Development of a master of science, nursing and interprofessional leadership program: AACN essentials in action.

BACKGROUND: Leadership acumen, interprofessional relationships, and knowledge of healthcare operations are essential proficiencies for nurses to navigate the dynamic and complex healthcare landscape. The American Association of Colleges of Nursing (AACN) re-envisioned the academic nursing standards, The Essentials: Core Competencies for Professional Nursing Education (Essentials), to guide curricular development in preparing nurses with the aptitude to meet these challenges. PURPOSE: The purpose of this project was to develop an innovative Master of Science nursing program to address the challenges facing the RN workforce. METHODS: A relationship-based framework and the Analysis, Design, Development, Implementation and Evaluation (ADDIE) model were used to guide the development of the program using the Essentials to inform curricular design. RESULTS: A Nursing and Interprofessional Leadership Master of Science program was designed comprising seven core courses with two tracks, Bachelor of Nursing and Post Graduate Option. LIMITATION: The program was created during the COVID-19 pandemic, which may have influenced the data used for the program's design. CONCLUSION: Healthcare complexities are requiring nursing education to evaluate curricula for advanced knowledge and skills. A Nursing and Interprofessional Leadership Master of Science degree program guided by the Essentials was developed to meet this challenge.

Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in the Elderly with Alzheimer's Disease (D-PRESCRIBE-AD): Trial protocol and rationale of an open-label pragmatic, prospective randomized controlled trial.

CONTEXT: Potentially inappropriate prescribing of medications in older adults, particular those with dementia, can lead to adverse drug events including falls and fractures, worsening cognitive impairment, emergency department visits, and hospitalizations. Educational mailings from health plans to patients and their providers to encourage deprescribing conversations may represent an effective, low-cost, "light touch", approach to reducing the burden of potentially inappropriate prescription use in older adults with dementia. OBJECTIVES: The objective of the Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer's Disease (D-PRESCRIBE-AD) trial is to evaluate the effect of a health plan based multi-faceted educational outreach intervention to community dwelling patients with dementia who are currently prescribed sedative/hypnotics, antipsychotics, or strong anticholinergics. METHODS: The D-PRESCRIBE-AD is an open-label pragmatic, prospective randomized controlled trial (RCT) comparing three arms: 1) educational mailing to both the health plan patient and their prescribing physician (patient plus physician arm, n = 4814); 2) educational mailing to prescribing physician only (physician only arm, n = 4814); and 3) usual care (n = 4814) among patients with dementia enrolled in two large United States based health plans. The primary outcome is the absence of any dispensing of the targeted potentially inappropriate prescription during the 6-month study observation period after a 3-month black out period following the mailing. Secondary outcomes include dose-reduction, polypharmacy, healthcare utilization, mortality and therapeutic switching within targeted drug classes. CONCLUSION: This large pragmatic RCT will contribute to the evidence base on promoting deprescribing of potentially inappropriate medications among older adults with dementia. If successful, such light touch, inexpensive and highly scalable interventions have the potential to reduce the burden of potentially inappropriate prescribing for patients with dementia. ClinicalTrials.gov Identifier: NCT05147428.

High-Risk Medications in Persons Living With Dementia: A Randomized Clinical Trial.

