Andrea Yevchak

“Wish we would have known that!” Communication Breakdown Impedes Person-Centered Care

PURPOSE To understand how nursing home staff obtain information needed for implementing person-centered care (PCC) to residents with dementia who exhibit behavioral and psychological symptoms of dementia (BPSD), and how they communicate this information to other staff. Barriers to PCC and information exchange were also explored. DESIGN AND METHODS Participants were 59 staff from two nursing homes. Focus group methodology captured discussions in eight 1-hr sessions. Sessions were audiotaped and transcribed. Data were analyzed using qualitative content analysis to provide a comprehensive summary of real world context of implementing PCC. RESULTS To deliver PCC staff identified a need for access to psychosocial/medical history of the resident and knowledge of strategies families used for managing BPSD in the past. However, resident information is not routinely shared with all staff and written documentation systems for communicating resident-specific information do not support the time-pressured work pattern of certified nursing assistants (CNAs). Word-of-mouth was considered more reliable and expedient than educational sessions. CNAs described themselves as visual learners who prefer educational programs addressing individual resident emergent behaviors and programs that are scheduled at dedicated times. IMPLICATIONS To improve PCC the flow of information exchange requires: inclusion of all staff, particularly CNAs; systems of communication that consider the time and resource constraints of nursing homes; development of educational programs for BPSD that are responsive to staff learning styles; administrative investment in nursing leadership to effect these changes; and reimbursement approaches to encourage culture change investments.

Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings.

Delirium occurs in more than half of hospitalized older adults with dementia, substantially worsening outcomes. The use of multiple strategies and a local opinion leader, unit champion, has cumulative and lasting effects compared with single-strategy interventions. The purpose of this article is to describe the early barriers and facilitators to rounding with unit champions in a cluster randomized clinical trial in Year 2 of a 5-year trial (5R01NR011042-02). This is a mixed-method study nested within an ongoing multisite cluster-randomized, controlled clinical trial. Descriptive and comparative statistics were collected on N = 192 nursing rounds. Qualitative data were thematically analyzed. On average, rounds lasted 25.54 min (SD = 13.18) and were conducted with the unit champion 64% of the time. This is one of the first studies to systematically address quantitative and qualitative barriers and facilitators to nurse-led delirium rounds, demonstrating the gradual adoption of an intervention in diverse clinical settings.

Managing delirium in the acute care setting: a pilot focus group study

BACKGROUND Delirium frequently occurs in hospitalised older adults leading to poor outcomes and frequent adverse events. Proper recognition and management of delirium by acute care nurses can minimise the effects of negative sequelae associated with delirium. AIM This pilot study used focus group methodology to: (i) describe acute care nurses experience and knowledge regarding assessment and management of delirium in hospitalised older adults; (ii) illustrate potential facilitators and barriers to non-drug management of delirium; and (iii) to explicate the use of non-drug interventions by acute care nurses to manage delirium in hospitalised older adults. DESIGN Qualitative, pilot study. METHODS A total of 16 nurse participants, working on medical, surgical and orthopaedic units from one acute care hospital participated in two focus groups. RESULTS Main themes included the following: confusion is normal; our duty is to protect; and finding a balance. Nurses were able to identify non-pharmacological interventions for delirium and facilitators and barriers to using these in clinical practice. CONCLUSIONS Findings from this pilot study illustrate the need for regular assessment of cognitive status in hospitalised older adults and nursing staff education regarding the use of non-pharmacological management of delirium. Based on their experience, nurses have a wealth of ideas for managing delirium. Areas for future research and policy are also highlighted. IMPLICATIONS FOR PRACTICE More research is needed on how to improve delirium management by acute care nurses to increase the efficacy and use of non-pharmacological interventions in the management of delirium in hospitalised older adults. To translate these findings into practice, nursing care needs to be guided by evidence-based guidelines to implement non-pharmacological strategies in the acute care setting.

Promoting cognitive health and vitality: a review of clinical implications.

To maintain cognitive health and vitality, multidimensional cognitive structures must be developed and preserved. With a focus on patient education and health promotion, nurses in general, and geriatric nurses in particular, can proactively address concerns and fears that their patients have about dementia-related illnesses through strategies geared at promoting cognitive health and sustaining abilities. A clinical review of the research literature on the topic of cognitive health revealed the transdisciplinary nature of research on this topic. Effective strategies identified for promoting cognitive health and vitality are categorized as follows: prevention and management of chronic conditions, nutrition, physical activity, mental activity, and social engagement. Current research findings on the promotion of cognitive health and vitality are explored, and research-based implications for geriatric nursing practice are discussed.

