The Post-caregiving Health Model: A Theoretical Framework for Understanding the Health of Former Family Caregivers of Persons with Dementia.

Presently, there is a dearth of theoretical models to guide research on the population of former dementia caregivers. The purpose of this article is to describe the development of the Post-caregiving Health Model and its potential for generating a more nuanced understanding of the health of family caregivers following the death of a care recipient with dementia. The model highlights the impact of personal and environmental characteristics, appraisal, coping, and emotion on long-term health outcomes in this population and offers a viable framework for studying long-term health outcomes among caregivers following the care recipient's death.

Predictors of psychological distress and sleep quality in former family caregivers of people with dementia.

Objectives: The stress-related psychological symptoms experienced by informal family caregivers do not always improve or resolve after the death of the care recipient. The purpose of this study was to explore the independent associations of sociodemographic variables, personality and coping, environmental variables, and caregiver guilt with the sleep quality and psychological distress of former family caregivers of individuals with dementia following care recipient's death.Method: A cross-sectional, correlational study was conducted with a sample of 171 former family caregivers of people with dementia. Participants completed an online survey comprised of six instruments and demographic items. Caregiver personal variables (e.g. personality and coping), environmental variables, guilt, psychological distress (depressive and anxiety symptoms), and sleep quality were evaluated using psychometrically validated measures.Results: In bivariate analysis, post-caregiving guilt was significantly associated with depressive and anxiety symptoms (p < 0.01). After controlling for covariates, dysfunctional coping and neuroticism explained 32% of the variance in depressive symptoms (R2 = .52, ΔR2 = .32, F(5, 165) = 36.24, p < .001) and 24% of the variance in anxiety symptoms (R2 = .41, ΔR2 = .24, F(5, 165) = 22.65, p < .001), while dysfunctional coping, pre-loss depression, and extraversion accounted for 16% of the variance in sleep quality (R2 = .30, ΔR2 = .16, F(6, 164) = 11.44, p < .001).Conclusion: This study demonstrates the critical role of personal variables, including personality traits, coping strategies, and pre-loss depression, in explaining psychological distress and sleep quality in this sample of former dementia caregivers.

Utilizing Internet-based recruitment and data collection to access different age groups of former family caregivers.

As Internet accessibility grows among adults in the United States, researchers' utilization of Internet-based surveys and recruitment strategies has increased, but there is a paucity of knowledge about their use in different age groups of former dementia caregivers. The purpose of this secondary analysis is to describe 1) the use of Internet-based recruitment in obtaining a sample inclusive of young and middle aged (age 18-64), young-old (age 65-74), and older-old (age 75 and older) former dementia caregivers and 2) the feasibility of collecting data using an online survey in young and middle aged, young-old, and older-old former dementia caregivers. Utilizing convenience sampling, a four-step recruitment strategy encompassing a combination of Internet-based and non-Internet-based recruitment strategies was employed. Participants (N = 171) completed an online survey. Older-old, young-old, and young and middle-aged participants comprised 9%, 30%, and 61% of the sample respectively. All age cohorts provided minimal missing data using an online survey, but older-old participants required 15 additional minutes to complete the survey than young-old participants. Both cohorts of older adults were directed to the survey less frequently through online referral sources than young and middle-aged participants, and no older-old participants were referred via Facebook. All three age cohorts consisted of mostly white women. Internet-based surveys and recruitment were feasible among the age groups but may present challenges for the older-old and minorities. Further research on Internet-based data collection and recruitment is indicated in minority and older-old caregivers, focusing on trust, educational and financial disparities, and technological proficiency as potential barriers.

Hospital nurses' lived experience of power.

PURPOSE: The purpose of this study was to explore hospital nurses' lived experience of power. DESIGN: A hermeneutic phenomenological approach informed by Merleau-Ponty's philosophy of the phenomenology of perception was used to further an understanding of nurses' embodiment of power. Fourteen hospital clinical nurses employed in intensive care units and on medical floors in two major medical centers in the northeastern United States participated in 1-hr semistructured interviews about their lived experience of power. FINDINGS: A hermeneutic analytic approach and reflexive (cultural) bracketing produced three relational themes of power: (a) knowing my patients and speaking up for them; (b) working to build relationships that benefit patients; and (c) identifying my powerful self. CONCLUSIONS: Hospital clinical nurses develop a sense of power. Nurses believe power develops through acquisition of knowledge, experience, and self-confidence; this process is enhanced by exposure to good mentors. Nurses use their power to build relationships and advocate for patients. They consciously use power to improve patient care. Nurses' voices need to be heard and acknowledged. To do this in the clinical setting and beyond, hospital nurses must invite themselves or find ways to be invited into the authoritative discourse of hospital organizations. CLINICAL RELEVANCE: Nurses use their power to advocate for positive outcomes for patients and families. The satisfaction that comes from these positive relationships may improve nurses' perceptions of their work environment. Nurses' understanding and use of sociopolitical knowing needs further study, so that nurses may understand how to participate in current and future debates and decisions about our changing healthcare delivery systems and services.

