" I'm not a risk taker " : Risk Perceptions of Nursing Home Residents With Dementia.

BACKGROUND: Persons living with Alzheimer disease and related dementia (ADRD) in nursing homes (NH) are often excluded from conversations about their health/safety. These omissions impinge on personhood and the rights to have care preferences heard and honored. While persons with ADRD maintain the ability to communicate their preferences long after their decision-making abilities are affected, little is known about how persons with ADRD understand the risks associated with their preferences. METHODS: As part of a larger focused ethnography, in-depth interviews and an adapted risk propensity questionnaire explored the risk perceptions of NH residents with ADRD (N=7) associated with their preferences for care and activities of daily living. RESULTS: Residents generally self-identified as risk avoiders ( M =3.2±1.84) on the risk propensity scale and were able to rate risk associated with preferences described within 5 thematic categories: 1) participation in decision-making, 2) risk awareness, 3) paying attention to safety, 4) reliance on nursing home staff and family, and 5) impacts on quality of life and quality of care. DISCUSSION: Results suggest NH residents with ADRD can express risk surrounding their preferences and should be encouraged to participate in discussions about their health and safety.

Evaluating the Implementation of the Individualized Positive Psychosocial Interaction (IPPI) as a Quality Improvement Project in Nursing Homes.

OBJECTIVES: The Individualized Positive Psychosocial Interaction (IPPI) is a non-pharmacological, person-centered, intervention for nursing home (NH) residents living with moderate to severe dementia. The purpose of this study was to assess the pragmatic implementation of the IPPI by leveraging Ohio's Nursing Home Quality Improvement Program (QIP). METHODS: Implementation teams collected resident mood ratings pre- and post-IPPI and completed virtual interviews to assess their Organizational Readiness for Implementing Change as well as the acceptability, feasibility, and appropriateness of the IPPI. Implementation strategies included: providing ongoing consultation; identifying and preparing champions; assessing for readiness and identifying barriers; and developing and distributing effective educational materials. RESULTS: Fifteen NHs completed the QIP (65% completion rate) and reported high organizational commitment to change and high change efficacy. NHs engaged n = 65 residents in n = 638 IPPIs. Residents experienced a positive mood change after 47% of IPPIs. NHs found the IPPI program to be highly acceptable, feasible, and appropriate. CONCLUSIONS: Overall, 65% of NHs successfully implemented the IPPI QIP with people living with moderate to severe dementia. CLINICAL IMPLICATIONS: Given the positive mood changes and high staff satisfaction, results suggest that these brief, individualized activities can be effective strategies to address the communication of distress among PLWD.

The PELI-D II Study: Development and Preliminary Validation of the Preferences for Leisure Activities Inventory (P-LAI) for Adult Day Services.

OBJECTIVES: The current study aimed to develop and preliminarily validate an initial version of an instrument to assess the leisure activity preferences of people receiving adult day services (ADS). METHODS: Based on previously conducted concept mapping steps, we identified 12 clusters of preferences for leisure activities. We adopted the structure of the Preferences for Everyday Living Inventory and phrased our cluster labels as questions to develop a first draft of the Preferences for Leisure Activities Inventory (P-LAI). We conducted cognitive interviews (n = 8) to revise, preliminarily validate, and preliminarily finalize the P-LAI. RESULTS: The draft of the P-LAI included 25 questions. Based on the results of the cognitive interviews, the number of questions was reduced to 21, three questions were rephrased, and evidence to support the preliminary validity of the P-LAI based on the response processes was provided. CONCLUSIONS: The P-LAI is the first instrument to assess preferences for leisure activities in the ADS environment. CLINICAL IMPLICATIONS: The preliminary results of the P-LAI allow ADS providers and healthcare professionals to assess the preferences for leisure activities of people who receive ADS in a structured way. Based on these results, preference-based services can be designed and planned, and the person-centered philosophy of care can be further operationalized in the ADS environment.

Can Implementing Person-Centered Care Tools Reduce Complaints? Evidence from the Implementation of PELI in Ohio Nursing Homes.

