Gail L. Towsley

Symptom experiences and quality of life of rural and urban older adult cancer survivors

This study examined the symptom experience, health-related quality of life, and functional performance of elderly cancer survivors at 1 and 3 months after the completion of initial treatment. The study used a descriptive, comparative, repeated-measures design. A mixed-methods approach combined completion of survey instruments with qualitative interviews. Of the 52 participants, 22 resided in rural (n = 12) or semirural (n = 10) areas and 30 lived in urban settings. There were 23 women and 29 men ranging in age from 65 to 81 years (mean age, 71.53 years). Survivors experienced a significant number of symptoms (mean, 4.58), which were, on average, moderate in intensity and did not differ based on urban or rural residence. The Medical Outcomes Study SF-12 Physical Component Summary was less than the national norm for elderly individuals or those with a chronic disease. There was minimal improvement 3 months after treatment. Elderly survivors, regardless of whether they were rural or urban, experienced a significant number of unrelieved symptoms, including fatigue, pain, and difficulty sleeping. Eighty-eight percent had other chronic diseases. Comorbidities were associated with greater symptom intensity and less physical health status. Survivorship care for elderly adults should include a comprehensive geriatric assessment and tailored strategies for symptom management.

Measuring the quality of care related to pain management: a multiple-method approach to instrument development.

Background:Research to document the effects of nursing on patient outcomes such as pain has been limited by the inability to measure the quality of nursing care effectively. Objective:The purpose of this study was to establish content validity and to evaluate patient understanding of Pain Care Quality (PainCQ) survey items using cognitive interviewing. Method:In the development phase, 101 items representing four constructs were generated from the transcriptions of 33 qualitative interviews conducted with cancer patients in pain. In the judgment phase, items were reviewed systematically by two panels of pain experts. In the final phase, cognitive interviews were conducted with hospitalized cancer patients reporting pain. Results:Content validity was established if eight of nine (p < .05) experts agreed the item was relevant or very relevant. On the basis of the expert panel review, items were deleted, reworded, and added, and 73 items remained. These items were evaluated by cognitive interviews with 39 hospitalized patients with multiple types of cancer in three states. The mean age was 58.87 years, and 60.5% were women. Most were non-Hispanic White (94.7%), and education varied. On a 0 to 10 scale, worst pain during the past shift averaged 5.24 (SD = 2.43). Participant responses to the PainCQ survey items were summarized for each item using a matrix tool and evaluated in team meetings. Through an iterative process, items were revised and reduced to produce the PainCQ survey (v3) with 44 items. Discussion:Through this deliberative and iterative process, an instrument was produced that will contribute to the measurement of the quality of nursing and interdisciplinary care related to pain management. The items retained in the PainCQ were understood and judged by hospitalized patients with pain easily. Further psychometric testing of the PainCQ is indicated.

Initial Psychometric Properties of the Pain Care Quality Survey (PainCQ).

UNLABELLED This study examined the psychometric properties of the Pain Care Quality (PainCQ) survey, a new instrument to measure the quality of nursing and interdisciplinary care related to pain management. Hospitalized medical/surgical oncology patients with pain from 3 states completed the 44-item version of the PainCQ survey following completion of a nursing shift. Interdisciplinary items were evaluated over the entire hospital stay; nursing care was evaluated during the previous shift. The sample included 109 patients ranging in age from 20 to 84 (mean = 53.09). The sample was 58.7% female, 88% non-Hispanic white. Principal Axis Factoring with an oblimin rotation was used as factors were correlated. Two scales resulted. The PainCQ-Interdisciplinary scale included 11 items representing 2 constructs and explaining 47.1% of shared item variance: partnership with the health care team (k = 6 items; α = .85) and comprehensive interdisciplinary pain care (k = 5 items; α = .76). The PainCQ-Nursing scale measured three constructs and explained 60.8 % of shared item variance: being treated right (k = 15 items; α = .95), comprehensive nursing pain care (k = 3 items; α = .77), and efficacy of pain management (k =4 items; α = .87). Results supported the internal consistency reliability and structural validity of the PainCQ survey with 33 items. PERSPECTIVE This article presents the psychometric properties of a new tool to measure interdisciplinary and nursing care quality related to pain management from the patients perspective. This tool can be used for research and as a clinical performance measure to monitor and improve quality of care and patient outcomes.

