Letters from the pandemic: Nursing student narratives of change, challenges and thriving at the outset of COVID-19.

AIM: The aim of this study is to explore the experience of third year baccalaureate nursing students during the outbreak of the COVID-19 pandemic. DESIGN: Research design is a narrative analysis of archived letters written by nursing students in Spring 2020. METHODS: Letters and other media were written between 1 April and 20 May 2020. Fifty-six letters, some with accompanying audio or visual media, were submitted in late May 2020. Approval from the University Institutional Review Board was obtained to explore the letters through narrative analysis (Riessman, 2008). As the letters were considered archival, consent from the students for the analysis was not indicated. Once thematic categories were identified independently, the authors discussed the findings until a list of narrative categories and narrative exemplars were agreed on. RESULTS: Three main thematic categories were found: stories of change, challenges and thriving. CONCLUSION: Findings were consistent with prior research and reveal new opportunities for understanding the perspectives and needs of undergraduate nursing students during times of crisis. Action by administrators and faculty are recommended.

Factors Associated With Health Service Use Among Older Adults in a Mobile Veterans Program.

The current retrospective, longitudinal study applied Andersen's Behavioral Model of Health Services Use to examine how demographic characteristics (age), available resources (e.g., a caregiver, the Mobile Veterans Program [MVP]) and health needs (e.g., cognitive and physical functioning, depressive symptoms) affect hospitalization and institutionalization outcomes among older adults using the MVP. Fifty-four Veterans (age 55 to 95) participating in the MVP for up to 2 years were examined using hierarchical linear modeling (HLM) and growth curve model. In the final HLM model, each 1-point increase in depressive symptoms was associated with 76% (p ≤ 0.05) greater risk of institutionalization and 40% (p ≤ 0.01) greater risk of hospitalization. Each 1-point increase in cognitive functioning was associated with 24% (p ≤ 0.05) lower risk of institutionalization. The relationship between caregiver burden and hospitalization was attenuated by frequency of MVP visits. Services focused on reducing depressive symptoms may influence health service use and reduce caregiver burden in this population. [Journal of Gerontological Nursing, 46(5), 15-22.].

Physical Activity Intervention Effects on Physical Function Among Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis.

The purpose of this systematic review and meta-analysis was to determine the effects of supervised resistance and/or aerobic training physical activity interventions on performance-based measures of physical functioning among community-dwelling older adults, and to identify factors impacting intervention effectiveness. Diverse search strategies were used to identify eligible studies. Standardized mean difference effect sizes (d, ES) were synthesized using a random effects model. Moderator analyses were conducted using subgroup analyses and meta-regression. Twenty-eight studies were included. Moderator analyses were limited by inconsistent reporting of sample and intervention characteristics. The overall mean ES was 0.45 (k = 38, p ≤ .01), representing a clinically meaningful reduction of 0.92 s in the Timed Up and Go for treatment versus control. More minutes per week (p < .01) and longer intervention session duration (p < .01) were associated with larger effects. Interventions were especially effective among frail participants (d = 1.09). Future research should clearly describe sample and intervention characteristics and incorporate frail populations.

Assessment of Fall Characteristics From Depth Sensor Videos.

Falls are a major source of death and disability in older adults; little data, however, are available about the etiology of falls in community-dwelling older adults. Sensor systems installed in independent and assisted living residences of 105 older adults participating in an ongoing technology study were programmed to record live videos of probable fall events. Sixty-four fall video segments from 19 individuals were viewed and rated using the Falls Video Assessment Questionnaire. Raters identified that 56% (n = 36) of falls were due to an incorrect shift of body weight and 27% (n = 17) from losing support of an external object, such as an unlocked wheelchair or rolling walker. In 60% of falls, mobility aids were in the room or in use at the time of the fall. Use of environmentally embedded sensors provides a mechanism for real-time fall detection and, ultimately, may supply information to clinicians for fall prevention interventions. [Journal of Gerontological Nursing, 43(7), 13-19.].

A New Paradigm of Technology-Enabled 'Vital Signs' for Early Detection of Health Change for Older Adults.

