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Donald E Bailey Jr,1,2 Sharron L Docherty,1 Judith A Adams,1 Dana L Carthron,3 Kirsten Corazzini,1,2 Jennifer R Day,1 Elizabeth Neglia,1 Marcus Thygeson,4 Ruth A Anderson1,21School of Nursing, Duke University, 2Center for the Study of Aging and Human Development, Duke University, Durham, NC, 3School of Health Science, Division of Nursing, Winston Salem State University, Winston Salem, NC, 4Medical Services, Blue Shield of California, San Francisco, CA, USAAbstract: In this paper we discuss the concept of leadership as a personal capability, not contingent on one's position in a hierarchy. This type of leadership allows us to reframe both the care-giving and organizational roles of nurses and other front-line clinical staff. Little research has been done to explore what leadership means at the point of care, particularly in reference to the relationship between health care practitioners and patients and their family caregivers. The Adaptive Leadership framework, based on complexity science theory, provides a useful lens to explore practitioners' leadership behaviors at the point of care. This framework proposes that there are two broad categories of challenges that patients face: technical and adaptive. Whereas technical challenges are addressed with technical solutions that are delivered by practitioners, adaptive challenges require the patient (or family member) to adjust to a new situation and to do the work of adapting, learning, and behavior change. Adaptive leadership is the work that practitioners do to mobilize and support patients to do the adaptive work. The purpose of this paper is to describe this framework and demonstrate its application to nursing research. We demonstrate the framework's utility with five exemplars of nursing research problems that range from the individual to the system levels. The framework has the potential to guide researchers to ask new questions and to gain new insights into how practitioners interact with patients at the point of care to increase the patient's ability to tackle challenging problems and improve their own health care outcomes. It is a potentially powerful framework for developing and testing a new generation of interventions to address complex issues by harnessing and learning about the adaptive capabilities of patients within their life contexts.Keywords: nursing, patient care, providers, health care practitioners, patient centered care, nursing providers, complex adaptive systems

The Duke Geriatric Nursing Educating Virtual Learning Community (Gero-VLC) is a newly developed online inquiry network that enables geriatric nurse educators to borrow, share, and collaborate to promote in-depth learning and optimal communication among instructors. Recently launched, the Gero-VLC website was developed to meet the needs of nurse educators who face increasing demands to develop quality, learner-centered online instruction focused on evidence-based geriatric care. Through the Gero-VLC, nurse educators can connect with nurse clinicians expert in geriatric care; access state-of-the-science information and learning opportunitites; participate in collaborative projects; and publish their work on the North Carolina Learning Object Repository. The authors present the Gero-VLC as a best practice for online geriatric nursing education, describe its theoretical underpinnings, and outline a strategy for evaluation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment.Data Sources/study Setting: Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders.Study Design: Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices.Data Collection/extraction Methods: Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients.Principal Findings: Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels.Conclusions: Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics. [ABSTRACT FROM AUTHOR]

Abstract Background Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures. Methods/design Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model. Discussion By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate. Trial Registration ClinicalTrials.gov: NCT00636675

Social connection is important for long-term care (LTC) residents' quality of life and care. However, there is a lack of consensus on how to measure it and this limits ability to find what improves and impairs social connection in LTC homes. We therefore aimed to systematically review and evaluate the measurement properties of existing measures of social connection for LTC residents, to identify which, if any, measures can be recommended. We searched eight electronic databases from inception to April 2022 for studies which reported on psychometric properties of a measure of any aspect(s) of social connection (including social networks, interaction, engagement, support, isolation, connectedness, and loneliness) for LTC residents. We used COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines to evaluate the measurement properties reported for each identified measure and make recommendations. We identified 62 studies reporting on 38 measures; 21 measured quality of life, well-being or life satisfaction and included a social connection subscale or standalone items and 17 measures specifically targeted social connection. We found there was little high-quality evidence on psychometric properties such as sufficient content validity ( n = 0), structural validity ( n = 3), internal consistency ( n = 3), reliability ( n = 1), measurement error ( n = 0), construct validity ( n = 4), criterion validity ( n = 0) and responsiveness ( n = 0). No measures demonstrated satisfactory psychometric properties on all these aspects, so none could be recommended for use. Thirty-four measures have the potential to be recommended but require further research to assess their quality and the remaining four are not recommended for use. Our review therefore found that no existing measures have sufficient evidence to be recommended for assessment of social connection in residents of LTC homes. Further validation and reliability studies of existing instruments or the development of new measures are needed to enable accurate measurement of social connection in LTC residents for future observational and interventional studies., Highlights: Social connection is fundamental to person-centered care in long-term care homes.There is insufficient evidence for the reliability and validity of existing measures.No current measures can be recommended for use based on existing evidence.A reliable and valid measure of social connection is needed for future research., Competing Interests: The authors declare no conflicts of interest. Author disclosures are available in the Supporting information., (© 2024 The Author(s). Alzheimer's & Dementia: Translational Research & Clinical Interventions published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