Measuring nurses' impact on health care quality: progress, challenges, and future directions.

Background:Quality measurement is central in efforts to improve health care delivery and financing. The Interdisciplinary Nursing Quality Research Initiative supported interdisciplinary research teams to address gaps in measuring the contributions of nursing to quality care. Objective:To summarize the research of 4 interdisciplinary teams funded by The Interdisciplinary Nursing Quality Research Initiative and reflect on challenges and future directions to improving quality measurement. Methods:Each team summarized their work including the targeted gap in measurement, the methods used, key results, and next steps. The authors discussed key challenges and recommended future directions. Results:These exemplar projects addressed cross-cutting issues related to quality; developed measures of patient experience; tested new ways to model the important relationships between structure, process, and outcome; measured care across the continuum; focused on positive aspects of care; examined the relationship of nursing care with outcomes; and measured both nursing and interdisciplinary care. Discussion:Challenges include: measuring care delivery from multiple perspectives; determining the dose of care delivered; and measuring the entire care process. Meaningful measures that are simple, feasible, affordable, and integrated into the care delivery system and electronic health record are needed. Advances in health information systems create opportunities to advance quality measurement in innovative ways. Conclusions:These findings and products add to the robust set of measures needed to measure nurses’ contributions to the care of hospitalized patients. The implementation of these projects has been rich with lessons about the ongoing challenges related to quality measurement.

Confirmatory Factor Analysis of the Pain Care Quality Surveys (PainCQ

OBJECTIVE To examine the reliability and validity and to decrease the battery of items in the Pain Care Quality (PainCQ(©) ) Surveys. DATA SOURCES/STUDY SETTING Patient-reported data were collected prospectively from 337 hospitalized adult patients with pain on medical/surgical oncology units in four hospitals in three states. STUDY DESIGN This methodological study used a cross-sectional survey design. Each consenting patient completed two PainCQ(©) Surveys, the Brief Pain Inventory-Short Form, and demographic questions. Clinical data were extracted from the medical record. DATA COLLECTION/EXTRACTION METHODS All data were double entered into a Microsoft Access database, cleaned, and then extracted into SPSS, AMOS, and Mplus for analysis. PRINCIPAL FINDINGS Confirmatory factor analysis using Structural Equation Modeling supported the initial factor structure. Modification indices guided decisions that resulted in a superior, parsimonious model for the PainCQ-Interdisciplinary Care Survey (six items, two subscales) and the PainCQ-Nursing Care Survey (14 items, three subscales). Cronbachs alpha coefficients all exceeded .80. CONCLUSIONS Cumulative evidence supports the reliability and validity of the companion PainCQ(©) Surveys in hospitalized patients with pain in the oncology setting. The tools may be relevant in both clinical research and quality improvement. Future research is recommended in other populations, settings, and with more diverse groups.

Evaluating the Cornell scale for depression in dementia as a proxy measure in nursing home residents with and without dementia

Objectives: We evaluated the use of the Cornell Scale for Depression in Dementia (CSDD) as a proxy measure. Study questions were: How do residents’ self-reports on the CSDD compare with the nurse proxy CSDD ratings of the resident? How do characteristics of depression as rated by the resident CSDD and the nurse CSDD compare? To what extent are demographic and clinical variables associated with resident CSDD, nurse CSDD, and the discrepancy between resident and nurse CSDD scores? Methods: Residents and nurse proxy pairs (n = 395 pairs) from 28 nursing homes (NHs) participated. We calculated discrepancy scores for total and subscale CSDD scores, examined correlations between resident and nurse CSDD scores, and described rates of clinical depression using each of the scores. We conducted multivariate analyses to examine factors associated with resident and nurse CSDD and discrepancy scores. Results: On average, participants had mild cognitive impairment, were White, and female. Associations between resident and nurse CSDD were low (r = 0.16). The mean discrepancy score was −2.03 (SD = 5.28, p < 0.001), indicating that nurses evaluated residents as less depressed than residents evaluated themselves. Discrepancy scores were not associated with residents’ cognitive status, but were associated with a measure of self-report reliability. Regression analyses indicated that depression diagnosis accounted for a small but significant association with resident CSDD, but was not significantly associated with nurse CSDD. Conclusion: These findings underscore the importance of obtaining resident input when assessing depression in NH residents with dementia, and educating NH nurses in the most effective ways to assess depression.