Environmentally embedded (nonwearable) sensor technology is in continuous use in elder housing to monitor a new set of 'vital signs' that continuously measure the functional status of older adults, detect potential changes in health or functional status, and alert healthcare providers for early recognition and treatment of those changes. Older adult participants' respiration, pulse, and restlessness are monitored as they sleep. Gait speed, stride length, and stride time are calculated daily, and automatically assess for increasing fall risk. Activity levels are summarized and graphically displayed for easy interpretation. Falls are detected when they occur and alerts are sent immediately to healthcare providers, so time to rescue may be reduced. Automated health alerts are sent to healthcare staff, based on continuously running algorithms applied to the sensor data, days and weeks before typical signs or symptoms are detected by the person, family members, or healthcare providers. Discovering these new functional status 'vital signs', developing automated methods for interpreting them, and alerting others when changes occur have the potential to transform chronic illness management and facilitate aging in place through the end of life. Key findings of research in progress at the University of Missouri are discussed in this viewpoint article, as well as obstacles to widespread adoption.

Enhanced registered nurse care coordination with sensor technology: Impact on length of stay and cost in aging in place housing.

BACKGROUND: When planning the Aging in Place Initiative at TigerPlace, it was envisioned that advances in technology research had the potential to enable early intervention in health changes that could assist in proactive management of health for older adults and potentially reduce costs. PURPOSE: The purpose of this study was to compare length of stay (LOS) of residents living with environmentally embedded sensor systems since the development and implementation of automated health alerts at TigerPlace to LOS of those who are not living with sensor systems. Estimate potential savings of living with sensor systems. METHODS: LOS for residents living with and without sensors was measured over a span of 4.8 years since the implementation of sensor-generated health alerts. The group living with sensors (n = 52) had an average LOS of 1,557 days (4.3 years); the comparison group without sensors (n = 81) was 936 days (2.6 years); p = .0006. Groups were comparable based on admission age, gender, number of chronic illnesses, SF12 physical health, SF12 mental health, Geriatric Depression Scale (GDS), activities of daily living, independent activities of daily living, and mini-mental status examination scores. Both groups, all residents living at TigerPlace since the implementation of health alerts, receive registered nurse (RN) care coordination as the standard of care. DISCUSSION: Results indicate that residents living with sensors were able to reside at TigerPlace 1.7 years longer than residents living without sensors, suggesting that proactive use of health alerts facilitates successful aging in place. Health alerts, generated by automated algorithms interpreting environmentally embedded sensor data, may enable care coordinators to assess and intervene on health status changes earlier than is possible in the absence of sensor-generated alerts. Comparison of LOS without sensors TigerPlace (2.6 years) with the national median in residential senior housing (1.8 years) may be attributable to the RN care coordination model at TigerPlace. Cost estimates comparing cost of living at TigerPlace with the sensor technology vs. nursing home reveal potential saving of about $30,000 per person. Potential cost savings to Medicaid funded nursing home (assuming the technology and care coordination were reimbursed) are estimated to be about $87,000 per person. CONCLUSIONS: Early alerts for potential health problems appear to enhance the current RN care coordination care delivery model at TigerPlace, increasing LOS for those living with sensors to nearly twice that of those who did not. Sensor technology with care coordination has cost saving potential for consumers and Medicaid.

The continued success of registered nurse care coordination in a state evaluation of aging in place in senior housing.

Older adults prefer to age in place, remaining in their home as their health care needs intensify. In a state evaluation of aging in place (AIP), the University of Missouri Sinclair School of Nursing and Americare System Inc, Sikeston, MO, developed an elder housing facility to be an ideal housing environment for older adults to test the AIP care delivery model. An evaluation of the first 4 years (2005-2008) of the AIP program at TigerPlace (n = 66) revealed that the program was effective in restoring health and maintaining independence while being cost-effective. Similar results evaluating the subsequent 4 years (2009-2012) of the program (N = 128) revealed positive health outcomes (fall risk, gait velocity, Functional Ambulation Profile, handgrips, Short-Form 12 Physical Health, Short-Form 12 Mental Health, and Geriatric Depression Scale); slightly negative activities of daily living, independent activities of daily living, and Mini-Mental State Examination; and positive cost-effectiveness results. Combined care and housing costs for any resident who was receiving additional care services and qualified for nursing home care (n = 44) was about $20,000 less per year per person than nursing home care. Importantly, residents continued to live in private apartments and were encouraged to be as independent as possible through the end of life.