During the coronavirus disease 2019 (COVID-19) pandemic, the Brazilian long-term care (LTC) sector faced many challenges, which accentuated other common issues experienced by persons living with dementia (PLWD). The current pilot study evaluated staff perspectives regarding the care of institutionalized PLWD during the COVID-19 pandemic. Using an online survey, we collected the perspectives of 24 workers from seven long-term care facilities (LTCFs) located in São Paulo State, Brazil, about the impact of COVID-19 in caring for PLWD. Results highlight concerns about challenges related to following precautionary measures and the negative effects of social distancing on PLWD. Aspects related to workforce and staffing and person-centered care approaches were recognized by staff as important to provide good care for PLWD. Future research is needed to consider how to support LTCFs in achieving a balance between the protection and well-being of PLWD. [ Journal of Gerontological Nursing, 49 (5), 45-52.].

Background: Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross-disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person-centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies., Method: In order to develop and test the roadmap, a COST Action project was initiated: COST-CARES, with 28 participating countries. This paper provides an overview of evidence about the effects of each of the identified enablers. Intersections between the drivers and the enablers are identified as critical for the success of future cost containment, in tandem with maintained or improved quality in healthcare. This will require further exploration through testing., Conclusion: Cost containment of future healthcare, with maintained or improved quality, needs to be addressed through a concerted approach of testing key factors. We propose a framework for test lab design based on these drivers and enablers in different European countries., Competing Interests: None declared., (© 2021 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Aims and Objectives: To explore nursing home residents' perspectives on their relationships with other residents, family members and staff., Background: The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility., Design: Qualitative secondary analysis., Methods: We analysed individual and group interviews obtained during "stakeholder engagement sessions" with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed., Results: Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents' relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship-peer, family and staff-made distinctive contributions residents' psychosocial well-being., Conclusion: Recognising the diverse roles of different actors from residents' social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents' psychosocial well-being., Relevance to Clinical Practice: This study highlights the need for nursing home staff to understand how residents' social relationships influence residents' psychosocial outcomes. Staff training programmes are needed to support residents' rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships., (© 2019 John Wiley & Sons Ltd.)

Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.

