The aging veteran population: Promoting awareness to influence best practices.

The older adult population is the most rapidly growing population in the United States. It is projected that by 2035, the population of adults older than 65 years is expected to be greater than the population of children. The projected number of Veterans age 60 and older is about 11 million. Along with common age-related complex and high-risk chronic medical conditions, care of older adult Veteran requires a holistic approach that focuses on the culture, and subcultures, and unique health care needs resultant of military service. Veterans' health care is often multifocal and complex, requiring an integrated, collaborative, and comprehensive model of care that better facilitates meeting health goals to the degree most realistic and attainable for each older adult Veteran. This highlights the need to promote awareness and provide educational opportunities for engaging in best practices that meet the unique needs of the aging Veteran population.

An online education approach to population health in a global society.

BACKGROUND: Health professions education content must keep pace with the ever-evolving and changing health care system. Population-based health care is advocated as a way to improve health outcomes, particularly in a technologically advanced health system like the United States. At the same time, global health knowledge is increasingly valued in health professions education, including nursing. AIMS: This article describes the design and implementation of an online population health course with a global viewpoint intended to accommodate the need for improved knowledge and skill application for graduate nurses. Attention was also given to faculty efficiency during the process of design and implementation. MATERIALS AND METHODS: This population-global health course was piloted in a renovated master's curriculum for two semesters. Administering a Course Improvement Survey after initial course offerings assisted faculty to assess and target essential course changes. Data were collected from 106 registered nurse graduate students. RESULTS: Population and global health course objectives were met and students identified areas for course enhancement. Students (90%-94%) reported achieving increased knowledge of population health and global health. DISCUSSION: Like other creative works, the first rendition of a course requires pedagogical adjustments and editing. Formal student input, when built into the design and implementation of a course can assist faculty to be efficient when crafting essential course changes for subsequent semesters. Data from the survey showed that major population and global subject matter was being grasped by students, the data also revealed that tweaking specific online strategies like making all course content mobile would enhance the course. CONCLUSION: The course development process and course improvement evaluation for this Population Health in a Global Society course proved valuable in the education of nurses, and helped maintain faculty work efficiency.

Meeting a Growing Need: An Online Approach to Cultural Competence Education for Health Professionals.

ABSTRACT: Prelicensure education may inadvertently lead to a belief that learning about different cultures is an end point, whereas cultural competency is an ongoing process. An online cultural competency education module incorporating organizational cultural assessment was developed for graduate nursing education. After completion, nurses have reported intent to continue career-long cultural competence learning and expressed determination to promote cultural competence in organizations where they work and lead.

Routine 24-Hour Computed Tomography Brain Scan is not useful in stable patients Post Intravenous Tissue Plasminogen Activator.

BACKGROUND: Obtaining a routine computed tomography (CT) brain scan 24 hours after treatment with intravenous tissue plasminogen activator (IV-tPA) is included in the American Heart Association/American Stroke Association acute stroke guidelines. The usefulness of the test in stable patients is not known. We hypothesized that the results of routine, 24-hour post-treatment neuroimaging (CT or magnetic resonance imaging [MRI] brain scans) would not alter the management of clinically stable patients. METHODS: Patients treated with IV-tPA between January 2011 and December 2013 were identified from a single hospital's stroke registry. All patients were closely monitored for changes in stroke severity. Demographics, changes in neurological status, neuroimaging results, and changes in therapy were abstracted from the patients' medical records. Patients having a neuroimaging study because of neurological deterioration were excluded. RESULTS: Of 136 patients treated with IV-tPA, 131 met criteria for inclusion. Of these, 86.7% had moderate to severe neurological deficits (i.e., initial National Institutes of Health Stroke Scale score > 5 points; median 8 points). All patients had routine imaging ~24 hours after treatment (CT brain 62.6%, MRI brain 12.4%, both CT and MRI brain 25%). Asymptomatic hemorrhagic transformation occurred in 6.7% and potentially changed management in a single patient (target systolic blood pressure was lowered from 185 to 180 mmHg). CONCLUSIONS: Over a 3-year period, routine neuroimaging ~24-hours after IV-tPA in clinically stable patients was associated with a change in therapy in only 1 (.95%) patient. If confirmed in other cohorts, these results suggest that routine neuroimaging after IV-tPA may be safely avoided in clinically stable patients, eliminating unnecessary radiation exposure in those having CT brain and reducing costs.