Functional status in older women following gynecological cancer surgery: can choice of measure influence evidence for clinical practice?

Although functional status serves as a major predictor of morbidity, researchers and clinicians use different terms and measures, limiting comparisons across studies. To demonstrate how differing measures may generate varied findings, we compared and contrasted data from the SF-12 Health Survey Physical Component Summary Scale (SF-12 PCS) and the Enforced Social Dependency Scale (ESDS). The sample consisted of 49 women aged 65 and older recovering from gynecological cancer surgery with data collection at baseline (postoperative period) and then at 3 and 6 months. Analysis of the relationship between SF-12 PCS and ESDS over time using generalized estimating equations (GEE) demonstrated the relationship was less than 1.0, signaling less than perfect agreement between measures (ß = 0.16, P = .002). These findings suggest that that the 2 measures are not interchangeable and may produce conflicting evidence. This highlights the importance of researchers' and clinicians' careful conceptualization and operationalization of functional status before measure selection.

Combining extant datasets with differing outcome measures across studies of older adults after cancer surgery.

Combining extant datasets with differing outcome measures, an economical method to generate evidence guiding older adults' cancer care, may introduce heterogeneity leading to invalid study results. We recently conducted a study combining extant datasets from five oncology nurse-directed clinical trials (parent studies) using norm-based scoring to standardize the differing outcome measures. The purpose of this article is to describe and analyze our methods in the recently completed study. Despite addressing and controlling for heterogeneity, our analysis found statistically significant heterogeneity (p < 0.0001) in temporal trends among the five parent studies. We concluded that assessing heterogeneity in combined extant datasets with differing outcome measures is important to ensure similar magnitude and direction of findings across parent studies. Future research should include investigating reasons for heterogeneity to generate hypotheses about subgroup differences or differing measurement domains that may have an impact on outcomes.

Home care in the last year of life: family member perceptions of unmet need associated with last place of care.

OBJECTIVE: To examine the association of family members' perception about the adequacy of home health services at the last place of care before death. DESIGN: Retrospective cross-sectional study. Mortality follow-back survey by telephone interview. SETTING: Home health services. PARTICIPANTS: Bereaved family members or knowledgeable informants of deceased persons in 22 states. MEASUREMENTS: Proxy perception of need of home health care during the last 12 months of decedent's life, whether the amount of care received was enough, and last place of care (ie, where the person spent at least 48 hours nearest to the time of death). RESULTS: Of the 1578 interviews, 622 informants reported that decedents needed home health care in the last year of life. Among decedents needing home health care, 144 informants reported that the home health services provided did not meet their needs. After adjusting for age, gender, insurance, education, race, cause of death, functional status, and place of residence, decedents reported as not receiving enough home health care were 1.8 (95% CI 1.1-2.9) times more likely to die in a nursing home. CONCLUSION: The perception that home health services before death did not meet the decedent's needs may contribute to greater nursing home use.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations.

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

Informed consent to research in long-term care settings.

Informed consent to nursing home research is a two-tiered process that begins with obtaining the consent of a long-term care community at the institutional level and progresses to the engagement of individuals in the consent process. Drawing on a review of the literature and the authors' research experiences and institutional review board service, this article describes the practical implications of nurse investigators' obligation to ensure informed consent among participants in long-term care research. Recommendations focus on applying a community consent model to long-term care research, promoting an evidence-based approach to the protection of residents with decisional impairment, and increasing investigators' attention to ethical issues involving long-term care staff.

Enhancing geriatric nursing competencies for RNs in nursing homes.

The purpose of this review was to determine the best method to deliver education that strengthens geriatric nursing competencies in RNs working in nursing homes to achieve excellent outcomes for a complex population. On the basis of the evidence reviewed, recommendations are made related to the kind of learning activities, structure of educational sessions, and instructor qualifications and consultation activities.

