Leaving a lasting legacy: A scoping review of ethical wills.

OBJECTIVES: Palliative care guidelines recommend an interdisciplinary approach to address patients' awareness of mortality and need for end-of-life preparation. An ethical will is a nonlegal way to address mortality by communicating a lasting and intangible legacy of values to others. The aim of this scoping review is to clarify the operationalization of ethical wills across disciplines and map the purposes and outcomes of creating an ethical will. METHODS: We followed the Joanna Briggs Institute methodology for scoping reviews. We searched 14 databases in November 2019 and January 2021 without filtering publication date or type. Two reviewers independently screened 1,948 publications. We extracted frequently used terms describing content, audience, format, purpose, and outcomes identified in ethical will creation. RESULTS: Fifty-one publications met inclusion criteria. Six (11.7%) were research articles. Twenty-four (47.1%) were lay literature published within law, estate, and financial planning. Collectively, our included studies defined an ethical will as a nonlegal way to express values, beliefs, life lessons and experiences, wisdom, love, history, hope for the future, blessings, apology, or forgiveness using any format (e.g., text, audio, video) that is meant to be shared with family, friends, or community. The most common purposes were to be remembered, address mortality, clarify life's meaning, and communicate what matters most. Creation provided opportunity to learn about self, served as a gift to both writer and recipient, and fostered generativity and sense of symbolic immortality. SIGNIFICANCE OF RESULTS: Our findings highlight interdisciplinary utilization and a lack of research of ethical wills. This review provides supportive evidence for ethical wills as a way for patients to address mortality, renew intergenerational connections, solidify self, and promote transcendence before their final days. Ethical wills have potential to be incorporated into interdisciplinary palliative care in the future to address psychological symptoms for patients anticipating the end of life.

"Being careful": How much caution is enough? The relational context of fear of older adult falling in older adult-family caregiver dyads.

Family caregivers play an important role in coping with older adult falls; however, their perspectives on fear of older adult falling are lacking from the falls prevention literature. A mixed-method design (N=25 dyads) with interview and survey data examined linguistic characteristics and coping strategies used by older adult and family caregiver dyads to manage fear of older adult falling. Fear of older adult falling consisted of both affective (e.g., worry) and cognitive (e.g., cautious) properties. Family caregivers more frequently used affective words and first-person plural pronouns ("we" language) when talking about fear of older adult falling, while older adults more frequently used cognitive and first-and-second person singular pronouns ("I", "you"). The concept of "being careful" was shared within dyads. However, dyad partners differed in their perspectives of what constituted "being careful" and the possibilities of future falling. Findings suggest that the need for family-centered interventions to prevent falls are needed.

Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review.

Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].

Development of a Long-Term Care Nurse Residency Program.

Nurses working in the long-term care (LTC) setting provide increasingly complex patient care, often without formal training on the specific needs of LTC patients, which can lead to burnout and high turnover rates. Nurse residency programs (NRPs) have been used effectively to orient novice RNs to their work setting, address transition-to-practice challenges, and promote retention, yet few LTC NRPs have been developed. The University of Utah Geriatric Education Consortium Geriatric Workforce Enhancement Program created an online LTC NRP to provide LTC nurses with the knowledge and skills to succeed in the LTC environment. RNs with <1 year of LTC experience were paired with experienced nurse mentors working within the same LTC facility. Synchronous and asynchronous curricular modules addressed leadership and communication, caring for older adult patients, quality improvement, and the LTC regulatory environment. A distance-based LTC NRP allows nurses flexibility in gaining gerontological nursing and leadership expertise that supports their professional goals. [Journal of Gerontological Nursing, 47(2), 37-43.].

Loneliness as a mediator of the impact of social isolation on cognitive functioning of Chinese older adults.