Staffing Levels in Rural Nursing Homes: A Mixed Methods Approach

This mixed methods study used multiple regression analyses to examine the impact of organizational and market characteristics on staffing hours and staffing mix, and qualitative interview to explore the challenges and facilitators of recruiting and retaining qualified staff. Rural nursing homes (NHs) certified by Medicare or Medicaid (N = 161) were sampled from the Online Survey Certification and Reporting system. A subsample (n = 23) was selected purposively for the qualitative analysis. Smaller NHs or government-affiliated homes had more total nursing hours per resident day and more hours of care by certified nursing assistants and RNs than larger and nongovernment-affiliated homes; however, almost 87% of NHs in this study were below the national recommendation for RN hours. Informants voiced challenges related to enough staff, qualified staff, and training staff. Development of nursing resources is critical, especially in rural locales where aging resources may not be well developed.

Predictors of Quality in Rural Nursing Homes Using Standard and Novel Methods

We examined the effect of market and organizational characteristics on nursing home quality as measured by deficiencies (number and weighted) on states in a rural region of the United States. Rural nursing homes in five Mountain West states (N = 161) were sampled from the Online Survey Certification and Reporting system between January 1, 2004 and June 15, 2005. State comparisons indicated that rural nursing homes in Nevada had a higher number of deficiencies and weighted deficiency score as compared with Utah, Colorado, Wyoming, and Idaho. Using regression analyses, we found that a higher percentage of licensed practical nurses in the staffing mix were predictive of a greater number of deficiencies. Nursing homes with more beds or higher Medicaid occupancy had higher weighted deficiency scores. Although rural Mountain West nursing homes average a similar number of deficiencies as nursing homes nationwide, these nursing homes had a greater number of serious deficiencies and higher weighted deficiency scores, suggesting greater actual harm to resident health and safety.

Me & My Wishes: Lessons Learned From Prototyping Resident Centered Videos About Care Preferences.

Me & My Wishes are facilitated, resident-centered video-recorded conversations to communicate current and end-of-life care preferences. We describe the video production process of two prototypes in the long-term care (LTC) setting and discuss lessons learned around developing this type of intervention. Partnering with an LTC community allowed us to create videos on-site, document staff time, handle any barriers with video production, and evaluate the process. In this article, we will describe the process of two residents creating Me & My Wishes videos. Both residents responded positively to viewing their edited video (about 20 min), saying the videos would be “good for family or staff to hear feelings about preferences.” Staff members also responded positively to the videos. We discuss two key issues to consider: the possibility that resident preferences may change and the resources to produce and view videos.

Rules of performance in the nursing home: A grounded theory of nurse–CNA communication

ABSTRACT This study offers an initial theoretical understanding of nurse–CNA communication processes from the perspectives of nurses and CNAs who are providing direct care to residents in nursing homes. A grounded theory approach provided an understanding of nurse–CNA communication process within the complexities of the nursing home setting. Four themes (maintaining information flow, following procedure, fostering collegiality, and showing respect) describe the “rules of performance” that intertwine in nuanced relationships to guide nurse–CNA communication processes. Understanding how these rules of performance guide nurse–CNA communication processes, and how they are positively and negatively influenced, suggests that nurse–CNA communication during direct care of nursing home residents could be improved through policy and education that is specifically designed to be relevant and applicable to direct care providers in the nursing home environment.