Understanding How Community Health Workers Build Trust with Low-Income Women of Color At-Risk for Maternal Child Health Disparities: A Grounded Theory Study.

This article examines how Community Health Workers (CHWs) build trust with low-income women of color who have a historical distrust of the healthcare system, and are at risk for maternal-child health disparities. This qualitative study used a grounded theory methodology guided by Charmaz's inductive social constructivist approach. Data were collected using open-ended semi-structured interviews and focus groups with CHWs who worked in community-based and hospital-based programs in California, Oregon, Illinois, Texas, South Carolina, New York, and Maine. Thirty-two CHWs participated, with 95% of participants being of Latinx and African American ethnicity. They served women from Latinx, African American, and Migrant communities. The CHW communication strategies represent aspects of respect and client-centered care and are applied in the development of a theoretical framework. CHWs were able to build and sustain trust at the initial encounter through these specific strategies: 1) addressing immediate needs related to social determinants of health; 2) embodying mannerisms and dress; 3) speaking appropriately to the client's age, culture, and knowledge; 4) easing client's fears through locus of control, and 5) allowing for time flexibility. These findings have implications for practice through interventions to train healthcare providers to build trust with low-income women of color who have a historical distrust of the healthcare system and who are at risk for maternal-child health disparities. Future research is recommended to explore how the communication trust-building constructs also benefit all other groups at similar risk, including those with mental health disorders and infectious diseases. The findings indicate specific communication strategies through which trust can be built, beginning at the initial encounter with low-income women at risk for maternal-child health disparities and who have a historical distrust of the healthcare system.

Evaluation of a care management program on family caregivers of persons with dementia.

As the U.S. population ages, dementia due to Alzheimer's or other disease is concerning for healthcare providers. Family caregivers (FCGs) of persons with dementia (PWDs) may experience negative outcomes. The University of California, Davis, Health (UCDH) Alzheimer's and Dementia Care (ADC) Program provides care management for PWDs and their FCGs. This pilot study evaluates the program's effect on FCG depression, strain, and distress. Despite an increase in dementia severity in PWDs, FCGs experienced decreased levels of depression, strain, and distress following 12 to 18 months in the UCDH ADC Program. Other findings include PWDs experiencing reductions in severity of neuropsychiatric symptoms and remaining at home with FCGs. Despite limitations, such as a relatively small sample size and lack of sample diversity, this pilot study demonstrated positive outcomes to both PWDs and their FCGs and contributes to the literature supporting dementia care management programs. Future projects should address these limitations to understand the experiences of a diverse population and to make dementia care management programs sustainable.

Frailty, Race/Ethnicity, Functional Status, and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis.

BACKGROUND: Although frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes. METHODS: The National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships. RESULTS: We identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA. CONCLUSION: Disparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.

Are We Ready for the CARE Act?: Family Caregiving Education for Health Care Providers.

The CARE Act, law in 40 states and territories in the United States, requires hospitals to identify and include family caregivers during admission and in preparation for discharge. Although the number of family caregivers has been steadily increasing, health care providers are ill-prepared to address their needs, and caregiving remains a neglected topic in health care providers' education. A market analysis was performed to explore the availability of and interest in interprofessional courses and programs focused on preparing health professionals to support family caregivers. Although nurses and chief nursing officers agreed on the importance of supporting caregivers, they were less likely to endorse formal educational preparation for this complex role. The current study elucidates a gap between what caregivers report they need and the preparation of health care professionals to advance family-centered approaches to care. [Journal of Gerontological Nursing, 45(3), 7-11.].

The relationship between exposure to dementia-related aggressive behavior and occupational stress among Japanese care workers.