BACKGROUND AND OBJECTIVE: older adults have increased risk of social isolation, loneliness and cognitive functioning impairment, but the relationships among these factors are not conclusive. We investigated the potential mediation mechanism of loneliness on the association between social isolation and cognitive functioning among Chinese older adults within their cultural context. DESIGN: secondary analysis of the baseline wave (2011-12) of the harmonised China Health and Retirement Longitudinal Study. SETTING AND SUBJECTS: community-dwelling older adults in China (N = 7,410 participants aged 60-101 years). METHODS: we applied a multiple indicator multiple cause approach to determine whether the construct of social isolation is well defined by four indicators (social activity engagement, weekly adult children contact, caregiving for grandchildren and living alone) and used structural equation modelling to examine the direct and indirect effects among variables of interest. RESULTS: the results demonstrated that social activity engagement, weekly adult children contact and caregiving for grandchildren were significantly related to social isolation (ß = -0.26 to -0.28) (Living alone was fixed to 1 for model identification.) The indirect effect of social isolation on cognitive functioning through loneliness was significant (ß = -0.15), indicating loneliness was an important mediator. However, the direct effect of social isolation on cognitive functioning also remained significant (ß = -0.83), suggesting a partial mediation effect. CONCLUSIONS: our study highlights the mediation role of loneliness in the relationship between social isolation and cognitive functioning among Chinese older adults. The findings support the beneficial effects of maintaining social relations and coping with feelings of loneliness on older adults' cognitive functioning.

Fear of older adult falling questionnaire for caregivers (FOAFQ-CG): Evidence from content validity and item-response theory graded-response modelling.

AIMS: (1) Determine the content validity of the Fear of Older Adult Falling Questionnaire-Caregivers using a panel of gerontological experts and a target sample of family caregivers (Stage 1) and (2) Examine the response patterns of the Fear of Older Adult Falling Questionnaire-Caregivers and compare it with older adult version of Fear of Falling Questionnaire Revised using graded-response modelling (Stage 2). DESIGN: Cross-sectional mixed-method design. METHODS: Five content experts and 10 family caregivers were involved in the Stage 1 study and 53 family caregiver-older adult dyads (N = 106) were included in the Stage 2 study. The content-validity index and graded-response modelling were used to analyse data. RESULTS: Among experts, the Fear of Older Adult Falling Questionnaire-Caregivers content-validity index for relevancy, importance, and clarity of individual items and total scale ranged from 0.60-1.00 and from 0.77-0.87, respectively. Among family caregivers, the ratings of the item and scale level content-validity index for relevancy, importance, and clarity ranged from 0.90-1.00 and from 0.95-0.97, respectively. Combining feedback from both groups, we revised one item. Subsequently, the graded-response modelling revealed that a 1-factor, 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers had acceptable psychometric properties. CONCLUSIONS: The brief 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers is promising for assessing caregivers' fear of their older adult care recipient falling. IMPACT: A significant concern for family caregivers is fearing that older adult care recipients will fall, but a lack of validated measures limits the study of this phenomena. A 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers has the potential to identify family caregivers with high fear of older adult falling so that fall risk can be appropriately assessed and addressed.

Opioid Use in Long-Term Care: Guidelines and Policy Recommendations.

Older adults living in long-term care (LTC) settings experience a higher incidence of chronic pain than those living in the community and are prescribed opioids at approximately twice the rate. Opioids are effective in managing pain in LTC residents, who are often not candidates for nonopioid pharmacological or nonpharmacological therapies. The recent Centers for Disease Control and Prevention guideline for opioid stewardship recommends conservative opioid prescribing and discourages long-term opioid use for chronic pain management, raising concern that pain may not be adequately treated for LTC residents. The Society for Post-Acute and Long-Term Care Medicine recently published a policy statement that addresses responsible opioid stewardship in LTC. The current article describes clinical guidelines and standards that can guide LTC nurses in assessing, treating, and monitoring opioid use so that residents have diminished pain without significant adverse events. [Journal of Gerontological Nursing, 45(9), 5-10.].

Development of a Gerontology Graduate Certificate in Post-Acute and Long-Term Care.