Impact of physical activity interventions on anthropometric outcomes: systematic review and meta-analysis.

Considerable research has tested physical activity (PA) interventions to prevent and treat overweight and obesity. This comprehensive meta-analysis synthesized the anthropometric effects of supervised exercise interventions and motivational interventions to increase PA. Eligible intervention studies included healthy participants with reported anthropometric outcomes [e.g., body mass index (BMI)]. Extensive searching located 54,642 potentially eligible studies. We included data from 535 supervised exercise and 283 motivational interventions in our syntheses, which used random-effects analyses. Exploratory moderator analyses used meta-analytic analogues of ANOVA and regression. We synthesized data from 20,494 participants in supervised exercise and 94,711 undergoing motivational interventions. The overall mean effect sizes (ES, d) for treatment versus control groups in supervised exercise interventions were 0.20 (treatment vs. control within-group comparison) and 0.22 (between-group comparison). The ES of 0.22 represents a post-intervention BMI of 26.7 kg/m(2) for treatment participants relative to 27.7 kg/m(2) for controls. The corresponding mean ES for motivational interventions was significantly smaller (d = 0.09 for between group, d = 0.10 for treatment vs. control within-group). Control group within-group comparisons revealed slightly worsening anthropometric outcomes during study participation (d = -0.03 to -0.04). Moderator analyses identified potential variables for future research. These findings document significant improvements in anthropometric effects from both supervised exercise and motivational interventions.

Perspectives and experiences related to physical activity of elders in long-term-care settings.

This qualitative study investigated individual and situational factors influencing physical activity (PA) practices of elders in residential-care/assisted-living (RC/AL) communities. This article describes the results of focus-group interviews involving 47 residents across 6 RC/AL settings. Thematic analysis revealed 6 themes: staying active, past PA experiences, value of PA, barriers to PA, strategies to facilitate PA, and support needs to promote PA. Staying active meant walking indoors and out, attending chair-exercise programs, performing professionally prescribed home exercises, and using available exercise equipment. Past PA experiences shaped current preferences and practices. Participants agreed that exercise helped maintain physical functioning but recounted cognitive and situational barriers to PA. Lack of dedicated exercise space and short corridors hampered efforts to stay active. Participants wished for individualized home exercise programs and supervised exercise sessions. Future research should examine the extent to which the physical environment and PA programming in RC/AL communities affect elders' PA.

Using meta-analyses for comparative effectiveness research.

Comparative effectiveness research seeks to identify the most effective interventions for particular patient populations. Meta-analysis is an especially valuable form of comparative effectiveness research because it emphasizes the magnitude of intervention effects rather than relying on tests of statistical significance among primary studies. Overall effects can be calculated for diverse clinical and patient-centered variables to determine the outcome patterns. Moderator analyses compare intervention characteristics among primary studies by determining whether effect sizes vary among studies with different intervention characteristics. Intervention effectiveness can be linked to patient characteristics to provide evidence for patient-centered care. Moderator analyses often answer questions never posed by primary studies because neither multiple intervention characteristics nor populations are compared in single primary studies. Thus, meta-analyses provide unique contributions to knowledge. Although meta-analysis is a powerful comparative effectiveness strategy, methodological challenges and limitations in primary research must be acknowledged to interpret findings.

Indicators of a new depression diagnosis in nursing home residents.