Importance: Individuals with Alzheimer disease (AD) and Alzheimer disease-related dementias (ADRD) may be at increased risk for adverse outcomes relating to inappropriate prescribing of certain high-risk medications, including antipsychotics, sedative-hypnotics, and strong anticholinergic agents. Objective: To evaluate the effect of a patient/caregiver and prescriber-mailed educational intervention on potentially inappropriate prescribing to patients with AD or ADRD. Design, Setting, and Participants: This prospective, open-label, pragmatic randomized clinical trial, embedded in 2 large national health plans, was conducted from April 2022 to June 2023. The trial included patients with AD or ADRD and use of any of 3 drug classes targeted for deprescribing (antipsychotics, sedative-hypnotics, or strong anticholinergics). Interventions: Patients were randomized to 1 of 3 arms: (1) a mailing of educational materials specific to the medication targeted for deprescribing to both the patient and their prescribing clinician; (2) a mailing to the prescribing clinician only; or (3) a usual care arm. Main Outcomes and Measures: Analysis was performed using a modified intention-to-treat approach. The primary study outcome was the dispensing of the medication targeted for deprescribing during a 6-month study observation period. Secondary outcomes included changes in medication-specific mean daily dose and health service utilization. Results: Among 12 787 patients included in the modified intention-to-treat analysis, 8742 (68.4%) were female, and the mean (SD) age was 77.3 (9.4) years. The cumulative incidence of being dispensed a medication targeted for deprescribing was 76.7% (95% CI, 75.4-78.0) in the patient and prescriber mailing group, 77.9% (95% CI, 76.5-79.1) in the prescriber mailing only group, and 77.5% (95% CI, 76.2-78.8) in the usual care group. Hazard ratios were 0.99 (95% CI, 0.94-1.04) for the patient and prescriber group and 1.00 (95% CI, 0.96-1.06) for the prescriber only group compared with the usual care group. There were no differences between the groups for secondary outcomes. Conclusions and Relevance: These findings suggest medication-specific educational mailings targeting patients with AD or ADRD and their clinicians are not effective in reducing the use of high-risk medications. Trial Registration: ClinicalTrials.gov Identifier: NCT05147428.

Motivating deprescribing conversations for patients with Alzheimer's disease and related dementias: a descriptive study.

Introduction: Older adults with Alzheimer's disease and related dementias (ADRD) are at increased risk of harm due to prescribing of potentially inappropriate medications. Encouraging patients and caregivers to talk with their providers about potentially inappropriate medications could stimulate deprescribing. Our objective was to explore whether mailing educational materials to patients with ADRD might activate patients or caregivers to initiate a conversation with their provider about potentially inappropriate medications. Methods: We conducted semi-structured interviews with patients with ADRD, caregivers of patients with ADRD, and healthcare providers. All participants were shown educational materials referencing potentially inappropriate medications and suggestions to promote deprescribing. Interviews explored reactions to the materials, the idea of patients and caregivers initiating a conversation about deprescribing, and the deprescribing process. Interview transcripts were analyzed using inductive thematic analysis. Results: We conducted a total of 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient-caregiver dyads, and 13 with providers. Patients and caregivers reported that if a medication might cause harm, it would motivate them to talk to their provider about the medication. Trust in the provider could facilitate or inhibit such conversations; conversations would be more likely if there were prior positive experiences asking questions of the provider. Providers were receptive to patients and caregivers initiating conversations about their medications, as they valued deprescribing as part of their clinical practice and welcome informed patients and caregivers as participants in decision-making about medication. Conclusion: Mailing educational materials about potentially inappropriate medications to community-dwelling patients with ADRD may promote deprescribing conversations. Ongoing pragmatic trials will determine whether such interventions stimulate deprescribing conversations and achieve reductions in prescribing of inappropriate medications. Plain Language Summary: Encouraging patients with Alzheimer's disease to talk with their providers about medications that may cause harm Introduction: Older adults with Alzheimer's disease and related dementias (ADRD) are sometimes prescribed medications that may cause harm, especially when taken for extended periods of time. Patients and their caregivers may not know about the risks. Doctors know of the risks but may not address them due to competing priorities or other challenges in providing care to these patients with complex needs. Encouraging the patient or their caregiver to talk to their doctor about their medications might help to reduce the use of medications that are not beneficial. This study's goal was to explore whether sending educational materials to patients with ADRD might encourage patients or caregivers to ask their doctor about their medications.Methods: We interviewed patients with ADRD, caregivers, and doctors. We showed them educational materials that suggested patients and their caregivers talk to their doctor about reducing or stopping medications that may be harmful. We asked for reactions to the materials and to the idea of talking to the doctor about stopping the medication.Results: We conducted 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient-caregiver dyads, and 12 with doctors. Patients and caregivers said learning that a medication might cause harm would motivate them to talk to their doctor about the medication. Trust in their doctor was important. Some patients and caregivers were comfortable asking questions about medications, while others were reluctant to challenge the doctor. Doctors were open to patients and caregivers asking about medications and felt it was important that patients not take medications that are not needed.Conclusion: Sending educational materials to patients with ADRD and caregivers may encourage them to talk with their doctors about stopping or reducing medications. Studies are needed to learn whether such materials lead to reductions in prescribing of potential harmful medications.