Nursing homes receive complaints when actual care provided to residents misaligns with desired care, suggesting that person-centered care (PCC) and honoring resident preferences in care delivery may help prevent complaints from arising. We explore whether nursing home implementation of a PCC tool, the Preferences for Everyday Living Inventory (PELI), is related to measures of complaints. Publicly available data on Ohio nursing homes was used to examine 1,339 nursing home-year observations. Regression techniques were used to evaluate the relationship between the extent of PELI implementation and four complaint outcomes: any complaint, number of complaints, any substantiated complaint, and number of substantiated complaints. Nursing homes with complete PELI implementation were less likely to have any complaints by 4.7% points (P < .05) and any substantiated complaints by 11.5% points (P < .001) as compared to partial PELI implementers. When complete PELI implementers did have complaints, they were fewer than partial PELI implementers. Complete PELI implementers were not immune from receiving complaints; however, the complaints they did receive were fewer in number and less likely to be substantiated as compared to communities who only partially implemented a PCC tool.

Pathway From Type 2 Diabetes Diagnosis to Action: How to Move People Forward.

Seven self-care behaviors-healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem-solving-are recommended for individuals with diabetes to achieve optimal health and quality of life. People newly diagnosed with type 2 diabetes may find it challenging to learn and properly incorporate all of these self-care behaviors into their life. This qualitative study explored the experiences and perceived immediate self-management and psychosocial support needs in individuals newly diagnosed with type 2 diabetes. Data analysis revealed the significant challenges individuals encounter after a type 2 diabetes diagnosis. Five main themes were identified: 1) type 2 diabetes diagnosis competes with other complex life challenges, 2) difficulty in performing behavior modification actions, 3) lack of support, 4) emergence of emotional and psychological issues, and 5) need for planned individualized follow-up support after a type 2 diabetes diagnosis. This study revealed a gap in care after type 2 diabetes diagnosis. Individualized support is needed to assist people in moving successfully from diagnosis to being well equipped with the knowledge and skills necessary to properly manage the condition.

Remodeling Type 2 Diabetes Diagnosis: What Individuals Need for Success.

The diagnosis of type 2 diabetes initiates a new health-illness transition. However, little is known about the immediate support that people need to successfully cope with this diagnosis. This qualitative study explored the experiences and immediate support needed at the point of diagnosis among individuals with type 2 diabetes. The findings suggest the need for health care professionals to render immediate emotional support in the form of reassurance and partnership to manage the condition together. Pre- and post-counseling sessions can minimize the emotional and psychological strain associated with the new diagnosis. Individuals should be given information on available resources, as well as an immediate connection with a health care partner who can provide guidance and help with the transition.

12-month trajectory and predictors of affect balance in nursing home residents living with dementia.

Objectives:Emotional expressions in late-stage dementia have traditionally been studied within a deficit paradigm. Moving the narrative of the dementia trajectory from a solely negative pathological experience to one that acknowledges the potential for positive experiences aligns with international recommendations for living well with dementia. The purpose of this study was to extend prior research by examining the pattern of well-being using affect balance, the ratio of positive to negative affect, in nursing home residents living with dementia over 12 months and its association to factors that could potentially influence resident well-being.Method:This study was a secondary analysis of baseline, 4 and 12-month data from a pragmatic clinical trial. A total of 536 residents with moderate to severe cognitive impairments from 55 nursing homes were included in the multivariable linear mixed model regression analyses.Results:Resident function, the number of registered nurse hours devoted to care in the facility, and the quality of staff interaction predicted higher affect balance over time after controlling for other variables.Conclusion:The findings provide support for the utility of affect balance as a meaningful outcome measure of well-being for persons living with dementia. In addition, results point to specific interventions (i.e. maintaining/improving resident function, providing adequate nurse staffing levels, and improving staff communications skills) that can serve as the focus for both research and practice to help residents live well with dementia. Clinicaltrials.gov (NCT03014570).

Racial Disparities in Care Interactions and Clinical Outcomes in Black Versus White Nursing Home Residents With Dementia.

BACKGROUND: With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised. PURPOSE: The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months. METHODS: This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included. RESULTS: Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department. CONCLUSIONS: Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions.