Depression affects approximately 30% to 40% of nursing home residents but frequently goes unrecognized. Using the Missouri Minimum Data Set, we aimed to determine whether changes in clinical status, other than mood changes, were associated with new depression diagnosis in residents 65 and older without a recorded depression diagnosis. Of 127,587 potential participants, 14,371 met inclusion criteria and were not depressed at baseline (Time 0). At the next quarterly assessment (Time 1), 1,342 (9.3%) had acquired a new diagnosis of depression. Residents with new depression were significantly younger and less cognitively impaired. Nearly 30% had a decline in activities of daily living (ADL) performance. The multivariate model predicting depression showed that increased verbal aggression, urinary incontinence, increased pain, weight loss, change in care needs, cognitive decline, and ADL decline significantly increased the likelihood of new depression diagnosis. The pattern of decline identified here may provide additional clues to the presence of underlying depression.

Changes in Physical and Cognitive Function Predict Sedentary Behavior in Older Adults With Mild Cognitive Impairment.

The current longitudinal study examined the influence of cognitive and lower extremity function on sedentary behavior continuously over 6 months in community-dwelling older adults with mild cognitive impairment (MCI). Multilevel models examined Montreal Cognitive Assessment (MoCA) change scores and the Short Physical Performance Battery (SPPB) on percent time in sedentary behavior among 17 older adults with MCI (50 to 74 observations for analysis). Sedentary behavior was measured daily and averaged monthly using wrist-worn actigraphy. Each 1-unit decrease in MoCA score was associated with an increase of 2 percentage points in sedentary behavior (p ≤ 0.01). In addition, each 1-unit decrease in chair stand score (lower extremity strength) was associated with an increase of 5 percentage points in sedentary behavior (p ≤ 0.01). Older adults experiencing cognitive decline and concurrent changes in lower extremity strength had the sharpest increase in sedentary behavior. Findings suggest lower body strengthening interventions may reduce sedentary behavior time and subsequently preserve physical functioning in this vulnerable population. [Research in Gerontological Nursing, 14(6), 285-291.].

Effects of a creative expression intervention on emotions, communication, and quality of life in persons with dementia.

BACKGROUND: Effective nonpharmacological interventions are needed to treat neuropsychiatric symptoms and to improve quality of life for the 5.3 million Americans affected by dementia. OBJECTIVE: The purpose of this study was to test the effect of a storytelling program, TimeSlips, on communication, neuropsychiatric symptoms, and quality of life in long-term care residents with dementia. METHODS: A quasi-experimental, two-group, repeated measures design was used to compare persons with dementia who were assigned to the twice-weekly, 6-week TimeSlips intervention group (n = 28) or usual care group (n = 28) at baseline and postintervention at Weeks 7 and 10. Outcome measures included the Cornell Scale for Depression in Dementia, the Neuropsychiatric Inventory-Nursing Home Version, the Functional Assessment of Communication Skills, the Quality of Life-Alzheimer's Disease, and the Observed Emotion Rating Scale (this last measure was collected also at Weeks 3 and 6 during TimeSlips for the treatment group and during mealtime for the control group). RESULTS: Compared with the control group, the treatment group exhibited significantly higher pleasure at Week 3 (p < .001), Week 6 (p < .001), and Week 7 (p < .05). Small to moderate treatment effects were found for Week 7 social communication (d = .49) and basic needs communication (d = .43). A larger effect was found for pleasure at Week 7 (d = .58). DISCUSSION: As expected, given the engaging nature of the TimeSlips creative storytelling intervention, analyses revealed increased positive affect during and at 1 week postintervention. In addition, perhaps associated with the intervention's reliance on positive social interactions and verbal communication, participants evidenced improved communication skills. However, more frequent dosing and booster sessions of TimeSlips may be needed to show significant differences between treatment and control groups on long-term effects and other outcomes.

Structural equation modeling of disability in women with fibromyalgia or multiple sclerosis.

