Tonya J. Roberts

How nursing home residents develop relationships with peers and staff: A grounded theory study

UNLABELLED Social support and social relationships have been repeatedly identified as essential to nursing home resident quality of life. However, little is known about ways residents develop relationships with peers or staff. OBJECTIVE This study was conducted to explore the ways resident develop relationships with peers and staff in nursing homes. DESIGN AND METHODS Fifteen cognitively intact nursing home residents from two facilities were interviewed for this grounded theory study. Sampling, interviewing, and analysis occurred in a cyclical process with results at each stage of the study informing decisions about data collection and analysis in the next. Unstructured interviews and field observations were conducted. Data were analyzed with open, axial, and selective coding. RESULTS Residents developed relationships with peers and staff largely as an unintended consequence of trying to have a life in the nursing home. Having a life was a two-step process. First, life motivations (Being Self and Creating a Positive Atmosphere) influenced resident preferences for daily activities and interaction goals and subsequently their strategies for achieving and establishing both. Second, the strategies residents used for achieving their required daily activities (Passing Time and Getting Needs Met) and interaction goals then influenced the nature of interaction and the subsequent peer or staff response to these interactions. Residents defined relationships as friendly or unfriendly depending on whether peers or staff responded positively or negatively. There was considerable overlap in the ways peer and staff relationships developed and the results highlight the role of peer and staff responsiveness in relationship development. IMPLICATIONS The results provide possible explanations for the success of interventions in the literature designed to improve staff responsiveness to residents. The results suggest that adapting these kinds of interventions for use with peers may also be successful. The conceptual model also presents a number of opportunities for developing interventions for residents.

Inside the Green House “Black Box”: Opportunities for High-Quality Clinical Decision Making

OBJECTIVE To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates. DATA SOURCES/SETTINGS Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states. STUDY DESIGN/DATA COLLECTION The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively. PRINCIPAL FINDINGS Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities. CONCLUSIONS Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements.

Consistent Assignment of Nursing Staff to Residents in Nursing Homes: A Critical Review of Conceptual and Methodological Issues

PURPOSE OF STUDY Consistent assignment of nursing staff to residents is promoted by a number of national organizations as a strategy for improving nursing home quality and is included in pay for performance schedules in several states. However, research has shown inconsistent effects of consistent assignment on quality outcomes. In order to advance the state of the science of research on consistent assignment and inform current practice and policy, a literature review was conducted to critique conceptual and methodological understandings of consistent assignment. DESIGN AND METHODS Twenty original research reports of consistent assignment in nursing homes were found through a variety of search strategies. RESULTS Consistent assignment was conceptualized and operationalized in multiple ways with little overlap from study to study. There was a lack of established methods to measure consistent assignment. Methodological limitations included a lack of control and statistical analyses of group differences in experimental-level studies, small sample sizes, lack of attention to confounds in multicomponent interventions, and outcomes that were not theoretically linked. IMPLICATIONS Future research should focus on developing a conceptual understanding of consistent assignment focused on definition, measurement, and links to outcomes. To inform current policies, testing consistent assignment should include attention to contexts within and levels at which it is most effective.

Rheumatologist and Primary Care Management of Cardiovascular Disease Risk in Rheumatoid Arthritis: Patient and Provider Perspectives

Despite increased cardiovascular disease (CVD) risk, rheumatoid arthritis (RA) patients often lack CVD preventive care. We examined CVD preventive care processes from RA patient and provider perspectives to develop a process map for identifying targets for future interventions to improve CVD preventive care.

Caregiver Person-Centeredness and Behavioral Symptoms in Nursing Home Residents With Dementia: A Timed-Event Sequential Analysis

PURPOSE Evidence suggests that person-centered caregiving approaches may reduce dementia-related behavioral symptoms; however, little is known about the sequential and temporal associations between specific caregiver actions and behavioral symptoms. The aim of this study was to identify sequential associations between caregiver person-centered actions, task-centered actions, and resident behavioral symptoms and the temporal variation within these associations. DESIGN AND METHODS Videorecorded observations of naturally occurring interactions (N = 33; 724min) between 12 nursing home (NH) residents with dementia and eight certified nursing assistants were coded for caregiver person-centered actions, task-centered actions, and resident behavioral symptoms and analyzed using timed-event sequential analysis. RESULTS Although caregiver actions were predominantly person-centered, we found that resident behavioral symptoms were significantly more likely to occur following task-centered caregiver actions than person-centered actions. IMPLICATIONS Findings suggest that the person-centeredness of caregivers is sequentially and temporally related to behavioral symptoms in individuals with dementia. Additional research examining the temporal structure of these relationships may offer valuable insights into the utility of caregiver person-centeredness as a low-cost strategy for improving behavioral symptom management in the NH setting.