The association between an ultrabrief cognitive screening in older adults and hospital outcomes

BACKGROUND Though often recommended, hospital cognitive assessment is infrequently completed due to clinical and time constraints. OBJECTIVE This analysis aimed to evaluate the relationship between performance on ultrabrief cognitive screening instruments and hospital outcomes. DESIGN This is a secondary data analysis of a quality improvement project. SETTING Tertiary Veterans Administration hospital in New England. PATIENTS Patients, ≥ 60 years old, admitted to the hospital. INTERVENTION None. MEASUREMENTS Upon admission, patients were administered 2 cognitive screening tools. The modified Richmond Agitation and Sedation Scale (mRASS) is a measure of arousal that can be completed in 15 seconds. The months of the year backward (MOYB) is a measure of attention that can be administered in ≤1 minute. In-hospital outcomes included restraints and mortality, whereas discharge outcomes included length of stay, discharge not home, and variable direct costs. Risk ratios were calculated for dichotomous outcomes and unadjusted Poisson regression for continuous outcomes. RESULTS Patients (n = 3232) were screened. Altered arousal occurred in 15% of patients (n = 495); incorrect MOYB was recorded in 45% (n = 1457). Relative to those with normal arousal and attention, those with abnormal mRASS and incorrect MOYB had increased length of stay (incident rate ratio [IRR]: 1.23, 95% confidence interval [CI]: 1.17-1.30); restraint use (risk ratio [RR]: 5.05, 95% CI: 3.29-7.75), in-hospital mortality (RR: 3.46, 95% CI: 1.24-9.63), and decreased discharge home (RR: 2.97, 95% CI: 2.42-3.64). Hospital variable direct costs were slightly, but not significantly, higher (IRR: 1.02, 95% CI: 0.88-1.17). CONCLUSION Impaired performance on ultrabrief cognitive assessments of arousal and attention provide valuable insights regarding hospital outcomes.

The Triple Challenge of Recruiting Older Adults With Dementia and High Medical Acuity in Skilled Nursing Facilities

PURPOSE To describe strategies, culled from experience, for responding to several recruitment challenges in an ongoing randomized clinical trial of delirium in persons with dementia. ORGANIZING CONSTRUCT Delirium in people with dementia is common across all cultures. Little research supports the use of specific interventions for delirium. Recruitment of an adequate sample is critical to the validity of findings from intervention studies that form the foundation for evidence-based practice. METHODS The trial referenced in this article tests the efficacy of cognitive stimulation for resolving delirium in people with dementia. Participants are recruited at the time of admission to one of eight community-based skilled nursing facilities (SNFs). Eligible participants are 65 years of age or older and community dwelling, and have a diagnosis of dementia and delirium. Recruitment challenges and strategies were identified during weekly team meetings over a 2-year period. FINDINGS Recruitment challenges include factors in the external and internal environment and the participants and their families. Strategies that address these challenges include early site evaluation and strong communication approaches with staff, participants, and families. CONCLUSIONS The recruitment of an adequate sample of acutely ill older adults with dementia in SNFs can pose a challenge to investigators and threaten the validity of findings. Recruitment strategies that help improve the validity of future studies are described. CLINICAL RELEVANCE Worldwide, over 100 million people will have dementia by 2050, placing them at increased risk for delirium. Recruitment strategies that improve the quality of nursing research and, by extension, the care and prevention of delirium in older adults with dementia during rehabilitation in SNFs are greatly needed.

What it takes: perspectives from developing nurse scientists.

The need for nurse scientists has never been greater, given the complexity of health problems facing our world and the rising cost of providing care to prevent and treat them. The development of nurse researchers is critical to preserve and advance the scientific foundation of the discipline. In this article, two successful doctoral students present their personal views about the cognitive and behavioral transformation they experienced during their program of study, highlighting what they believe to be important resources that enhance doctoral education and sharing how they overcame the challenges encountered. The framework of transformational leadership is used to highlight important aspects of their development as nurse scientists. Action steps for attracting a greater number of nurses to a career in science are recommended.

The Model of Care Partner Engagement: Use in delirium management

Care partner engagement is a central tenant of person-centered care. Despite widespread interest in transforming current health care delivery to a more person-centered system, little is known about effective strategies for engaging care partners. The Model of Care Partner Engagement is introduced and described as an evidence-informed framework that nurses can use to guide the development of care partnerships. The case of hospitalized older adults with cognitive impairment and delirium is used to illustrate implementation of the model. Care partner engagement is integral to national efforts that promote affordable, equitable, high quality care and is a growing expectation of older adults and their families.

Gender Differences in Factors Associated With Delirium Severity in Older Adults With Dementia

The purpose of this descriptive correlational study was to explore potential gender differences in the relationship of dementia severity, age, APOE status, cognitive reserve and co-morbidity (two potentially modifiable factors), to delirium severity in older adults. Baseline data from an ongoing clinical trial and a Poisson regression procedure were used in the analyses. Participants were 148 elderly individuals with dementia and delirium admitted to post-acute care. In women, delirium severity was related to dementia severity (p=0.002) and co-morbidity moderated that effect (p=0.03). In men, education was marginally associated with delirium severity (p=0.06). Implications for research are discussed.

Sundown Syndrome: A Systematic Review of the Literature

The label sundown syndrome continues to be frequently used in long-term and acute care settings without consistent meaning. This study adds to the understanding of this label by synthesizing findings from research published since 1987 linked to sundown syndrome. The purpose of this systematic review is to describe, synthesize, and critique the theoretical definitions, operational definitions and measurement methods, prevalence, antecedent and precipitating factors and consequences, and effectiveness of interventions for sundown syndrome found in the published literature. Implications for research and practice are presented.