International research on long-term care (LTC) can valuably inform LTC policy and practice, but limited transnational collection of data on key LTC issues restricts the contributions of international LTC research. This special collection of Gerontology and Geriatric Medicine helps close the gap between the status quo and the potential for international LTC research by cultivating a transnational common ground of internationally prioritized measurement concepts and sowing the seeds of international LTC common data elements. The articles in this special collection address both adaptive and technical challenges to international LTC measurement, build on and complement existing LTC measurement systems, and provide diverse international perspectives on the measurement of LTC across four overarching domains: LTC contexts, workforce and staffing, person-centered care , and care outcomes . From large transnational teams of scholars specifying the meanings of central LTC concepts, to smaller subnational research teams testing new measures of person-centered care across diverse local LTC settings, contributors spark new insights and point in new directions for a LTC measurement infrastructure supportive of person-centered care and lifelong thriving., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: Federal regulations require nursing homes in the United States to support residents in directing their own care rather than having their care plans developed for them without their engagement, but knowledge of person-directed approaches to care planning in nursing homes is limited. The purpose of this study was to advance understanding of person-directed care planning (PDCP)., Methods: A multidisciplinary research team conducted a scoping review on individual and family involvement in care planning, including literature from a variety of care contexts. Search results were systematically screened to identify literature that addressed individual or family involvement in care planning as a primary concern, and then analysed using thematic content analysis., Results: Several themes were identified, including definitions of the concept of PDCP, essential elements of PDCP, barriers, facilitators and outcomes. The concept of PDCP is informed by multiple disciplines, including humanist philosophy, disability rights and end-of-life care. Essential elements of PDCP include knowing the person, integrating the person's goals in care planning and updating care plans as individuals' needs or preferences change. Limited time for care planning in nursing homes hinders PDCP. Facilitators include regulatory mandates and humanist social trends. Outcomes of PDCP were found to be positive (e.g., increased independence), but were inconsistently assessed across studies., Conclusion: This study offers pragmatic information that can support PDCP within nursing homes and insights for policy reform that may more effectively support PDCP., Implications for Practice: These findings can be used to guide implementation of PDCP., (© 2018 The Authors. International Journal of Older People Nursing Published by John Wiley & Sons Ltd.)

Background: Licensed nurse (registered nurse [RN] and licensed practical nurse [LPN]) roles in nursing homes are often viewed as interchangeable. Interchangeability occurs when the differences in RN and LPN education and scopes of practice are not recognized or acknowledged, leading to staffing patterns where the roles and clinical contributions of RNs and LPNs are perceived as equivalent., Purpose: This study describes the perspectives of directors of nursing about interchangeability between RNs and LPNs and factors that contribute to interchangeability., Method: This is a secondary analysis of data from a larger study in which 44 Directors of Nursing from Nurisng Homes in two different states were interviewed about their perceptions of the roles of RNs and LPNs., Findings: Interchangeability of RNs and LPNs was influenced by directors of nursing's knowledge and awareness of the scopes of practice for the two types of licensed nurses, corporate policies, and educational background of RNs. The findings suggest opportunities for better differentiating roles through the use of job descriptions that more clearly delineate the distinctive contributions of both RNs and LPNs in nursing home settings., Discussion: While increasing the number of RNs in nursing homes is desirable, there is immediate opportunity to ensure that the few RNs in nursing homes are used effectively to ensure that the professional nursing care needs of residents are met. NOTE: The review process and decision for this article was managed by Barbara S. Smith, PhD, R, FAAN Associate Editor, Nursing Outlook., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The current study operationalized, assessed, and evaluated the feasibility and preliminary effects of implementing a person-centered approach to incontinence care for older adults with cognitive decline in residential care facilities (RCFs) in Sweden. Twenty health care workers were purposively sampled from two intervention RCFs. Process outcome was measured as number of assessments conducted for incontinence management. Impact outcome measures were quality of life, basal assessment of incontinence, incontinence actions taken, and personally chosen incontinence aids. A usual care control group RCF was matched by resident case-mix and geographic region. Introduction of a person-centered approach showed an increase in residents' quality of life in the intervention group compared to baseline and the control group. A positive effect was found on the number of urinary incontinence assessments conducted (p < 0.05). In addition, the number of person-centered caring actions (e.g., toilet assistance) was significantly higher during and 6 months after implementation of the person-centered approach. Implementing a person-centered approach in clinical practice focused on incontinence care, quality of care, and quality of life is supported for RCF residents. [Journal of Gerontological Nursing, 44(11), 10-19.]., (Copyright 2018, SLACK Incorporated.)

Importance: New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls., Objective: To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS)., Design, Setting, and Participants: Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls., Interventions: CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program., Main Outcomes and Measures: Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate., Results: Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration., Conclusions and Relevance: An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed., Trial Registration: clinicaltrials.gov Identifier: NCT00636675.