Structural equation modeling (SEM), a popular statistical technique for analysis of multivariate data in the social sciences, is increasingly being used in the behavioral and clinical sciences. SEM is appropriate for posing complex models that evaluate the direct and indirect influence of several variables on one or more outcome variables. A biosocial model of disability, the Disablement Process Model, lends itself to evaluation by SEM. Using SEM, this study examined predictors of disability (Age, Education, Duration of Illness, and Economic Adequacy Functional Limitations, Depressive Symptoms, and Social Support) separately in women with multiple sclerosis (MS) and women with fibromyalgia syndrome (FMS) and compared the respective models across groups. Data were analyzed with Analysis of Moment Structures (Amos) 7.0. Problems identified in initial confirmatory model testing included collateral correlated errors, a negative error variance, and poor performance of the disability indicators. After specifying well-fitting confirmatory models for each group, a structural model for the larger FMS group was estimated. Model refinement resulted in the reversal of the path between Depressive Symptoms and Social Support. Further model revisions were based on comparative fit statistics and theoretical logic. The structural model developed from the FMS sample required minimal changes to fit the MS sample. The multisample model explained greater variance in disability in women with FMS than in women with MS. Social support and depressive symptoms mediated the effect of functional limitations on disability. Interventions that target modifiable characteristics, such as depression and social support, may improve outcomes such as disability.

Physical Function, Relocation, and Mortality Outcomes in Residential Care and Assisted Living Residents.

Objective: This study aimed to identify predictors of 6-month physical function and 12-month relocation or death in 272 residents of 34 residential care/assisted communities. Method: Measures collected at baseline, 6, and 12 months included health and demographic characteristics; self-reported pain, fatigue, and depressive symptoms; exercise self-efficacy, barriers, and expectations; attitudes on aging; performance-based physical function and physical activity; and community demographics, programs, and policies. GLIMMIX procedures for regression analyses with community as a random effect were run. Results: Better baseline physical function and grip strength, female sex, and residential care community predicted better 6-month physical function. At 12 months, 25.6% had relocated or died. The odds of 12-month relocation or death for 1-point increase in physical function score was 0.84 and for 1-point increase in depression score was 1.16. Discussion: Targets to promote longer tenure in residential care/assisted living include programs to ameliorate functional decline and depression screening and treatment.

The influence of positive experiences on depression and quality of life in persons with multiple sclerosis.

PURPOSE: This correlational study determined the extent to which positive, rather than negative, experiences influence depressive symptoms and quality of life in persons with multiple sclerosis (MS). METHOD: Data collected during the 7th year of an ongoing longitudinal study of quality of life in community-dwelling persons with MS were used for this analysis. FINDINGS: Higher number of positive experiences was associated with fewer depressive symptoms, less functional limitations, and better quality of life. Using hierarchical multiple regression, age, education, functional limitations, and positive experiences accounted for 21.7% of the variance in depressive symptoms, and functional limitations, positive experiences, and depressive symptoms explained 58% of the variance in quality of life. CONCLUSIONS: Higher number of positive experiences predicted lower levels of depressive symptoms, even while taking disease-related functional limitations into account. Incorporating positive experiences into daily life may improve quality of life, even when battling depression and substantial limitations in functioning.

The Effectiveness of Simulation on Recognizing and Managing Clinical Deterioration: Meta-Analyses.

The purpose of these meta-analyses was to quantitatively synthesize the effectiveness of simulation on student nurses' and registered nurses' ability to recognize and manage clinical deterioration in the acute care setting. A search of the literature resulted in 22 reports and 19 studies meeting inclusion criteria. Four random-effects analyses were conducted to examine two-group posttest and single-group pre-posttest intervention effect sizes for knowledge and performance. A total of 41 effect sizes were calculated from the data extracted. The standardized mean difference ( d) for two-group posttest knowledge was d = 0.964 ( p = .001) and for performance was d = 1.382 ( p ≤ .001). The standardized mean difference for single-group pre-posttest knowledge was d = 1.231 ( p ≤ .001) and performance was d = 1.610 ( p ≤ .001). Findings indicate that simulation-based interventions have a positive effect on knowledge and performance. As simulation is increasingly used as a teaching modality in nursing, further research should aim to test standardized simulation-based education programs.

An observational study of antipsychotic medication use among long-stay nursing home residents without qualifying diagnoses.