Traumatic injury in the older adult from head to toe.

This review demonstrates essential issues to consider when caring for older trauma patients, including baseline physical status, mental health, comorbidities, and risk factors for sequelae and future injuries. The impact of a traumatic injury on older adults is complex. Issues of normal aging, functional status, chronic health conditions, and response to treatment affect health care and related decisions. Studies that have examined outcomes for older trauma patients to date have been mainly descriptive or confined to a single institution, limiting our ability to generalize. Other studies, using large data sets, have provided some information regarding possible primary prevention strategies, yet have limitations in the individual level detail collected. Nevertheless, this review also demonstrates the dearth of available evidence-based recommendations that provides support to treatment protocols in this complex and diverse patient population. The lack of an evidence base to use in the management of older trauma patients demonstrates the critical need for research in this rapidly growing population. An example of one such area includes the use of pulmonary artery catheters in older trauma patients. Although evidence to date suggests that pulmonary artery catheters are of benefit in the management of patients with physiologic compromise, it is unclear whether using these published cardiac output management recommendations leads to improved outcomes. In light of newly published data suggesting equivocal benefit from use of pulmonary artery catheters, with increased side effects, this controversy is an important area for future research. Critical care nurses, with their emphasis on multidisciplinary, holistic practice, can expand their influence as essential members of the interdisciplinary team caring for older trauma patients by cultivating geriatric specialty knowledge. Older trauma patients would benefit greatly from this type of specialty nursing care during all phases of the recovery trajectory, particularly in terms of adequate symptom management and prevention of sequelae, as well as with timely and appropriate initiation of consultative services. Using the intersection of primary and secondary prevention as the overall guide for practice, critical care nurses and other health care providers who possess an understanding of aging processes and comorbid conditions can significantly improve outcomes for older adults with traumatic injuries.

The use of contract licensed nursing staff in U.S. nursing homes.

The extent to which nursing homes rely on the use of contracted licensed staff, factors associated with this staffing practice, and the resultant effect on the quality of resident care has received little public attention. Merging the On-line Survey Certification and Reporting System database with the Area Resource File from 1992 through 2002, the authors regressed organizational and market-level variables on the use of 5 percent or more contract full-time equivalent registered nurses and licensed practical nurses. Since 1997, the proportion of facilities using 5 percent or more contract licensed staff more than tripled. Use of contract nurses was associated with more deficiency citations, characteristics of poorer facilities, and tight labor markets. Nursing homes increasingly rely on contract nurses. The failure of nursing homes to attract and retain a competent, stable workforce creates a vicious cycle of staffing practices, which may lead to decline in quality of care.

Cancer care in nursing homes.

OBJECTIVES: To review the available scientific literature on cancer care in nursing homes and recommendations for clinical practice and further research are offered. DATA SOURCES: Research studies and review articles. CONCLUSION: Overlooked issues for older adults with cancer in nursing homes include screening, treatment, and symptom management. Cancer care and survivorship in nursing homes receives little direct attention. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can improve cancer care and survivorship in nursing homes by considering nursing homes as a practice venue.

The employment of nurse practitioners and physician assistants in U.S. nursing homes.

PURPOSE: Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs. DESIGN AND METHODS: The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics. RESULTS: Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively). IMPLICATIONS: More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.

Palliative care needs of cancer patients in U.S. nursing homes.

BACKGROUND: Increasingly, nursing homes are the place of care for older Americans with cancer. Yet, few studies has characterized the quality of care for this growing population. OBJECTIVE: Characterize the scope and quality of cancer care in U.S. nursing homes. DESIGN: Secondary analysis of the national repository of the Minimum Data Set (MDS) SETTING AND SUBJECTS: Nursing home residents noted to have cancer diagnosis on the MDS. RESULTS: Of the 190,769 New Hampshire residents (8.8%) with a cancer diagnosis, 1 in 4 had weight loss (23.4%), received intravenous medications (27.7%), or used oxygen (25.4%). Overall, 45.3% had a do-not-resuscitate (DNR) order, with state variations ranging from 17.8% (New Jersey) to 70.5% (Wisconsin). More than 1 in 10 (12.0%) were defined as terminally ill, although only 29.3% of these received hospice services. Among patients with pain, half of those who survived to a second assessment had persistent, severe pain (51.3%), which also varied by state, ranging from 43.3% (Iowa) to 65.8% (Nevada). Active treatment was rare; less than 5% received chemotherapy or radiotherapy. However, 15.5% had parenteral and/or tube feedings for nutrition. Approximately, 1 in 10 New Hampshire residents had advanced cancer. CONCLUSION: Our findings suggest important opportunities to improve the quality of cancer care for older adults.