Objectives: Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias., Design: Randomized factorial clinical vignette survey., Setting: Sixteen nursing homes in North Carolina., Participants: Nursing, rehabilitation, and social services staff (n = 433)., Measurements: Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories., Results: Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1)., Conclusion: Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Background: Knowledge about long-term change in health related quality of life (HQoL) among older adults after hospitalization for treatment of depression has clinical relevance. The aim was firstly to describe the change of HQoL one year after admission for treatment of depression, secondly to explore if improved HQoL was associated with remission of depression at follow-up and lastly to study how HQoL in patients with remission from depression were compared to a reference group of older persons without depression., Method: This study had the one year follow-up information of 108 older patients (≥60 years), all hospitalized for depression at baseline, and a reference sample of 106 community-living older adults (≥60 years) without depression. HQoL was measured using the EuroQol Group's EQ-5D Index and a visual analog scale (EQ-VAS). Depression and remission were diagnosed according to ICD-10. Socio-demographic variables (age, gender, and education), depressive symptom score (Montgomery-Aasberg Depression Rating Scale), cognitive functioning (Mini Mental State Examination scale), instrumental activities of daily living (the Lawton and Brody's Instrumental Activities of Daily Living Scale), and poor general physical health (General Medical Health Rating) were included as covariates., Results: HQoL had improved at follow-up for the total group of depressed patients, as indicated by better scores on the EQ-5D Index and EQ-VAS. In the multivariate linear regression model, improved EQ-5D Index and EQ-VAS was significantly better in those with remission of depression and those with better baseline physical health. In adjusted analyses, the HQoL in patients with remission from depression at follow-up did not differ from the HQoL in a reference group without depression., Conclusion: Older hospital patients with depression who experienced remission one year after admission gained HQoL and their HQoL was comparable with the HQoL in a reference group of older adults without depression when adjusting for differences in socio-demographics and health conditions.

Background: Nursing homes are becoming increasingly complex clinical environments because of rising resident acuity and expansion of postacute services within a context of historically poor quality performance. Discrete quality markers have been linked to director of nursing (DON) leadership behaviors. However, the impact of DON leadership across all measured areas of DON jurisdiction has not been tested using comprehensive domains of quality deficiencies., Purpose: The aim of this study was to examine the effects of DON leadership style including behaviors that facilitate the exchange of information between diverse people on care quality domains through the lens of complexity science., Methodology: Three thousand six hundred nine DONs completed leadership and intent-to-quit surveys. Quality markers that were deemed DON sensitive included all facility survey deficiencies in the domains of resident behaviors/facility practices, quality of life, nursing services, and quality of care. Logistic regression procedures estimated associations between variables., Findings: The odds of deficiencies for all DON sensitive survey domains were lower in facilities where DONs practiced complexity leadership including more staff input and shared decisional authority. DON quit intentions were aligned with higher odds of facility deficiencies across all domains., Practice Implications: Results supported the hypotheses that DONs using complexity leadership approaches by interacting more freely with staff, discussing resident issues, and sharing decision making produced better care outcomes from every DON sensitive metric assessed by Centers for Medicare and Medicaid Services. The mechanism linking poor quality with high DON quit intentions is an area for future research. Encouraging DON use of complexity leadership approaches has the potential to improve a broad swath of quality outcomes.

The aim of this study was to investigate relationships between coping and health related quality of life (HRQoL) in older adults (aged ≥60 years) with and without depression. This cross-sectional study included 144 depressed inpatients from seven psychogeriatric hospital units in Norway and 106 community-living older adults without depression. HRQoL was measured using Euro Qol Group's EQ-5D Index and visual analog scale (EQ-VAS). Two aspects of coping were of primary interest for HRQoL: locus of control (LOC) and ways of coping (WOC). Measures of depressive symptoms, cognitive functioning, instrumental activities of daily living, and general physical health were included as covariates. In linear regression analyses adjusted for age, stronger external LOC was associated with poorer HRQoL in both depressed and non-depressed older adults. In the fully-specified regression models for both groups, the association between stronger external LOC and poorer HRQoL remained significant for the EQ-VAS score but not the EQ-5D Index. WOC was not associated with HRQoL in either group. Total amount of explained variance in fully-specified models was considerably lower in the sample of depressed, hospitalized older adults (17.1% and 15.5% for EQ-5D index and EQ-VAS, respectively), than in the sample of non-depressed, community-based older adults (45.8% and 48.9% for EQ-5D Index and EQ-VAS, respectively). One aspect of coping (LOC orientation) was associated with HRQoL in both depressed and non-depressed older adult samples, and therefore may be an important target for intervention for both groups. Differences in the amount of variance explained in models for the two groups warrant further research., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