Aggressive behaviors (ABs) related to dementia in older adults have been associated with increased occupational stress among care workers (CWs) in the United States and other Western countries, and they may contribute to staff turnover. However, few studies related to this issue have been conducted in Japan. The current cross-sectional study examined (a) the relationship between CW frequency of exposure to dementia-related ABs and CW occupational stress (i.e., job burnout, job satisfaction, and intention to resign), and (b) mediator effects between frequency of exposure to dementia-related ABs and CW occupational stress. A total of 137 CWs in dementia special care units from 10 nursing homes in Japan were recruited as study participants. Major findings indicate that the relationship between exposure to ABs and work outcomes was fully mediated by the appraisal of stress. Findings from this study may be used to develop culturally relevant training and educational interventions targeted at reducing ABs in individuals with dementia and occupational stress from exposure to ABs among CWs.

Pre-death grief in the context of dementia caregiving: a concept analysis.

AIM: The aim of this study was to report on an analysis of the concept of pre-death grief in the context of dementia family caregiving. BACKGROUND: Research indicates that witnessing changes and losses in a family member with dementia can lead to pre-death grief. Pre-death grief is associated with depression, burden and maladaptive caregiver coping. However, the concept lacks a refined definition and blurs with similar constructs. DESIGN: Concept analysis using a hybrid of Penrod and Hupcey's principle-based concept analysis and Chin and Kramer's conceptualization of meaning. DATA SOURCES: 49 peer-reviewed papers (2000-2013) that addressed pre-death grief in dementia family caregivers were used for the principle-based analysis; two examples from the popular media were used for the analysis of conceptual meaning. METHODS: The scientific papers were examined for epistemological, linguistic, pragmatic and logical clarity. The two examples from the popular media were explored for conceptual meaning. RESULTS: Pre-death grief in the context of dementia caregiving is a meaningful concept found in the popular media. From a scholarly point of view, it is an emerging concept. A definition is offered to advance conceptual clarity. Discussion focuses on advancing the concept into a situation-specific middle-range theory of pre-death grief in family caregiving. CONCLUSIONS: The concept of pre-death grief has salience for researchers and caregivers. This analysis lays the foundation for use of the concept in nursing research and practice across cultural, environmental and illness domains.

Managing Complex Medication Regimens: Nurses can enhance a family caregiver's knowledge, skill, and confidence.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Foundation. Results of focus groups conducted as part of the AARP Foundation's No Longer Home Alone video project supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The first video can be accessed at http://links.lww.com/AJN/A74.

Administration of Subcutaneous Injections: Nurses can help family caregivers enhance their knowledge, experience, and skill in managing injectable treatments.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Foundation. Results of focus groups conducted as part of the AARP Foundation's No Longer Home Alone video project supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The second video can be accessed at http://links.lww.com/AJN/A75.

Using the Preparedness Assessment for the Transition Home After Stroke Instrument to Identify Stroke Caregiver Concerns Predischarge: Uncertainty, Anticipation, and Cues to Action.

PURPOSE: The aim of the study was to better understand caregivers' concerns about long-term implications of stroke and the caregiving role after completing the Preparedness Assessment for the Transition Home After Stroke (PATH-s). DESIGN/METHODS: In this qualitative study, cognitive interviews were conducted with 20 stroke caregivers who completed the PATH-s tool as part of an instrument validation study. Data were analyzed for salient themes related to their perceptions about stroke and the caregiving role. FINDINGS: Interviews yielded robust narrative data describing how the PATH-s items aided caregivers in recognizing potential issues and concerns about stroke and the caregiving role. Caregivers experienced uncertainty about the long-term stroke prognosis, which provoked anticipation and cues to action to begin addressing their concerns. CONCLUSIONS/CLINICAL RELEVANCE: Completing the PATH-s helped caregivers identify concerns regarding the long-term implications of stroke and their caregiving role. It may serve as an important assessment tool to assist rehabilitation nurses to better understand and address caregiver needs predischarge.

Psychometric Properties of the Preparedness Assessment for the Transition Home After Stroke Instrument.

