORANJ BOWL panel, a representative sample of adults in New Jersey, aged 50 to 74 years ( N = 5,688). Results indicated that income had a significant moderating effect on the association between the adult child's residential status and parents' positive and negative affect. Among parents with coresident adult children, an observed decline in positive affect and rise in negative affect were amplified as parental income level increased, suggesting differential strains on parental well-being across income levels.

Mapping Core Concepts of Person-Centered Care in Long-Term Services and Supports.

Person-centered care (PCC) has a wide range of definitions, most based on expert opinion rather than empirical analysis. The current study used an empirical concept mapping approach to identify core components of PCC used in long-term services and supports (LTSS). The aim is to help providers and researchers develop a unified set of domains that can be used to assess and improve the quality of PCC in real-world settings. Results yielded six domains describing essential elements of PCC in LTSS: Enacting Humanistic Values, Direct Care Worker Values, Engagement Facilitators, Living Environment, Communication, and Supportive Systems; and two underlying dimensions: Intrapersonal Activities and Extrapersonal Services and Social and Physical Environment. Nurses can use the results to enhance clinical knowledge and skills around delivery of PCC. Researchers can use the results to build a comprehensive and unified measure to accelerate adoption of PCC practices shown to benefit older adults, families, and the LTSS workforce. [Journal of Gerontological Nursing, 45(2), 6-13.].

Illness Representations of Multiple Chronic Conditions and Self-Management Behaviors in Older Adults: A Pilot Study.

This article explores the intraindividual variability in illness representations of people with multiple chronic conditions and examines how representations of hypertension and arthritis are associated with self-management. Intraclass correlations determined the proportion of within-person variability in illness representations including Timeline, Consequences, Personal Control, and Timeline-Cyclical for 25 adults aged 64 and older. Within-person consistency across illnesses was present for Timeline and Timeline-Cyclical, but variability across illnesses in Personal Control and Consequences. Correlations revealed associations of diet, exercise, and sleep with illness representations of people with arthritis and hypertension. Representations of hypertension (Personal Control, Timeline-Cyclical, and Consequences) were associated with adherence to a reduced fat diet, walking, and total sleep time. Representations of arthritis were not associated with health behaviors. Findings demonstrate that clinical practice must consider the illness representations patients have about each of their chronic illnesses to begin to sustain positive self-management behaviors.

Preferences for Everyday Living: Understanding the Impact of Cognitive Status on Preference Importance Ratings in Nursing Homes.

Assessing everyday living preferences for nursing home residents is a cornerstone of delivering person-centered care (PCC), yet little is known about how cognitive ability can influence the importance of reported preferences. The current study examined the effect of cognitive ability on the level and stability of reported importance of preferences for everyday living in a sample of 255 nursing home residents across 3 months. Participants were grouped by cognitive impairment status (none-to-low, mild, and moderate) at baseline and completed the Preferences for Everyday Living Inventory, Nursing Home version interview at baseline and 3 months. Repeated measures analyses of covariance revealed no significant differences (p > 0.001) between cognitive groups on their reported level of importance of preferences at baseline and no significant change over 3 months. These data highlight the value of assessing everyday care preferences to help support delivery of PCC for individuals with and without cognitive impairment. [Journal of Gerontological Nursing, 44(5), 9-17.].

Exposure to Hurricane Sandy, neighborhood collective efficacy, and post-traumatic stress symptoms in older adults.

OBJECTIVES: Older adults exposed to natural disasters are at risk for negative psychological outcomes such as post-traumatic stress disorder (PTSD). Neighborhood social capital can act as a resource that supports individual-level coping with stressors. This study explores the ability of perceived neighborhood collective efficacy, a form of social capital, to moderate the association between exposure to Hurricane Sandy and PTSD symptoms in older adults. METHOD: Data from 2205 older individuals aged 54-80 residing in New Jersey who self-reported exposure to Hurricane Sandy in October of 2012 were identified and extracted from the ORANJ BOWL™ research panel. Participants completed baseline assessments of demographic and individual-level characteristics in 2006-2008 and follow-up assessments about storm exposure, perceived neighborhood collective efficacy (social cohesion and social control), and PTSD symptoms 8-33 months following the storm. Zero-inflated Poisson regression models were tested to examine the association between exposure, neighborhood collective efficacy, and PTSD symptoms. RESULTS: After accounting for known demographic and individual-level covariates, greater storm exposure was linked to higher levels of PTSD symptoms. Social cohesion, but not social control, was linked to lower reports of PTSD symptoms and moderated the association between exposure and PTSD. The impact of storm exposure on PTSD symptoms was less for individuals reporting higher levels of social cohesion. CONCLUSION: Mental health service providers and disaster preparedness and response teams should consider the larger social network of individuals served. Building social connections in older adults' neighborhoods that promote cohesion can reduce the negative psychological impact of a disaster.