We aimed at assessing time shift in the severity of neuropsychiatric symptoms (NPS) in nursing home residents between 2004/2005 and 2010/2011 and associations between NPS and socio-demographic variables, physical health status, dementia severity, and the use of psychotropic drugs. The Neuropsychiatric Inventory Nursing Home Version was used in 2004/2005 (n = 1,163) and 2010/2011 (n = 1,858). Linear mixed model analysis was applied. There was no time shift in the severity of apathy, psychosis, and affective symptoms, but agitation did exhibit a time shift. Agitation was less severe in 2010/2011 than in 2004/2005 in residents with a Clinical Dementia Rating (CDR) sum of boxes score ≤4, and more severe in residents with a CDR sum of boxes score >16. Higher CDR sum of boxes scores and use of psychotropic medication were associated with more severe apathy, agitation, psychosis, and affective symptoms. Poor physical health was associated with more severe apathy, psychosis, and affective symptoms. Women had more severe agitation and less severe affective symptoms than men. A longer stay in a nursing home was associated with more severe agitation and less severe affective symptoms. In conclusion, agitation was less severe in 2010/2011 than in 2004/2005 among nursing home residents with a milder degree of dementia, and more severe in residents with severe dementia.

Research evidence suggests that educating nurses about traditional Chinese medicine (TCM) significantly improves their nursing care practice and the health care outcomes of community residents. The purpose of this study was to describe the current use of TCM by China's nursing workforce, as well as the typical nurse to physician ratio and types of TCM education that nurses receive in health care facilities. A large retrospective survey was conducted in Hubei Province, China, in 2010. The sample included 620 non-TCM hospitals, 120 TCM hospitals, and 1254 community health centers (CHCs). Descriptive analysis and 1-way analysis of variance were used to test statistical differences. There were 79 447 nurses employed, of which 1527 had a TCM degree and 5689 had on-the-job TCM education. Non-TCM hospitals employed more nurses than TCM hospitals and CHCs, and TCM hospitals employed more TCM nurses than non-TCM hospitals and CHCs. The median nurse to physician ratio varied by level of urbanization and type of health care facility, from 0.6 in rural CHCs to 1.3 in rural non-TCM hospitals. Differences in TCM education preparation of nurses were significantly different in the urban and rural settings and by type of health care facility. The study suggested a shortage of nurses educated in TCM in Hubei Province China, as well as uneven TCM workforce distribution. More opportunities for TCM education are needed for nurses, especially in CHCs where health promotion and chronic disease management are the most important and mandated functions.

Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed within the context of the comprehensive interdisciplinary assessment framework-the Resident Assessment Instrument (RAI). Consistent compliance with this requirement has been difficult to achieve. To improve the quality of CCP development within this framework, an increased understanding of complex factors contributing to inconsistent compliance is required. In this commentary, we examine the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse staffing; empirical evidence of the CCP's efficacy; and the limitations of extant standards of practices in CCP development. Because of the registered nurse's educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized. Recommendations for evidence-based micro and macro level practice changes with the potential to improve the quality of CCP development and regulatory compliance are presented. Suggestions for future research are given.

Purpose of the Study: To describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care., Design and Methods: The study design was a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of 3 nursing homes. We conducted 7 focus groups of licensed and unlicensed nursing staff, medical care providers, and administrators. Questions explored perceptions of facilitators and barriers to culture change. Using a template organizing style of analysis with immersion/crystallization, themes of barriers and facilitators were coded for adaptive challenges and leadership., Results: Six key themes emerged, including relationships, standards and expectations, motivation and vision, workload, respect of personhood, and physical environment. Within each theme, participants identified barriers that were adaptive challenges and facilitators that were examples of adaptive leadership. Commonly identified challenges were how to provide person-directed care in the context of extant rules or policies or how to develop staff motivated to provide person-directed care., Implications: Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We propose the Adaptive Leadership Framework for Chronic Illness as a novel framework for conceptualizing, studying, and providing care. This framework is an application of the Adaptive Leadership Framework developed by Heifetz and colleagues for business. Our framework views health care as a complex adaptive system and addresses the intersection at which people with chronic illness interface with the care system. We shift focus from symptoms to symptoms and the challenges they pose for patients/families. We describe how providers and patients/families might collaborate to create shared meaning of symptoms and challenges to coproduce appropriate approaches to care.