PURPOSE: The aim of this study was to evaluate psychometric properties of the Preparedness Assessment for the Transition Home After Stroke (PATH-s), a novel instrument to assess stroke caregiver commitment and capacity. The PATH-s instrument can be obtained at www.rehabnurse.org/pathtool. DESIGN: The design of this study is cross-sectional. METHODS: The PATH-s, the Preparedness for Caregiving Scale (PCS), the Patient Health Questionnaire, the Perceived Stress Scale, and the Global Health Scale were self-reported from a convenience sample of caregiver-stroke survivor dyads (n = 183) during inpatient rehabilitation. RESULTS: Exploratory factor analysis revealed eight factors underlying the PATH-s structure. The PATH-s Cronbach's alpha of .90 demonstrated criterion-related validity with the PCS (r = .79, p < .01). Both the PATH-s and the PCS were negatively correlated with the Patient Health Questionnaire (r = -.26 and -.27, respectively; p < .01) and the Perceived Stress Scale (r = -.12 and -.15, respectively; p > .05) and positively correlated with the Global Health Scale (r = -.46 and .46, respectively; p < .01), indicating convergent validity. CONCLUSIONS: The PATH-s demonstrates excellent internal consistency and satisfactory criterion-related and convergent validity. CLINICAL RELEVANCE: The PATH-s may be used to assess the risk/needs of caregivers over time.

Research Priorities in Family Caregiving: Process and Outcomes of a Conference on Family-Centered Care Across the Trajectory of Serious Illness.

The number of older adults living with functional decline and serious illness is growing exponentially at a time when availability of both family and professional caregivers is strained. Achieving optimal outcomes for this vulnerable population involves advancing the knowledge needed to improve the quality of care delivered by families, health professionals, and community programs. Recent reports from National Institute of Health and the National Academy of Science, Engineering and Medicine have called for the identification of gaps in key areas of family caregiving intervention research. In March 2018, the Family Caregiving Institute at UC Davis convened an invitational meeting of over 50 thought leaders in family caregiving-representing service agencies, funding organizations, and academia-to participate in the Research Priorities in Caregiving Summit: Advancing Family-Centered Care across the Trajectory of Serious Illness. Using an iterative process, attendees identified the top 10 research priorities and created research priority statements that incorporated a definition of the priority topic, rationale for the priority; problem(s) to address; priority population(s); and example research topics. The research priority statements serve as a roadmap for research development that will address the most significant gaps in the caregiving field.

Roles enacted by Clinical Nurse Leaders across the healthcare spectrum: A systematic literature review.

The Clinical Nurse Leader (CNL) is a master's prepared nurse envisioned to provide clinical leadership at the microsystem level to ensure safe, high quality patient-centered care. The American Association of Colleges of Nurses defined ten 'fundamental aspects' of CNL practice, but as the certified CNL population grows, data suggest they are filling a variety of positions besides formally designated CNL roles. This article reports the results of a systematic review of CNL literature to better understand what roles and activities certified CNLs are enacting when not hired into formally designated CNL roles. Sixty-nine articles met inclusion criteria. Roles identified include: faculty, 62%; clinical management/executive, 12%; specialty clinician, 11%; and staff nurse, 9%. In these roles, certified CNLs are reviewing literature, conducting research, and/or writing commentaries on CNL education and practice and other health foci such as alarm fatigue, insulin practices, and physical exercise for cancer-related fatigue. Results indicate that despite a lack of formal tracking of certified CNLs over time, the available information identifies a variety of roles and job titles used by this group of professional nurses. The study findings add to the body of knowledge informing overall understanding of the CNL initiative.

Nurses' experiences with hospice patients who refuse food and fluids to hasten death.