Mutual caregiving: Living meaningfully as an older couple.

BACKGROUND: More older couples are living independently while managing chronic health conditions. Though research is replete in identifying the influence of spouse's behaviours on each other's health, there is little known of the specific factors underlying the older couples' relational processes to explain this dynamic. Knowledge development is needed to provide a grounding for interventions to address such influences to improve health and well-being. AIM: The aim of this study was to advance the understanding of older couples' experiences of living with chronic health conditions to gain insights into the potential benefits of 'being a couple' to manage behavioural health and life adjustments. METHOD: A hermeneutic-dialectic phenomenology design based on Newman's theory of Health as Expanding Consciousness was used. Fourteen older couples were jointly interviewed. The interviews were non-structured and designed to capture their experience as a couple. RESULTS: Three themes emerged (a) living meaningfully through mutual caregiving, (b) a pattern of spousal movement facilitating change and (c) co-creating as an older couple to move forward. CONCLUSION: The study supports reframing older couple's care as a 'dyad of care'. This approach provides an opportunity to leverage the couples' mutuality to support health management as a couple. A motivation to action process between the spouses appeared to enable mutual caregiving, a reliance of each spouse on the another for identity, socialisation, health and daily living, which facilitated an evolving understanding of their lives and its meaning. IMPLICATIONS FOR PRACTICE: Mutual caregiving should be acknowledged as a significant relational dynamic within older couples, as a dyad of care, when managing health and well-being.

Couples' experiences with continuous positive airway pressure treatment: a dyadic perspective.

OBJECTIVE: The majority of adults sleep with a partner, making sleep a dyadic experience. However, interventions to improve sleep have primarily focused on individuals. This qualitative analysis used a dyadic approach to identify facilitators and barriers to successful treatment of one of the most common sleep disorders, obstructive sleep apnea, with continuous positive airway pressure (CPAP). METHODS: Twenty joint qualitative interviews were conducted with couples, one couple at a time, with a sample of 20 patients with obstructive sleep apnea and their partners to develop an understanding of couples' experiences with CPAP use. Interviews were audio recorded and transcribed. Conventional qualitative content analysis was used to analyze the interview data. RESULTS: Facilitators of CPAP use were the following: the partner aiding diagnosis and treatment, couples working together using CPAP, the perceived benefits of CPAP for both partners, the patient being motivated to use CPAP for the benefit of the partner, and various types of support provided by the partner to encourage CPAP use. Major barriers to CPAP use were the following: anxiety related to CPAP use particularly in the beginning of therapy, bothersome equipment causing disruptions in sleep and bedtime routine, interruptions to intimacy, and concern about image change while wearing CPAP. CONCLUSIONS: Findings from this study suggest that couple-directed interventions that advocate for a mutually engaging perspective and promote supportive relationships and positive dyadic coping may be targets for improving CPAP adherence. Further research evaluating the potential of couple-focused interventions to improve sleep health is warranted.

Procedural sedation and implications for quality and risk management.

A successful procedural sedation program requires a robust institutional policy backed by a solid educational program and an administrative structure. Given the nature of the services provided, combined with the growth in complexity of both patients and procedures, sedation presents a potential liability for both the provider and the institution. A sedation program is built with a multidisciplinary team of experts representing all stakeholders: healthcare providers, risk and quality improvement managers, and facility administration. An institutional procedural sedation policy should be based on nationally and state recognized practice requirements and guidelines. Clinical care must be supported with a robust risk and quality structure built within the program to ensure best practice at the point of care.

Restraint management: moving from outcome to process.

Restraint management continues to be a challenge despite years of attention to the issue. This article demonstrates how a restraint prevention program, built on an analysis of care processes and a set of "bundled" interventions, can successfully decrease restraint prevalence and enhance safe patient care.