Nurse practitioners (NPs) can provide safe, effective, quality care to older adults in post-acute and long-term care (PALTC) settings. However, there is a paucity of exposure to PALTC settings in most NP educational programs. Therefore, the current authors developed an elective graduate certificate in gerontology with an emphasis in PALTC for NP students. The graduate certificate curriculum was developed by faculty with expertise in nursing and gerontology education. The PALTC certificate comprises 15 credit hours of online didactic courses, 80 leadership hours, 200 clinical hours, and a scholarly project dedicated to PALTC. Completion of a graduate certificate in PALTC is a novel model for preparing NP students for practice in PALTC settings. The current article serves as a framework for other programs to reference as they develop individualized graduate certificate PALTC programs in their academic institutions. [Journal of Gerontological Nursing, 45(10), 47-52.].

Can I relate? A review and guide for nurse managers in leading generations.

AIMS: The purpose of this review is to help the nurse leader develop an understanding of the five generations currently in the health care workforce by providing defining characteristics, general behaviours, and strategies for the nurse manager to employ for each generational cohort. BACKGROUND: Generations are groups of people born during the same 15-20 year time period who share similar experiences before adulthood, which shape long-term behaviours. Key descriptors and characteristics are provided. EVALUATION: The current generational cohorts in the health care workforce are Traditionalists (born between 1922 and 1945), baby boomers (born between 1946 and 1964), Generation X (born between 1965 and 1979), millennials (born between 1980 and 1995), and Generation Z (born after 1995). KEY ISSUES: Health care teams often comprise members of three or more generations. Intergenerational differences in team members can result in challenges; however, different perspectives provided by multiple generations can be used advantageously to strengthen the team's efficiency and outcomes. CONCLUSIONS: There are strengths in each generation. Key differences can be harnessed to build stronger teams through comprehensive communication strategies, customized reward systems, and workplace flexibility. Examples are provided for each area. IMPLICATIONS: Managers can use intergenerational differences to create a rich environment that bridges generational differences and fosters workforce cohesion.

Evaluation of a peer mentoring program for early career gerontological nursing faculty and its potential for application to other fields in nursing and health sciences.

BACKGROUND: As the retirement rate of senior nursing faculty increases, the need to implement new models for providing mentorship to early career academics will become key to developing and maintaining an experienced faculty. PURPOSE: This evaluation of a peer mentorship program for predoctoral and postdoctoral gerontological nurses examined its efficacy, utility, and potential for improvement. METHODS: A web-based survey was developed, implemented, and completed by 22 mentees and 17 mentors (71% and 61% response rates, respectively) as part of the evaluation. DISCUSSION: The peer mentorship program was found to be valuable by both mentors (64.7%) and mentees (72.7%) in helping mentees further develop their careers and networks and providing mentors with supported mentorship experience. CONCLUSION: The peer mentorship program could serve as a model for other professional organizations, academic institutions, and consortiums to enhance and extend the formal vertical mentorship provided to early academic career individuals.

Development and implementation of a peer mentoring program for early career gerontological faculty.

PURPOSE: The Hartford Gerontological Nursing Leaders (HGNL) formerly known as the Building Academic Geriatric Nursing Capacity Initiative (BAGNC), in conjunction with the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE), developed and executed a peer mentoring program beginning in 2011 to enhance both (a) the experience of newly selected scholars and fellows to the NHCGNE and (b) the ongoing professional development of HGNL members. The purpose of this article is to describe key strategies used to develop and execute the peer mentoring program and to present formative program evaluation. DESIGN: The program was launched in January 2011 with seven peer mentor and mentee matches. In June 2012, the peer mentoring committee solicited feedback on the development of the peer mentoring program and changes were made for the subsequent cohorts. FINDINGS: An additional 12 matches were made in the following 2 years (2012 and 2013), for a total of 31 matches to date. We have learned several key lessons from our three cohorts regarding how to structure, implement, and carefully evaluate a peer mentoring program. CONCLUSIONS: Informal evaluation of our peer mentoring program noted several challenges for both peer mentors and mentees. Having knowledge of and addressing those challenges may increase the overall quality and effectiveness of peer mentoring programs and, in turn, benefit academic nursing by strengthening the faculty workforce. CLINICAL RELEVANCE: Findings from development and implementation of a peer mentoring program for gerontological faculty could lead to new and adaptable programs in a variety of clinical and education settings.