Unlabelled: The purpose of the manuscript is to describe long-term care (LTC) staff perceptions of a music cueing intervention designed to improve staff integration of pressure ulcer (PrU) prevention guidelines regarding consistent and regular movement of LTC residents a minimum of every two hours. The Diffusion of Innovation (DOI) model guided staff interviews about their perceptions of the intervention's characteristics, outcomes, and sustainability., Methods: This was a qualitative, observational study of staff perceptions of the PrU prevention intervention conducted in Midwestern U.S. LTC facilities (N = 45 staff members). One focus group was held in each of eight intervention facilities using a semi-structured interview protocol. Transcripts were analyzed using thematic content analysis, and summaries for each category were compared across groups., Results: The a priori codes (observability, trialability, compatibility, relative advantage and complexity) described the innovation characteristics, and the sixth code, sustainability, was identified in the data. Within each code, two themes emerged as a positive or negative response regarding characteristics of the innovation. Moreover, within the sustainability code, a third theme emerged that was labeled "brainstormed ideas", focusing on strategies for improving the innovation., Implications: Cueing LTC staff using music offers a sustainable potential to improve PrU prevention practices, to increase resident movement, which can subsequently lead to a reduction in PrUs.

Background: To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff., Methods: We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases., Results: Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these 'local interaction strategies'. We categorized these two sets of local interaction strategies as the 'common pattern' and the 'positive pattern' and summarize the results in two models of local interaction., Conclusions: The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.

Purpose of the Study: The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone., Design and Methods: Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities., Results: Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls., Implications: CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.

Objective: To assess how non-nutritive sucking (NNS) using a pacifier affected physiological and behavioral outcomes of preterm infants., Design: Short-term longitudinal, experimental design., Setting: The study took place at the neonatal intensive care unit at Al-Mansoura, Egypt., Methods: Forty-seven preterm infants were divided into intervention and control groups. Preterm infants in the intervention group received NNS during nasogastric tube feeding while infants in the control group never received NNS. During 10 days, behavioral responses were videotaped and physiological responses were monitored., Results: Significantly higher oxygen saturation occurred during and after nasogastric feeding for the intervention infants as compared to the control group. No significant group differences occurred in heart rate. The NNS group showed an accelerated transition to nipple feeding and had better weight gain and earlier discharge., Conclusion: Non-nutritive sucking was found to improve physiological and behavioral responses of preterm infants., (© 2014 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Director of nursing turnover is linked to staff turnover and poor quality of care in nursing homes; however the mechanisms of these relationships are unknown. Using a complexity science framework, we examined how nurse management turnover impacts system capacity to produce high quality care. This study is a longitudinal case analysis of a nursing home (n = 97 staff) with 400% director of nursing turnover during the study time period. Data included 100 interviews, observations and documents collected over 9 months and were analyzed using immersion and content analysis. Turnover events at all staff levels were nonlinear, socially mediated and contributed to dramatic care deficits. Federal mandated, quality assurance mechanisms failed to ensure resident safety. High multilevel turnover should be elevated to a sentinel event for regulators. Suggestions to magnify positive emergence in extreme conditions and to improve quality are provided.