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.].

Instruments for assessing the preferences for everyday living of older people with various care needs across different care settings: an evidence map.

Considering the preferences for everyday living of older people with various care needs across different care settings is important in nursing care. Currently, there is no systematic overview of the various instruments, and it is unclear what instruments exist, and which preferences they measure. We systematically searched for studies in the electronic databases MEDLINE, CINAHL and PsycInfo. Title/abstract and full text screening were performed independently by two researchers. We mapped and described the identified instruments in two tables and one interactive evidence atlas. We identified 67 instruments for assessing the preferences for everyday living of older people with various care needs across different care settings. We clustered the identified instruments into two main categories: broad and specific. The results show a wide range of instrument types and assessment methods. Research gaps exist, for instruments developed for assessing preferences comprehensively for a particular topic for everyday living, particular populations, and settings.

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives.

BACKGROUND: Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders' perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings. METHODS: EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. RESULTS: The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning. CONCLUSION: Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success. TRIAL REGISTRATION: The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov ( NCT03014570 ) January 9, 2017.

Implementation of the Evidence Integration Triangle for behavioral and psychological symptoms of dementia (EIT-4-BPSD) in care communities.

BACKGROUND: Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches. PURPOSE: This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD. METHODS: About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model. FINDINGS: There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation. DISCUSSION: EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided.

Differences in Staff-Resident Interactions Between Male and Female Residents in Nursing Homes.

The purpose of the current study was to describe gender differences in the quality of interactions between nursing home residents with behavioral and psychological symptoms of dementia and staff. Data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) implementation study were used for the current study. A total of 535 residents (72% female and 28% male) from 55 settings were included in the analyses. The highest percentage of interactions occurred in dining rooms (38.4%) and with nursing staff (68%). There were no significant differences in the quality of staff interactions with male or female residents. Most interactions were positive social (n = 360, 71% males, 66% females), positive care (n = 312, 60% males, 58% females), or neutral (n = 123, 25% males, 22% females). There were 31 (7% males, 6% females) negative protective and 23 (3% male, 5% female) negative restrictive interactions. Future work should focus on eliminating neutral and negative interactions across both genders and address whether the gender of staff is related to the quality of staff-resident interaction. [Journal of Gerontological Nursing, 47(5), 19-25.].

"It's Been a Whole New World": Staff Perceptions of Implementing a Person-Centered Communication Intervention During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) has challenged the way nursing homes deliver person-centered care (PCC). Preferences for Activity and Leisure (PAL) Cards are a tool to communicate residents' important preferences to staff. Monthly interviews (N = 32) were conducted with champions who were conducting a PAL Card quality improvement project in Tennessee nursing homes (N = 11) between March and August 2020. Three major themes emerged: Structural Changes (e.g., halting admissions, adding an isolation unit), Resident Burden (e.g., physical isolation, loneliness), and Provider Burnout (e.g., increased workload, mental exhaustion). Further, providers expressed the benefits to using PAL Cards, specifically in regard to blunting the negative impact of each theme. Results showed the overall negative impact of COVID-19 on nursing home communities. Nursing staff experienced greater burden than other staff, reflecting their prominent role in providing direct care to residents with COVID-19. Staff reported that PAL Cards helped promote PCC. [Journal of Gerontological Nursing, 47(5), 9-13.].

Development of the 'Intimacy and Sexuality Expression Preference' tool for residential aged care.

OBJECTIVES: To outline development of the Intimacy and Sexuality Expression Preference (ISEP) tool that elicits preferences for the expression of intimacy and sexuality of older people, living with and without dementia, in residential aged care. METHODS: Using two rounds of the Delphi technique involving 14 panelists, tool items were evaluated for importance, usefulness, relevancy and clarity on a 5-point Likert scale. RESULTS: All tool items achieved a mean score of ≥3.4 across the four areas of evaluation with an overall average tool-level content validity index of 0.89. Instructions were deemed appropriate (M=4.6; SD=0.8), easy to understand and simple to follow (M=4.6; SD=0.6). DISCUSSION: The ISEP tool can improve care and support older people's expression of intimacy and sexuality from a person-centered approach. Further research into the use of the tool in 'real' residential aged care settings is required to establish external validity prior to implementation.