Agents of Change: Geriatrics Workforce Programs Addressing Systemic Racism and Health Equity.

Many factors affect how individuals and populations age, including race, ethnicity, and diversity, which can contribute to increased disease risk, less access to quality healthcare, and increased morbidity and mortality. Systemic racism-a set of institutional policies and practices within a society or organization that perpetuate racial inequalities and discrimination-contributes to health inequities of vulnerable populations, particularly older adults. The National Association for Geriatrics Education (NAGE) recognizes the need to address and eliminate racial disparities in healthcare access and outcomes for older adults who are marginalized due to the intersection of race and age. In this paper, we discuss an anti-racist framework that can be used to identify where an organization is on a continuum to becoming anti-racist and to address organizational change. Examples of NAGE member Geriatric Workforce Enhancement Programs (GWEPs) and Geriatrics Academic Career Awards (GACAs) activities to become anti-racist are provided to illustrate the framework and to guide other workforce development programs and healthcare institutions as they embark on the continuum to become anti-racist and improve the care and health of vulnerable older adults.

Social media use and mental health among older adults with multimorbidity: the role of self-care efficacy.

OBJECTIVES: To describe the prevalence and trends in the use of social media over time and explore whether social media use is related to better self-care efficacy and thus related to better mental health among United States older adults with multimorbidity. MATERIALS AND METHODS: Respondents aged 65 years+ and having 2 or more chronic conditions from the 2017-2020 Health Information National Trends Survey were analyzed (N = 3341) using weighted descriptive and logistic regression analyses. RESULTS: Overall, 48% (n = 1674) of older adults with multimorbidity used social media and there was a linear trend in use over time, increasing from 41.1% in 2017 to 46.5% in 2018, and then further up to 51.7% in 2019, and 54.0% in 2020. Users were often younger, married/partnered, and non-Hispanic White with high education and income. Social media use was associated with better self-care efficacy that was further related to better mental health, indicating a significant mediation effect of self-care efficacy in the relationship between social media use and mental health. DISCUSSION: Although older adults with multimorbidity are a fast-growing population using social media for health, significant demographic disparities exist. While social media use is promising in improving self-care efficacy and thus mental health, relying on social media for the management of multimorbidity might be potentially harmful to those who are not only affected by multimorbidity but also socially disadvantaged (eg, non-White with lower education). CONCLUSION: Great effort is needed to address the demographic disparity and ensure health equity when using social media for patient care.

Dying with dementia in nursing homes: A population-based study of decedents and their families.

BACKGROUND: Families play a critical role in end-of-life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs. METHODS: This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first-degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi-square tests, and t-tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%). RESULTS: Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non-White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF. CONCLUSIONS: Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF-factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies.

Survey methods and response rates among rural community dwelling older adults.

BACKGROUND: Rural older adults are not often targeted for surveys, and little is known about survey response rates in this population. Because overall numbers of rural older adults are small, it is important to consider techniques to improve their survey response rates. OBJECTIVES: The purpose of this study was to work with community partners to determine whether rural older adults participating in a rural county home-delivered meals program were more likely to respond to an injury risk survey hand-delivered via the postal service or hand-delivered by the home-delivered meals drivers. METHODS: All home-delivered meals clients older than 65 years old were randomized to one of two groups. One group (n = 70) received the following via the postal service: a prenotice letter, a survey packet containing a description of the survey, the survey, a stamped and addressed return envelope, and a reminder/thank-you card. Older adults in the other group (n = 69) were personally handed the survey packet by the home-delivered meals driver. RESULTS: The overall survey response rate was 43.9%. Older adults who were handed the survey packets by the home-delivered meals drivers were older and significantly more likely to return the survey (57%) compared with those who received survey materials in the mail (31%). Only 27% of respondents agreed to be contacted regarding participation in future face-to-face interviews. When taking into account response rates, postage costs alone were over five times higher for the postal-delivered surveys compared with the hand-delivered surveys. DISCUSSION: By working with community partners, we were able to determine that older adults in a rural community were more likely to respond to surveys personally handed to them by someone they knew.

Linking clinical research data to population databases.