Objectives: To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS)., Design: Cluster randomized trial., Setting: Community (n=4) and Veterans Affairs (VA) NHs (n=4)., Participants: Staff in any role with resident contact (n=497)., Intervention: NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback., Measurements: NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning., Results: Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20)., Conclusion: CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Objectives. To (1) describe participation in decision-making as a systems-level property of complex adaptive systems and (2) present empirical evidence of reliability and validity of a corresponding measure. Method. Study 1 was a mail survey of a single respondent (administrators or directors of nursing) in each of 197 nursing homes. Study 2 was a field study using random, proportionally stratified sampling procedure that included 195 organizations with 3,968 respondents. Analysis. In Study 1, we analyzed the data to reduce the number of scale items and establish initial reliability and validity. In Study 2, we strengthened the psychometric test using a large sample. Results. Results demonstrated validity and reliability of the participation in decision-making instrument (PDMI) while measuring participation of workers in two distinct job categories (RNs and CNAs). We established reliability at the organizational level aggregated items scores. We established validity of the multidimensional properties using convergent and discriminant validity and confirmatory factor analysis. Conclusions. Participation in decision making, when modeled as a systems-level property of organization, has multiple dimensions and is more complex than is being traditionally measured. Managers can use this model to form decision teams that maximize the depth and breadth of expertise needed and to foster connection among them.

After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.

Background: As the American population ages and the proportion of individuals over the age of 65 expands, the demand for high-quality nursing home care will increase. However, nursing workforce instability threatens care quality and sustainability in this sector. Despite increasing attention to nursing home staff turnover, far less is known about registered nurse (RN) retention., Purpose: In this study, the relationships between retention strategies, employee benefits, features of the practice environment, and RN retention were explored. Further, the utility of Herzberg's two-factor theory of motivation as a framework for nursing home retention studies was evaluated., Methodology: This study was a secondary analysis of the nationally representative 2004 National Nursing Home Survey. The final sample of 1,174 participating nursing homes were either certified by Medicare or Medicaid or licensed by state agencies. We used a weighted multinomial logistic regression using an incremental approach to model the relationships., Findings: Although most nursing homes offered some combination of retention programs, the majority of strategies did not have a significant association with the level of RN retention reported by facilities. Director of nursing tenure and other extrinsic factors had the strongest association with RN retention in adjusted analyses., Practice Implications: To improve RN retention, organizations may benefit greatly from stabilizing nursing home leadership, especially the director of nursing position. Second, managers of facilities with poor retention may consider adding career ladders for advancement, awarding attendance, and improving employee benefits. As a behavioral outcome of motivation and satisfaction, retention was not explained as expected using Herzberg's two-factor theory.

Objectives: To explore the perspectives and priorities of nursing home residents, family members, and frontline nursing staff concerning a broad range of items representing common targets of culture change initiatives., Design: Qualitative study., Setting: A Veterans Affairs Community Living Center and two community nursing homes in North Carolina., Participants: Residents (n = 21), family members (n = 21), and direct-care nursing staff (n = 21) were recruited, with equal numbers in each group from each site., Measurements: Participants rated the importance of 62 items from the Centers for Medicare and Medicaid Services Artifacts of Culture Change instrument. Participants sorted cards reflecting each culture change artifact in two phases, identifying and ranking those of more and less importance to them to derive one distribution of preferences for each respondent. Q-sort analysis identified groups of respondents who prioritized similar items; qualitative analysis sought themes or explanations for the responses., Results: Wide variation in respondent preferences was observed. Some respondents viewed several items that others valued highly as unimportant or undesirable. Some items were not high priorities for any respondents. Four groups of respondents with similar preferences were identified: practical and independence-focused respondents, who prioritized ease of use of the physical environment; staff-focused respondents, who prioritized nursing staff retention and development; consistency and choice-focused respondents, who prioritized stable nurse staff-resident relationships and resident choice; and activity and community-focused respondents, who prioritized community gathering spaces and activities., Conclusion: Resident, family, and staff priorities for culture change vary, and diverse priorities of stakeholders should be considered to inform culture change efforts on a local and national level., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

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.

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.

Staff development nurses in long-term care are challenged to implement training programs that foster quality unlicensed assistive personnel (UAP) care and improve the transfer of their observations to licensed nursing staff for care planning. This study describes the outcomes of a program where UAP recorded behavioral problems of residents to inform care. Findings suggest that staff development nurses who aim to improve UAP reporting without simultaneously targeting licensed nursing staff behaviors may worsen nursing staff relationships.

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.

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.