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.

Preference Consistency: Veteran and Non-Veteran Nursing Home Resident Self-Reported Preferences for Everyday Living.

Understanding patient preferences is core to person-centered care. The consistency of everyday preference reporting was assessed comparing responses of Veteran (VA) and non-VA nursing home (NH) residents on the Preferences for Everyday Living Inventory (PELI) at baseline and 5 to 7 days later. Non-VA NH residents demonstrated higher perfect agreement than VA residents (66% vs. 56%, respectively) and higher acceptable agreement (95% vs. 88%, respectively). Multiple regression analyses examined significant predictors of reliability using demographics, cognitive functional variables, and interviewer ratings. In the VA group, higher perfect agreement was associated with residents who were less likely to have hearing deficits, better cognition, and better interviewer ratings related to energy, attention, and comprehension. In the non-VA group, higher perfect agreement was associated with residents who were younger and more independent with walking. Overall, higher agreement was associated with being female, non-VA, and having better cognition. Implications for future research and clinical practice are highlighted. [Journal of Gerontological Nursing, 46(3), 15-25.].

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.].

Reliability and Validity of the Adult Hope Scale among Nursing Home Residents with and without Cognitive Impairment.

Objectives: The current study aims to examine the reliability and validity of the Adult Hope Scale among older adults with and without cognitive impairment who were recently admitted to a nursing home.Methods: Sixty-four recently admitted nursing home residents, 32 of whom had cognitive impairment, were administered the Adult Hope Scale and measures of concurrent and divergent validity.Results: In this sample, the Adult Hope Scale demonstrated good to excellent reliability. The Adult Hope Scale also correlated as expected with measures of concurrent and divergent validity, thus supporting the validity of the scale to measure hope in older adults despite level of cognitive functioning.Conclusions: This study shows that the Adult Hope Scale is a reliable and valid measure of hope in this sample of older adults with and without cognitive impairment who were recently admitted to a nursing home. Given the small sample size, additional research on the psychometric properties of the utility of the Adult Hope Scale in older adults with and without cognitive impairment is warranted.Clinical Implications: These preliminary findings allow future researchers and clinicians to consider administration of the Adult Hope Scale to individuals with and without cognitive impairment living in long-term care facilities. Gathering additional data on the psychometrics of this measure will enable new directions in research involving self-report measures for older adults with cognitive impairment, and in the development of interventions involving hope to improve physical and mental health in long-term care residents.

Treatment fidelity evidence for BE-ACTIV - a behavioral intervention for depression in nursing homes.

Objectives: Evidence-based depression therapies are difficult to implement in nursing homes. We present data for BE-ACTIV, a 10-week depression treatment designed for implementation in nursing homes, to address questions of treatment fidelity (delivery, receipt, and enactment) in that context. Method: Participants were 41 patients from 13 nursing homes in the treatment arm of a clinical trial, treated by graduate student therapists. Therapists and their supervisor rated their audio-recorded sessions for adherence to treatment protocol and session quality. Results: Delivery of core program elements averaged from 80-94% across all sessions; mean quality was 5.6 (SD 0.61) out of 6 points. Delivery of core components to nursing home activities staff who collaborated in the treatment was similarly high. Patients received an average of 7.32 sessions (SD 3.39); 17 completed 10 sessions. The theoretical basis of BE-ACTIV is behavioral activation; therapist-client dyads planned new pleasant events weekly, from a mean of 3.66 (SD 1.35) after the first session to a mean of between 5 and 6 activities a week across sessions 6-9, with a similar progression in percent activities completed. Activities enactment was significantly related to the likelihood of remission at post-treatment, and of maintaining improvement at 3-month follow-up. Treatment receipt and enactment were also related to improved mood from baseline to 3 months. Conclusion: Results demonstrate delivery, receipt, and successful enactment of BE-ACTIV core components in diverse nursing homes and patients, and support the theoretical premise of the intervention. These findings support further implementation work for the BE-ACTIV intervention.