BACKGROUND: Most clinical nursing research is limited to funded study periods. However, if clinical research data can be linked to population databases, researchers can study relationships between study measures and poststudy long-term outcomes. OBJECTIVES: The objective was to describe the feasibility of linking research participant data to data from population databases in order to study long-term poststudy outcomes. As an exemplar, participants were linked from a completed oncology nursing research trial to outcomes data in two state population databases. METHODS: Participant data from a previously completed symptom management study were linked to the Utah Population Database and the Utah Emergency Department Database. The final data set contained demographic, cancer diagnosis and treatment and baseline data from the oncology study linked to poststudy long-term outcomes from the population databases. RESULTS: One hundred twenty-nine of 144 (89.6%) study were linked to their individual data in the population databases. Of those, 73% were linked to hospitalization records, 60% were linked to emergency department visit records, and 28% were identified as having died. DISCUSSION: Study participant data were successfully linked to population databases data to describe poststudy emergency department visit and hospitalization numbers and mortality. The results suggest that data linkage success can be improved if researchers include linkage and human subjects protection plans related to linkage in the initial study design.

Preparing for the Future While Living in the Present: Older Adults' Experiences Creating a Legacy of Values.

BACKGROUND AND OBJECTIVES: A legacy of values (e.g., legacy letter) is a nonlegal way to intentionally communicate intangible assets (e.g., values, life lessons, and emotional and supportive instruction) with others. There is scant research on legacy creation outside of a palliative care context, and no studies have explored the experiences of community-dwelling older adults creating a legacy of values. RESEARCH DESIGN AND METHODS: As part of an exploratory sequential mixed methods study, we conducted semistructured interviews with older adults (N = 16) who had previously created a legacy of values. We analyzed transcribed interviews using an interpretive descriptive approach. We iteratively coded interviews deductively with sensitizing concepts identified in the literature (existential well-being, end-of-life preparation and completion, generativity, and resilience), and inductively, based on participants' descriptions. Codes were categorized by patterns of motivations, content, outcomes, and meaning, and thematically summarized. RESULTS: We conceptualized the overall experience of creating a legacy of values as Preparing for the Future While Living in the Present and identified 4 themes: Preserving the Intangible for You and for Me, Sharing What I Want You to Know, Obtaining Peace through Reflection and Preparation, and Living into a Continuing Legacy. Participants attained peace, realized their life was not complete, and were challenged to live intentionally through legacy creation. DISCUSSION AND IMPLICATIONS: Creating a legacy of values may concurrently prepare older adults for the end of life and the remainder of life. These findings offer insight into a generative act that can promote intentional living among older adults.

What is the relationship between falls, functional limitations, and depressive symptoms among Chinese older adults? The role of living alone.

OBJECTIVES: Although the association between falls and depressive symptoms is well documented, the mechanisms underlying this association remain largely unexplored. We investigated the mediation role of functional limitations in the association between falls and depressive symptoms among Chinese older adults and determined whether the living arrangement (living alone or not) is a significant moderator of the above-mentioned mediation pathway. STUDY DESIGN: Cross-sectional study. MAIN OUTCOME MEASURES: Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale short form (CESD-10), on which higher scores indicate higher levels of depressive symptoms. RESULTS: We used the harmonized China Health and Retirement Longitudinal Study national baseline data (2011-2012 year) involving 7410 participants aged 60 years and over. After adjusting for covariates (e.g., age and sex), the effects of falls on depressive symptoms were seen to be mediated by functional limitations among Chinese older adults (ß = 0.82, p < .001). The moderated mediation analysis, which assesses whether an indirect effect is conditional on values of a moderating variable, found that the mediation effect was contingent upon the living arrangement (ß = -0.60, p = .029). Specifically, the levels of functional limitations and depressive symptoms were higher for people with falls who were living with others relative to those living alone. CONCLUSIONS: These results suggest that functional limitations are an important intervening variable that links falls to depressive symptoms among Chinese older adults. Interventions to promote older adults' physical function and prevent falls are recommended to decrease the risk of depressive symptoms. These interventions can particularly benefit those who live with others.