WHAT IS KNOWN ON THE SUBJECT?: In the United States, 15.5% of nursing home residents without qualifying diagnoses of schizophrenia, Huntington's' Disease, and/or Tourette Syndrome receive antipsychotic medications. Antipsychotic medications are used off-label (i.e., used in a manner the United States Food and Drug Administration's packaging insert does not specify) to treat neuropsychiatric symptoms, often before attempting nonpharmacologic interventions, despite evidence that this drug class is associated with significant adverse events including death. Less than optimal staffing resources and lack of access to geropsychiatric specialists are barriers to reducing antipsychotic use. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Antipsychotic use occurred in 11.6% of nursing home residents without qualifying or potentially qualifying diagnoses (bipolar disorder and psychotic disorder); antipsychotic use was more prevalent in residents with a dementia diagnosis than those without. One additional registered nurse hour per resident day could reduce the odds of antipsychotic use by 52% and 56% for residents with and without a dementia diagnosis respectively. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Given the influence of total staffing and professional staff mix on risk of antipsychotic use, nursing home administrators may want to consider aspects of facility operation that impact antipsychotic use. More stringent Unites States' survey and certification standards for dementia care implemented in 2017 demand proactive person-centered care that promotes maximal well-being and functioning without risk of harm from inappropriate psychoactive medications. Mental health nurses have requisite training to provide expert person-centered care to nursing home residents with mental illness and geropsychiatric disorders. ABSTRACT: Introduction Antipsychotic use in nursing homes varies widely across the United States; inadequate staffing, skill mix, and geropsychiatric training impede sustained improvement. Aim This study identified risk factors of antipsychotic use in long-stay residents lacking qualifying or potentially qualifying diagnoses. Method This secondary analysis used 2015 Minimum Data Set and cost report data from 458 Missouri nursing homes. The full sample (N = 29,679) was split into two subsamples: residents with (N = 15,114) and without (N = 14,565) a dementia diagnosis. Separate logistic regression models were run. Results Almost 15% of the dementia subsample and 8.4% of the nondementia subsample received an antipsychotic medication in the past week. Post-traumatic stress disorder, psychosis indicators, behavioral symptoms, anxiety medication with and without anxiety diagnosis, depression medication with and without depression diagnosis, and nurse staffing were among the strongest predictors of antipsychotic use in both subsamples. Simulation analyses showed decreased odds of receiving an antipsychotic in both subsamples when registered nurse hours matched the national average. Discussion Matching nurse staffing mix to the national average may improve antipsychotic use in nursing homes. Implications Knowledge of antipsychotic use risk factors use can inform care planning and staff education to minimize use of these medications in all but severe cases.

Exploring Path Models of Disablement in Residential Care and Assisted Living Residents.

This study examined the relationships between individual and environmental factors and physical activity, and between physical activity and functional limitations and disability in residential care/assisted living (RC/AL) residents. Participants completed questionnaires and physical performance tests, and wore the Fitbit Motion Tracker® to capture physical activity. Model fit was analyzed using two-level path models with residents nested within RC/AL settings. Model parameters were estimated using the MPlus robust maximum likelihood method. A multilevel model with good fit (root mean square error of approximation = 0.07, comparative fit index [CFI] = 0.91) showed that persons with greater exercise self-efficacy were more physically active, and persons who were more physically active had better physical function and less disability. Setting-level factors did not significantly correlate with physical activity or disability. Although environmental factors may influence physical activity behavior, only individual factors were associated with physical activity in this sample of RC/AL residents.

Using Embedded Sensors in Independent Living to Predict Gait Changes and Falls.

This study explored using Big Data, totaling 66 terabytes over 10 years, captured from sensor systems installed in independent living apartments to predict falls from pre-fall changes in residents' Kinect-recorded gait parameters. Over a period of 3 to 48 months, we analyzed gait parameters continuously collected for residents who actually fell ( n = 13) and those who did not fall ( n = 10). We analyzed associations between participants' fall events ( n = 69) and pre-fall changes in in-home gait speed and stride length ( n = 2,070). Preliminary results indicate that a cumulative change in speed over time is associated with the probability of a fall ( p < .0001). The odds of a resident falling within 3 weeks after a cumulative change of 2.54 cm/s is 4.22 times the odds of a resident falling within 3 weeks after no change in in-home gait speed. Results demonstrate using sensors to measure in-home gait parameters associated with the occurrence of future falls.