Regulation and mindful resident care in nursing homes.

Regulatory oversight is intended to improve the health outcomes of nursing home residents, yet evidence suggests that regulations can inhibit mindful staff behaviors that are associated with effective care. We explored the influence of regulations on mindful staff behavior as it relates to resident health outcomes, and offer a theoretical explanation of why regulations sometimes enhance mindfulness and other times inhibit it. We analyzed data from an in-depth, multiple-case study including field notes, interviews, and documents collected in eight nursing homes. We completed a conceptual/thematic description using the concept of mindfulness to reframe the observations. Shared facility mission strongly impacted staff perceptions of the purpose and utility of regulations. In facilities with a resident-centered culture, regulations increased mindful behavior, whereas in facilities with a cost-focused culture, regulations reduced mindful care practices. When managers emphasized the punitive aspects of regulation we observed a decrease in mindful practices in all facilities.

Barriers to and facilitators of clinical practice guideline use in nursing homes.

OBJECTIVES: To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs). DESIGN: Qualitative analysis. SETTING: Four randomly selected community nursing homes. PARTICIPANTS: NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs). MEASUREMENTS: Interviews (n=35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description. RESULTS: None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were "checklists" to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities. CONCLUSION: Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.

Avoiding socialization pitfalls in accelerated second-degree nursing education: the returning-to-school syndrome model.

Second-degree students are highly motivated and tend to excel academically. However, nurse educators in accelerated programs face challenges in socializing these students to the nursing role. One pitfall is the hostility that may develop if students perceive a mismatch between their expectations and their new role as baccalaureate nursing (BSN) students in a fast-paced and intense program. This article discusses the applicability of the returning-to-school syndrome model in helping second-degree nursing students maneuver successfully through an accelerated BSN program. This 3-stage model has been previously applied in RN-to-BSN education. Using the model in an accelerated BSN curriculum to identify transition points and offer student support through specific stages can better prepare students to meet the challenges of accelerated education, as well as help nurse educators become more adept at providing resources and implementing supportive strategies at the appropriate time.

Exit interview-consultation for research validation and dissemination.

Dissemination of research findings to practice and maintenance of rigor and validity in qualitative research are continuing challenges for nurse researchers. Using three nursing home case studies as examples, this article describes how exit interview-consultation was used as (a) a validation strategy and (b) a rapid research dissemination tool that is particularly useful for nursing systems research. Through an exit interview-consultation method, researchers validated inferences made from qualitative and quantitative data collected in three comprehensive nursing home case studies that examined nursing management practices. This exit interview-consultation strategy extends the traditional member-check approach by providing confirmation at the individual and organizational level. The study examined how using the exit interview-consultation strategy can potentially assist nursing home organizations to increase their capacity for improving operations. Benefits from research participation are often indirect; this study's results suggest that exit interview-consultation can provide direct and immediate benefits to organizations and individuals.

MDS coordinator relationships and nursing home care processes.

This study describes how Minimum Data Set (MDS) coordinators' relationship patterns influence nursing home care processes. MDS coordinators interact with nursing home staff to coordinate resident assessment and care planning, but little is known about how they enact this role or influence particular care processes beyond paper compliance. Guided by complexity science and using two nursing home case studies, the authors describe MDS coordinators' relationship patterns by assessing the extent to which they used and fostered good connections, new information flow, and cognitive diversity. MDS coordinators at one site fostered new information flow, good connections, and cognitive diversity, which positively influenced assessment and care planning, whereas those at the other site did little to foster these three relationship parameters, with little influence on care processes. This study revealed that MDS coordinators are an important new source of capacity for the nursing home industry to improve quality of care.

Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science.

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical "chain of command" between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

Nurse assistant mental models, sensemaking, care actions, and consequences for nursing home residents.

In a nursing home case study using observation and interview data, the authors described two mental models that guided certified nurse assistants (CNAs) in resident care. The Golden Rule guided CNAs to respond to residents as they would want someone to do for them. Mother wit guided CNAs to treat residents as they would treat their own children. These mental models engendered self-control and affection but also led to actions such as infantilization and misinterpretations about potentially undiagnosed conditions such as depression or pain. Furthermore, the authors found that CNAs were isolated from clinicians; little resident information was exchanged. They suggest ways to alter CNA mental models to give them a better basis for action and strategies for connecting CNAs and clinical professionals to improve information flow about residents. Study results highlight a critical need for registered nurses (RNs) to be involved in frontline care.

