Bethel Ann Powers

Review of nurse home visiting interventions for community-dwelling older persons with existing disability.

Despite there being a considerable number of meta-analyses and reviews synthesizing the nurse in-home visiting literature, there have been no reviews examining nurse in-home visiting for patients who are already disabled. This article presents a literature review and synthesis of 10 trials targeted on older adults with disability. The review is organized into structure and process components related to the outcome variable disability based on the classic Donabedian model. The review suggests that the components of in-home visiting associated with favorable disability outcomes include multiple home visits, geriatric training and experience, health provider collaboration, multidimensional assessment, and theory use. In contrast, lack of process measures, physician collaboration, training, and specific intervention components targeting disability are associated with ineffective interventions. This review helps provide insight into variables that influence disability outcomes as well as the development of best-practice models of in-home visiting to older adults with existing disability.

Ethnographic analysis of everyday ethics in the care of nursing home residents with dementia: a taxonomy.

BackgroundThe concept of everyday ethics was used to emphasize the moral basis of ordinary issues of daily living affecting quality of life for nursing home residents with dementia. ObjectivesTo critically examine ethical issues of daily living affecting nursing home residents with dementia and to construct a descriptive taxonomy inductively derived from ethnographic fieldwork data. MethodCombined anthropological methods of participant observation and in-depth interviewing were used in the natural setting of a 147-bed, voluntary, not-for-profit nursing home. Experiences of 30 residents, their family members, and nursing home staff were explored. In addition, the records of 10 ethics committee cases involving residents with dementia further enlarged the database. ResultsThe taxonomy of everyday ethical issues includes the following four domains: (a) learning the limits of intervention; (b) tempering the culture of surveillance and restraint; (c) preserving the integrity of the individual; and (d) defining community norms and values. Each is representative of constellations of concerns that are grounded in the cultural and moral environment of the nursing home. ConclusionsResults highlight the challenges of recognizing the ethical in the ordinary, and of resolving everyday issues in ways that enhance quality of life for residents with dementia and those (family and staff) who care for them.

The meaning of nursing home friendships.

This research report on the social networks of institutionalized elderly people describes four types of networks and focuses on resident-resident interaction. Friendship themes of intimacy, social support, reciprocity, and companionship provide a basis for examining similarities in and differences between the network types. Discussion draws on the study results through examination of the meaning of friendship and interpretation of life-span themes.

Everyday ethics of dementia care in nursing homes: A definition and taxonomy

Too often the attention of formalized ethical decision making in health care settings turns to hard to deal with life and death issues. Consequently, consideration of the ethical aspects of ordinary everyday issues affecting nursing home residents with dementia and those who care for them remains limited. The purpose of this twoyear anthropological study was to develop a taxonomy of commonplace ethical issues, taking into account resident, family member, and nursing home staff member points of view. This paper defines the guiding concept of everyday ethics as it has been used in the research and describes the taxonomy, of which there are four domains: • Learning the limits of intervention; • Tempering the culture of surveillance and restraint; • Preserving the integrity of the individual; and • Defining community norms and values. Discussion considers the usefulness of the taxonomy as a framework for thinking about what may be involved in understanding the ethics of the ordinary and resolving common types of issues and concerns.

Randomized Controlled Trial of CARE: An Intervention to Improve Outcomes of Hospitalized Elders and Family Caregivers

In this randomized controlled trial we tested the efficacy of an intervention program (CARE: Creating Avenues for Relative Empowerment) for improving outcomes of hospitalized older adults and their family caregivers (FCGs). FCG-patient dyads (n = 407) were randomized into two groups. The CARE group received a two-session empowerment-educational program 1-2 days post-admission and 1-3 days pre-discharge. The attention control group received a generic information program during the same timeframe. Follow-up was at 2 weeks and 2 months post-discharge. There were no statistically significant differences in patient or FCG outcomes. However, inconsistent evidence of role outcome differences suggests that CARE may benefit certain FCG subgroups instead of being a one-size-fits-all intervention strategy. Closer examination of CAREs mechanisms and effects is needed.

Meaning and practice of palliative care for hospitalized older adults with life limiting illnesses.