The Great Recession, Life Events, and Mental Health of Older Adults.

Historical events and personal experiences have the potential to alter the way people age. Using a life-course model, we examined how the Economic Recession of 2008 and experienced life events affected the mental health of 3,393 older adults in New Jersey. Data collected between 2006 and 2012 revealed a significant increase in mean depressive symptoms. Multinomial logistic regression analyses indicated that people with incident depression were more likely to have lost a job, become a caregiver, experienced a major illness, or have a family member with a major illness than people with no depression. Compared with the incident depression group, those with remitted depression were less likely to report having lost a job or experienced a major illness. Modeling the effects of individual life events and the economic recession on depression enriches understanding about the association between macro socioeconomic events, life events, and the mental health of older adults.

Older adults' influence in family care: how do daughters and aging parents navigate differences in care goals?

OBJECTIVE: This study seeks to address how older adults influence their daily care when their preferences conflict with those of their adult daughter caregivers. METHOD: Using a sample of 10 dyads (N = 20) of an older adult and adult daughter, we utilize content analysis strategies to analyze in-depth, semi-structured interview data with QSR NVIVO to investigate how older adults influence their care, how daughters respond to such efforts of influence, and how dyads navigate differences in care goals. RESULTS: When there is agreement in goals, dyads report tasks going well and both individuals' requests are honored. When there are differences in care goals, daughters most frequently reason with their older parents, while parents walk away or 'let go' of their requests. Daughters report making decisions for their parents for health or safety-related needs. However, all dyads discuss differences in care goals, whereby parents are perceived as insisting, resisting, or persisting in care. CONCLUSION: Findings illustrate complex patterns of responses by families when navigating differences in daily care goals that carry important implications for research and the development of dyadic-based family interventions.

Health Care Preferences Among Nursing Home Residents: Perceived Barriers and Situational Dependencies to Person-Centered Care.

Although much research has examined end-of-life care preferences of nursing home (NH) residents, little work has examined resident preferences for everyday health care. The current study conducted interviews with 255 residents recruited from 35 NHs. Content analysis identified barriers (i.e., hindrances to the fulfillment of resident preferences) and situational dependencies (i.e., what would make residents change their mind about the importance of these preferences) associated with preferences for using mental health services, choosing a medical care provider, and choosing individuals involved in care discussions. Barriers and situational dependencies were embedded within the individual, facility environment, and social environment. Approximately one half of residents identified barriers to their preferences of choosing others involved in care and choosing a medical care provider. In contrast, the importance of mental health services was situationally dependent on needs of residents. Results highlight opportunities for improvement in practice and facility policies that promote person-centered care. [Journal of Gerontological Nursing, 42(2), 11-16.].

Religiosity and quality of life: a dyadic perspective of individuals with dementia and their caregivers.

OBJECTIVES: Dyadic coping theory purports the benefit of joint coping strategies within a couple, or dyad, when one dyad member is faced with illness or stress. We examine the effect of religiosity on well-being for individuals with dementia (IWDs). In particular, we look at the effect of both dyad members' religiosity on perceptions of IWDs' quality of life (QoL). Neither of these issues has been extensively explored. METHOD: One hundred eleven individuals with mild-to-moderate dementia and their family caregivers were interviewed to evaluate IWDs' everyday-care values and preferences, including religious preferences. Using an actor-partner multi-level model to account for the interdependent relationship of dyads, we examined how IWD and caregiver ratings of religiosity (attendance, prayer, and subjective ratings of religiosity) influence perceptions of IWDs' QoL. RESULTS: After accounting for care-related stress, one's own religiosity is not significantly related to IWDs' or caregivers' perceptions of IWD QoL. However, when modeling both actor and partner effects of religiosity on perceptions of IWDs' QoL, caregivers' religiosity is positively related to IWDs' self-reports of QoL, and IWDs' religiosity is negatively associated with caregivers' perceptions of IWDs' QoL. CONCLUSION: These findings suggest that religiosity of both the caregiver and the IWD affect perception of the IWD's QoL. It is important that caregivers understand IWDs' values concerning religion as it may serve as a coping mechanism for dealing with dementia.