Nursing intervention and older adults who have cancer: specific science and evidence based practice.

This review of a small and heterogeneous body of literature suggests intriguing and useful approaches to nursing interventions with older adults who have cancer and areas that clearly deserve greater attention in future research. Research such as that done by McCorkle and Goodwin,while disparate in design, clearly demonstrate the ability of interventions to achieve better continuity of care and appropriate treatment for physically and socially vulnerable older adults with cancer. Comparison across settings and studies that investigate similar clinical phenomena would illuminate further how to achieve more effective intervention with elders who have cancer. In studies addressing case management, comparison of work by McCorkle et al with that completed by Goodwin et al suggests that programs that are longer than 4-week interventions are more likely to be beneficial than are shorter programs. Goodwin et al constructed a 12-month intervention that might be extended even further to improve continuity to older adults who may lack family/social support. Continuity may be especially important as older patients move from primary or geriatric care to surgical care to medical oncology care. Such a program also may offer added benefits in care of older adults who survive an initial cancer but require vigilant follow-up for recurrence or a second primary cancer and who may face ageist assumptions about screening and early detection of those cancers. The work of Coleman, Earp, and Powe and Weinrich underscores the necessity of understanding the precise needs of rural elders in relation to cancer. These studies strongly suggest that nurses can improve screening rates and symptom management. Rural health care may have particularly poor specialty resources for cancer and aging. Increasing oncology nurses' presence in rural communities and supporting those nurses with specific content in aging may be a successful mechanism to ameliorate these deficits. Coleman's study especially found that increasing opportunities to ensure that practice is grounded in current evidence is critical to improving evidence-based practice and avoiding misconceptions about the effects of age in cancer care. The weak effects associated with the use of lay educators to improve cancer screening behaviors strongly reinforce the influence of nurses over other personnel to carry out educational interventions. In rural and urban areas alike, the credibility and professionalism of nurses was clearly of benefit. McDougall's research highlights the effects of cancer treatment on older people's cognitive status. His intervention supports the further testing of group activities led by nurses as a way to improve aspects of memory. Clinical application of this low-risk, possibly high-benefit intervention strategy, which is congruent with current work in dementia care, implies that elder care facilities might benefit from having a nurse on staff to address institutional and individual concerns related to cognitive function among older residents with cancer. A single often unstated theme throughout these studies is the impact of the nurse-patient relationship on outcome variables for older adults at risk for or living with cancer. The nurse-patient relationship, a touchstone of practice, reminds each nurse to focus on the individual elder, to look past chronological age and cancer diagnosis to understand that individual as having a life that, though it may be decades long in time, is still to be lived each day in the manner and capacity that the person can command and desires. Knowledge of that elder will aid the nurse in asking critical questions, using existing research, adapting other relevant evidence, and intervening more effectively over the course of that relationship.

Organizational characteristics and restraint use for hospitalized nursing home residents.

OBJECTIVES: To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents. DESIGN: Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents. SETTING: Eleven medical and surgical units in one 600-bed teaching hospital. PARTICIPANTS: One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days. MEASUREMENTS: Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient-registered nurse (RN) ratio, patient-total nursing staff ratio, and skill mix. RESULTS: Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient-RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38-2.68, P <.001; weekend day and patient-total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37-2.66, P <.001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37-2.67, P <.001). CONCLUSION: Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.

Advanced practice nursing in the care of frail older adults.

Models of care for frail older adults have increasingly used advanced practice nurses (APNs) to achieve outcomes. Knowledge of the common APN functions and skills that contribute to the success of these models could better inform education and evidence-based practice and guide further research, but published investigations associated with models of gerontologic care neither describe fully these functions and skills nor link the activities of the APN with specific outcomes. Using examples primarily from the University of Pennsylvania School of Nursing, this paper identifies, describes, and analyzes common functions and skills of APNs in published gerontologic care models; examines the strength of the evidence for the effect of APNs on outcomes of care; and identifies areas for further study.