Objective. To illustrate distinctions and intersections of palliative care (PC) and end-of-life (EOL) services through examples from case-centered data of older adults cared for during a four-year ethnographic study of an acute care hospital palliative care consultation service. Methods. Qualitative narrative and thematic analysis. Results. Description of four practice paradigms (EOL transitions, prognostic uncertainty, discharge planning, and patient/family values and preferences) and identification of the underlying structure and communication patterns of PC consultation services common to them. Conclusions. Consistent with reports by other researchers, study data support the need to move beyond equating PC with hospice or EOL care and the notion that EOL is a well-demarcated period of time before death. If professional health care providers assume that PC services are limited to assisting with and helping patients and families prepare for dying, they miss opportunities to provide care considered important to older individuals confronting life-limiting illnesses.

Spiritual nurturance and support for nursing home residents with dementia

This mixed method study examined nursing home resident, family and staff views regarding spiritual nurturance and support for persons with dementia and analyzed institutional resources/approaches for meeting residents’ spiritual needs. For residents able to communicate in words (n = 47/83 or 57%), this topic evoked a range of emotional content, brought back memories, and yielded information about what mattered to them spiritually/religiously. Some observations and reported behaviors of residents unable to be interviewed directly (n = 36/83 or 43%) suggested emotional awareness of spiritual activities. Family member/staff perspectives revealed beliefs, concerns, and needs for support/training in the provision of spiritual care. Quantitative findings were consistent and identified differences between surveyed nursing homes (n = 48) with and without religious affiliations. Discussion of personhood, spiritual/ religious coping, and meeting spiritual care needs led to conclusions about the role of professional chaplaincy in educating and modeling for staff and others appropriate behaviors for providing spiritual support as well as the importance of accommodating diversity and maximizing resources.

Short of breath and dying: State of the science on opioid agents for the palliation of refractory dyspnea in older adults

The purpose of this narrative literature review was to describe the state of the science on the effectiveness of opioid medications to palliate dyspnea in older adults with advanced disease. A three-stage critical appraisal process was used to evaluate articles published between 2000-2011 that were retrieved from the CINAHL, Ovid MEDLINE, and PsycINFO databases. Low-dose opioid medication use was associated with statistically significant reductions in dyspnea intensity scores in the majority of studies included in the analysis. Many recent articles on this topic shed light on the importance but underuse of opioid agents to palliate dyspnea, particularly in older adults with advanced chronic illnesses, such as heart failure and chronic obstructive pulmonary disease. ADRA (Assess, Document, Re-assess, Advocate) is a proposed framework that gerontological nurses can use to ensure patients receive adequate symptom management for refractory dyspnea.

Evaluation of Geriatric Home Healthcare Depression Assessment and Care Management: Are OASIS-C Depression Requirements Enough?

OBJECTIVE Research is scarce on how depression is identified and treated among Medicare home healthcare (HHC) patients age 65+ with disability. The Centers for Medicare & Medicaid Services (CMS) recently incorporated depression screening into the OASIS-C HHC assessment. Our study objectives were to evaluate and characterize depression care management (DCM) in an HHC agency after CMS increased its depression requirements and to determine if there was an association of DCM with disability (activities of daily living [ADLs]) outcomes. METHODS The authors conducted a retrospective chart review of 100 new Medicare HHC admissions patients age 65+ (mean age: 81.7) who screened positive for depression and had disability and multimorbidity. Clinical and administrative records were examined and descriptive analyses used. Multivariate regression analyses investigated the association of six DCM components with ADLs improvement. RESULTS Depression was recognized in care plans of 60% of patients. Documentation of only one nurse care management activity, antidepressant use, indicated the use of evidence-based standards of depression assessment and DCM. Depression measures were not administered at discharge, recertification, or transfer. Forty percent of patients had a formal depression diagnosis by the referring physician in the chart, and 65% were receiving an antidepressant. Having a depression care plan and depression medication were significantly associated with a large ADLs improvement. CONCLUSION Despite the association of depression care plans with patient disability improvement, inadequate compliance to evidence-based DCM was found. Medicare and HHC agencies must ensure compliance to DCM, including follow-up depression assessment for patients with positive screens.

Which Components of a Primary Care Affiliated Home Visiting Nurse Program Are Associated With Disability Maintenance/Improvement?

A process evaluation of a primary care affiliated home visiting nurse intervention was performed to determine which intervention components were associated with disability maintenance/improvement. This secondary analysis (N = 238) used data recorded in intervention databases and patient interviews among community-dwelling elders with disability. Intervention components were examined in descriptive, correlational, bivariate, and logistic regression analyses. Results demonstrated that two structure components—physician-patient-family-nurse conference visits and intervention (education) materials—and three process components—disease management activities, goal setting, and medication management activities—were linked to maintaining/improving activities of daily living disability status. Confirmation of these findings may help home care nurses to delay disability worsening.