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.

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.

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.

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.

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.

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.

It's about time: use of nonpharmacological interventions in the nursing home.

PURPOSE: To provide a stronger evidence base for cultural change in the nursing home, this study elicited nursing, recreational therapy, and medical staff perceptions of barriers to the implementation of nonpharmacological interventions for the behavioral and psychological symptoms of dementia (BPSD). DESIGN: Thirty-five staff members (registered nurses, licensed practical nurses, nurses' aides, recreational therapists, activity personnel, and medical directors) from six nursing homes located in Pennsylvania and North Carolina participated in the qualitative study. METHODS: A focus group methodology was used to capture discussions that were audio-recorded and transcribed verbatim. Data were analyzed using standard methods of content and thematic analysis. FINDINGS: Four broad themes were identified: the changing landscape; resident behaviors; reaching out to the person with dementia; and the educational needs of staff. The concept of time emerged as a key barrier to the use of nonpharmacological interventions for BPSD. CONCLUSIONS: Successful use of nonpharmacological interventions requires the right staff with the right education at the right time. The Vulnerability Framework is a model that helped organize these findings into a meaningful perspective. CLINICAL RELEVANCE: To effect change in the nursing home, the findings indicate a need for: implementation of staffing patterns that allow staff the time to make a difference in the care of residents with BPSD; development of educational programs that promote staff understanding versus control; and design of research studies that answer questions about the influence of time on the selection of interventions for BPSD.

Missed opportunities: under-detection of trauma in elderly adults involved in motor vehicle crashes.

INTRODUCTION: Geriatric trauma, mainly as a result of motor vehicle crashes (MVCs), has been a persistent and serious problem for those older than 65 years of age. Because of physiological changes and pre-existing disease, older adults present a unique clinical challenge to emergency nurses and staff. "Are older adults involved in MVCs appropriately assessed and treated?" METHODS: A review of the research literature, including 17 articles from 2003 to 2009, on the topic of geriatric trauma, specifically trauma that resulted from MVCs will be explored. RESULTS: Four different areas were discussed: (1) the under-detection of geriatric trauma, (2) prehospital triage guidelines, (3)the injury severity score, and (4) common resultant injuries encountered by older adults. DISCUSSION: Understanding specific patterns of injury in older adults and the geriatric trauma outcomes data is essential to emergency nursing practice. Following this literature review, the emergency nurse will be more comfortable managing the next geriatric patient arriving in the emergency department.

Principle-based concept analysis: recognition in the context of nurse-patient interactions.

AIM: This paper is a report of a principle-based concept analysis of recognition in the context of nurse-patient interactions. BACKGROUND: Recognition is a concept employed in practice and research. Since nursing is patient-centred and care is problem-driven, the specificity and accuracy of recognition may have an impact on how nurses label patient phenomena, interventions initiated and patient outcomes. DATA SOURCES: The data set included 98 English language articles published from 1997 to 2008 and retrieved through Medline and CINAHL searches. METHODS: Principle-based concept analysis was used to examine the state of the science according to major perspectives of the philosophy of science. Conceptual components were integrated into a theoretical definition and the process of recognition was conceptually modelled. FINDINGS: The scientific literature dealing with recognition in the context of nurse-patient interactions relies on implied meaning. Recognition is a process marked by an awareness of evidence coupled with the formulation of a conceptual label summarizing the identified pattern of patient phenomena. Contextual features of the nurse, patient and organization are relevant during nurse-patient interactions, resulting in pivotal points in nursing care. These pivotal points are the moments of recognition when the nurse consciously applies a summary label to interpreted evidence. Outcomes of recognition include a choice to act or not to act, each option carrying significant outcomes for nurses, patients, and at times, organizations. CONCLUSION: A working definition was produced that will serve as a foundation for future concept-driven research to advance the concept toward greater precision and usefulness in nursing science.

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.

Living with type 2 diabetes: marital perspectives of middle-aged and older couples.