"The Golden Rule": Only a starting point for quality care.

The Golden Rule guides people to choose for others what they would choose for themselves. The Golden Rule is often described as 'putting yourself in someone else's shoes', or 'Do unto others as you would have them do unto you'(Baumrin 2004). The viewpoint held in the Golden Rule is noted in all the major world religions and cultures, suggesting that this may be an important moral truth (Cunningham 1998). The Golden Rule underlies acts of kindness, caring, and altruism that go above and beyond "business as usual" or "usual care" (Huang, 2005). As such, this heuristic or 'rule of thumb' has universal appeal and helps guide our behaviors toward the welfare of others. So why question the Golden Rule? Unless used mindfully, any heuristic can be overly-simplistic and lead to unintended, negative consequences.A heuristic is a rule of thumb that people use to simplify potentially overwhelming or complex events. These rules of thumb are largely unconscious, and occur irrespective of training and educational level (Gilovich, Griffin & Kahneman 2002). Rules of thumb, such as the Golden Rule, allow a person to reduce a complex situation to something manageable-e.g., 'when in doubt, do what I would want done'. Because it is a simplifying tool, however, the Golden Rule may lead to inappropriate actions because important factors may be overlooked.In this article we describe "The Golden Rule" as used by administrators, supervisors, charge nurses, and CNAs in case studies of four nursing homes. By describing use of this rule-of-thumb, we aim to challenge nurses in nursing homes to: 1) be mindful of their use of "The Golden Rule" and its impact on staff and residents; and 2) help staff members think through how and why "The Golden Rule" may impact their relationships with staff and residents.

5 competencies needed by new baccalaureate graduates.

As nurse educators prepare new graduates for practice, part of the challenge is to ensure that these nurses are capable of functioning in a broad continuum of care with increased responsibilities. To identify competencies needed by new baccalaureate graduates in today's health care environment and determine whether these competencies fall into particular dimensions, a cross-sectional survey design was used to query 363 nurse administrators from three health care settings. Nurse administrators rated the importance of 45 nursing competencies. Factor analysis was conducted on the competency items, and factor scores were calculated to determine the importance ratings by work setting groups. Findings revealed a simple six-factor competency structure (Health Promotion Competency, Supervision Competency, Interpersonal Communication Competency, Direct Care Competency, Computer Competency, and Caseload Management Competency). MANOVA indicated significant differences in the importance of these competence factors by work setting. The findings are an important beginning for evidence-based decision-making about nursing curriculum reform, both in the classroom and clinical practice areas. The study also provides a foundation for further measurement of nursing competencies.

The Nature of Staff - Family Interactions in Nursing Homes: Staff Perceptions.

Each year thousands of older adults are admitted to nursing homes. Following admission, nursing home staff and family members must interact and communicate with each other. This study examined relationship and communication patterns between nursing home staff members and family members of nursing home residents, as part of a larger multi-method comparative case study. Here, we report on 6- month case studies of two nursing homes where in-depth interviews, shadowing experiences, and direct observations were completed. Staff members from both nursing homes described staff-family interactions as difficult, problematic and time consuming, yet identified strategies that when implemented consistently, influenced the staff-family interaction positively. Findings suggest explanatory processes in staff-family interactions, while pointing toward promising interventions.

Connection, regulation, and care plan innovation: a case study of four nursing homes.

We describe how connections among nursing home staff impact the care planning process using a complexity science framework. We completed six-month case studies of four nursing homes. Field observations (n = 274), shadowing encounters (n = 69), and in-depth interviews (n = 122) of 390 staff at all levels were conducted. Qualitative analysis produced a conceptual/thematic description and complexity science concepts were used to produce conceptual insights. We observed that greater levels of staff connection were associated with higher care plan specificity and innovation. Connection of the frontline nursing staff was crucial for (1) implementation of the formal care plan and (2) spontaneous informal care planning responsive to changing resident needs. Although regulations could theoretically improve cognitive diversity and information flow in care planning, we observed instances of regulatory oversight resulting in less specific care plans and abandonment of an effective care planning process. Interventions which improve staff connectedness may improve resident outcomes.