BACKGROUND: Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted suicide for terminally ill patients who wish to hasten death. There are few reports of patients who have made this choice. METHODS: We mailed a questionnaire to all nurses employed by hospice programs in Oregon and analyzed the results. RESULTS: Of 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, and considered their quality of life poor. The survey showed that 85 percent of patients died within 15 days after stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8. On the basis of the hospice nurses' reports, the patients who stopped eating and drinking were older than 55 patients who died by physician-assisted suicide (74 vs. 64 years of age, P<0.001), less likely to want to control the circumstances of their death (P<0.001), and less likely to be evaluated by a mental health professional (9 percent vs. 45 percent, P<0.001). CONCLUSIONS: On the basis of reports by nurses, patients in hospice care who voluntarily choose to refuse food and fluids are elderly, no longer find meaning in living, and usually die a "good" death within two weeks after stopping food and fluids.

Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide.

BACKGROUND: Oregon's 1997 Death with Dignity Act legalizes physician-assisted suicide. To date, information about patients who have requested this option has come from surveys of physicians. Although 78 percent of the 91 Oregonians who have died by assisted suicide were enrolled in hospice programs, there is little information about the experiences of hospice practitioners with these patients. METHODS: In 2001, we mailed a questionnaire to all hospice nurses and social workers in Oregon. RESULTS: Of 545 eligible hospice nurses and social workers, 397 (73 percent) returned the survey, including 71 percent of nurses and 78 percent of social workers. Since November 1997, 179 of the respondents (45 percent) had cared for a patient who requested assistance with suicide. Hospice nurses reported on 82 patients who had received prescriptions for lethal medication. Ninety-eight percent of the nurses had discussed the request with a coworker, and 77 percent of the requests had been presented at a hospice interdisciplinary conference on patient care. A very important reason for the request was to control the circumstances of death. The least important reasons included depression, lack of social support, and fear of being a financial drain on family members. Although the patients were concerned about burdening others, only 11 percent of hospice nurses rated their family caregivers as more burdened than family caregivers for other hospice patients. CONCLUSIONS: Since assisted suicide was legalized in Oregon, many hospice nurses and social workers have provided care for a patient who requested assistance with suicide. They rated desire for control as a very important reason for these requests.

Remote wound care consultation for nursing homes: using a web-based assessment and care planning tool.

Pressure ulcers represent a particular challenge in long-term care (LTC) facilities, where many frail older adults with reduced mobility reside. Guidelines for preventing and treating pressure ulcers have existed for many years; however, nurses in LTC facilities do not always use best practices in pressure ulcer care. In this article, the authors report on the development and pilot testing of a Web-based pressure ulcer management tool used for remote consultation in LTC.

Best practices initiative: nurturing partnerships that promote change.

As the science of nursing continues to evolve, efforts to develop strategies to integrate nursing research into clinical practice are increasing. To address the gap between research findings and the use of these findings to improve practice, Oregon Health & Science University School of Nursing established the Best Practices Initiative in conjunction with three clinical partners, all in the Pacific Northwest: a large Veterans Affairs medical center, a large health maintenance organization, and a state agency that oversees health care for older adults. This article presents the Best Practices Initiative Partnership Model, some of the lessons learned about partnering with clinical agencies, and an overview of the projects that involved each partner.

Managing chronic, nonhealing wounds using a research-based protocol.

The physical, emotional, and financial costs of caring for patients with chronic, nonhealing leg wounds are substantial. In fiscal year 2001, the home care department of a large Veterans Affairs medical center in the Pacific Northwest spent nearly half of its annual budget on veterans needing wound care. In this article, the authors describe a practice improvement project designed to improve the wound care management of homebound veterans with chronic, nonhealing lower extremity wounds using a research-based protocol and consultation by a certified wound care specialist, as well as the effect of this program on home care expenditures.

Managing Complex Medication Regimens.

: This article is the first in a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The first video can be accessed at http://links.lww.com/AJN/A74.

Administration of Subcutaneous Injections.

: This article is the second in a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The second video can be accessed at http://links.lww.com/AJN/A75.

Teaching Caregivers to Administer Eye Drops, Transdermal Patches, and Suppositories.

: This article is the third in a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The third video can be accessed at http://links.lww.com/AJN/A76.