Type 2 diabetes is a significant health problem among middle-aged and older adults in the United States. Given the life-altering nature of this condition, examination of the psychosocial context in which people with diabetes live may enhance long-term diabetic care. This qualitative study aimed to understand the similarities and differences in spouses' beliefs about diabetes, the perceived effects on daily life, and the management of diabetes in the context of marriage. Data analysis revealed three themes: vulnerability, burden, and getting by. This descriptive study provides a unique perspective on couples' beliefs about diabetes, which have important implications for the nursing community in acknowledging spousal beliefs in the management of diabetes.

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.

Focus groups and older adults: Tactics for success.

Factors a nurse clinician should consider when planning focus group size are the number of questions to be posed, depth of responses desired, anticipated "no shows," and time period allotted. Establishing the ground rules for the session and explaining confidentiality expectations are essential starting points for the group. Nurse clinicians are well situated to use focus groups with older adults to explore a number of inquiries, from clinical problems to service utilization. Things to consider when planning focus groups with older adults include length of time the older adult group can participate, seating arrangements that comfortably accommodate individuals with disabilities, and accessible location.

Integrating gerontology competencies into graduate nursing programs.

Current demographic and health care utilization trends strongly indicate a rapidly increasing demand for nurses who are well qualified to care for older adults. Advanced practice nurses are positioned to assume leadership roles in geriatric nursing care; however, they must first acquire adequate preparatory education. This article describes two graduate nursing schools' curricular innovations that were funded by The John A. Hartford Foundation, in collaboration with the American Association of Colleges of Nursing (AACN), through the Geriatric Nursing Education Project: Enhancing Gerontological/Geriatric Nursing for Advanced Practice Nursing. These programs at University of North Carolina at Greensboro and Pennsylvania State University incorporated techniques to translate the Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care [American Association of Colleges of Nursing. (2004). Nurse practitioner and clinical nurse specialist competencies for older adult care. Washington, DC: AACN] into an advanced practice curriculum and developed strategies to sustain curricular innovations. Finally, lessons learned from these two projects are discussed and recommendations are made for integrating geriatric nursing competencies into graduate programs.

Healthcare providers' perspectives: estimating the impact of chronicity.

PURPOSE: To compare elders' self-ratings of the impact of their chronic conditions with healthcare providers' estimates of the impact of the same conditions on older adults. The effect of length of time in clinical practice and rural or urban clientele on healthcare providers' impact ratings was also explored. DATA SOURCES: A pen-and-paper survey was administered to 122 community-dwelling adults aged 55 years and older, attending health education or exercise programs held by a hospital in a city of approximately 60,000 people. Elders were asked to identify which of 11 common chronic conditions they had and then to rate the impact each condition had on their daily lives. A sample of 290 healthcare providers who are members of the Gerontological Society of America completed a mailed survey asking them to estimate the impact that each of the 11 conditions had on older adults. CONCLUSIONS: Healthcare providers consistently overestimated the impact that chronic health conditions had on older adults when compared with the elders' self-ratings of impact. Greater levels of experience were not significantly related to providers' impact ratings of chronic conditions. IMPLICATIONS FOR PRACTICE: Nurse practitioners, as primary care providers, must understand the impact of chronic conditions on older adults' daily lives in order to provide effective, efficient, and evidence-based health care. This study points to the need for more research to discover why older adults and healthcare providers have such different perspectives on the impact of chronic health conditions.

"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.

Supporting older adults living with multiple chronic conditions.

This qualitative study was conducted using focus groups to explore the strategies commonly employed by older adults (N = 37) to manage multiple chronic conditions. Key strategies identified were relating with health care providers, medicating, exercising, changing dietary patterns, seeking information, relying on spirituality and/or religion, and engaging in life. Although social support was not mentioned as a discrete strategy, the participants' social networks were embedded in all of the categories. This study supports building a partnership of care in which nurses and other health care professionals function in supportive and educative roles to enhance the older person's lifelong self-care management and ability to stay in control of multiple chronic health conditions.