The consistency of self-reported preferences for everyday living: implications for person-centered care delivery.

Preferences are the expression of an individual's basic psychosocial needs and are related to care outcomes. The current study tested the consistency of 87 individuals' everyday preferences over 1 week, comparing responses of nursing home residents (n = 37; mean age = 82) and university students (n = 50; mean age = 20). Participants completed the Preferences for Everyday Living Inventory at baseline and 5 to 7 days later. Preference consistency was calculated three ways: (a) correlations (range = 0.11 to 0.90); (b) overall percent of exact agreement (e.g., response was "very important" at both time points) (66.1%); and (c) responses collapsed as "important" or "not important" (increase in percent agreement to 86.6%). Personal care preferences were more stable, whereas leisure activities were less stable. The groups did not have significant differences in consistency. Some preferences are more consistent than others; age and frailty do not appear to be related to preference instability.

How Do We Achieve Person-Centered Care across Health Care Settings? Expanding Ideological Perspectives into Practice to Advance Person-Centered Care.

Person or patient-centered care (PCC) is touted as the gold standard in geriatric medical care across care settings. However, despite more than 3 decades of research and practice initiatives, it remains a challenge to consistently implement PCC that fully places the individual at the center of care planning and the delivery process. The lack of universal implementation of PCC, we argue, may be in large part due to the use of multiple terms and ideologies leading to an inability to coordinate efforts across medical settings. This article reviews recent ideological PCC movements ("What Matters to You," the Age Friendly Health Systems 4 Ms/5 Ms, "Whole Health," Patient Priorities Care, and Medicare/Medicaid person-centered care initiatives), provides a discussion of how these ideologies are implemented in a nursing home setting through preference-based care and provides implications for coordinated integration of PCC across all care settings now and into the future. We argue for the need to draw on known information and validated methodologies for assessing and implementing PCC to collectively move beyond an ideological representation of the concept into an integrated model of PCC for all older adults receiving care.

Sustainability of the Preferences for Everyday Living Inventory Use in Ohio Nursing Homes Over Time.

OBJECTIVES: In 2015 the Ohio Department of Medicaid incentivized use of the Preferences for Everyday Living Inventory (PELI) as a quality initiative. The pay-for-performance (P4P) program, however, was then deimplemented in 2019. This study investigated the sustainability of use of the PELI in Ohio nursing homes (NHs) from 2017 to 2021 and examined barriers to PELI implementation. DESIGN: This study analyzed 2 waves of Ohio Biennial Survey of Long-Term Care Facilities data. SETTING AND PARTICIPANTS: Data were drawn from 433 NHs in Ohio that reported on PELI implementation efforts between 2017 and 2021. METHODS: This study examined the change in proportion of NHs implementing the PELI (ie, conducted for all residents, used in care planning) and change in proportion of NHs using different PELI assessment formats (ie, the full 72-item PELI, MDS 3.0 Section F items only). Frequencies of reported barriers to PELI implementation by NH administrators were tabulated. RESULTS: Results indicate that although use of the full 72-item PELI decreased over time, only a small percentage discontinued its use despite possible impacts of P4P changes in 2019 and challenges posed by the COVID-19 pandemic. NHs adapted their PELI assessment formats likely in response to perceived barriers of PELI use (ie, length of the full PELI, time constraints, and residents' level of cognitive impairment). CONCLUSIONS AND IMPLICATIONS: Findings suggest that Ohio NHs sustained PELI implementation over time in the context of large systemic changes in P4P financial incentives and COVID-19 safeguards. Barriers were reported at the organizational level, yet NHs continued to prioritize PCC with the PELI. Policy/P4P mandates may serve as effective implementation incentives that encourage sustainability of quality care practices. Future research should explore long-term sustainability and stakeholder perspectives on PELI utilization.