Preparing Tomorrow’s Nursing Home Nurses: The Wisconsin Long Term Care Clinical Scholars Program

Preparing future nurses to care for the growing population of older adults has become a national priority. The demand for long term care services is expected to double between 2000 and 2040, yet the field remains stigmatized as an undesirable place for highly skilled nurses to work. Recent efforts to increase student preparation in geriatrics have been shown to improve student attitudes toward working with older adults and increase knowledge, but long term care settings remain unattractive to students. This article reports on the development, implementation, and evaluation of The Wisconsin Long Term Care Clinical Scholars Program, a nursing home internship for baccalaureate nursing students. The program couples a paid nursing home work experience with an evidence-based long term care nursing curriculum. The program increased student preparation and interest in working both with older adults and in nursing homes, while increasing the capacity of nursing homes to provide a positive student experience.

Impact of Hospital Context on Transitioning Patients From Hospital to Skilled Nursing Facility: A Grounded Theory Study

Background Twenty-five percentage of patients who are transferred from hospital settings to skilled nursing facilities (SNFs) are rehospitalized within 30 days. One significant factor in poorly executed transitions is the discharge process used by hospital providers. Objective The objective of this study was to examine how health care providers in hospitals transition care from hospital to SNF, what actions they took based on their understanding of transitioning care, and what conditions influence provider behavior. Design Qualitative study using grounded dimensional analysis. Participants Purposive sample of 64 hospital providers (15 physicians, 31 registered nurses, 8 health unit coordinators, 6 case managers, 4 hospital administrators) from 3 hospitals in Wisconsin. Approach Open, axial, and selective coding and constant comparative analysis was used to identify variability and complexity across transitional care practices and model construction to explain transitions from hospital to SNF. Key Results Participants described their health care systems as being Integrated or Fragmented. The goal of transition in Integrated Systems was to create a patient-centered approach by soliciting feedback from other disciplines, being accountable for care provided, and bridging care after discharge. In contrast, the goal in Fragmented Systems was to move patients out quickly, resulting in providers working within silos with little thought as to whether or not the next setting could provide for patient care needs. In Fragmented Systems, providers achieved their goal by rushing to complete the discharge plan, ending care at discharge, and limiting access to information postdischarge. Conclusions Whether a hospital system is Integrated or Fragmented impacts the transitional care process. Future research should address system level contextual factors when designing interventions to improve transitional care.

Implementation of daily chlorhexidine bathing to reduce colonization by multidrug-resistant organisms in a critical care unit

HighlightsPrevalence decreased in the immediate aftermath of daily CHG bathing and for the most part remained at that level over the observation period.Low rates of incidence of MDRO colonization was observed with VRE>FQRGNB>MRSA.Absence of efforts to sustain the initial momentum observed in the immediate aftermath of the daily CHG bathing intervention will likely affect its successful implementation. Background: Colonized patients are a reservoir for transmission of multidrug‐resistant organisms (MDROs). Not many studies have examined the effectiveness of daily chlorhexidine gluconate (CHG) bathing under routine care conditions. We present a descriptive analysis of the trends of MDRO colonization following implementation of daily CHG bathing under routine clinical conditions in an intensive care unit (ICU). Methods: From May 2010‐January 2011, we screened patients admitted to a 24‐bed ICU for and methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin‐resistant enterococci (VRE), and fluoroquinolone‐resistant gram‐negative bacilli (FQRGNB). We calculated and plotted monthly incidence and prevalence of colonization of these MDROs. Results: Prevalence decreased in the immediate aftermath of daily CHG bathing implementation and generally remained at that level throughout the observation period. We observed low rates of incidence of MDRO colonization with VRE>FQRGNB>MRSA. Monthly prevalence of colonization and incidence for the composite of MRSA, VRE, and/or FQRGNB was 1.9%‐27.9% and 0‐1.1/100 patient‐days, respectively. Conclusions: Following the implementation of daily CHG bathing, the incidence of MDROs remained low and constant over time, whereas the prevalence decreased immediately after the implementation.

Building capacity for the conduct of nursing research at a Veterans Administration hospital.

Evidence is the bedrock of nursing practice, and nursing research is the key source for this evidence. In this article, we draw distinctions between the use and the conduct of nursing research and provide a perspective for how the conduct of nursing research in a Veterans Administration hospital can build an organization’s capacity for nursing research.

Self-management assessment in multiple chronic conditions: A narrative review of literature

OBJECTIVES Effective self-management in individuals with multiple chronic conditions is necessary to optimize health outcomes. Self-management in multiple chronic conditions involves an iterative process prioritizing multiple changing needs/conditions. However, self-management in multiple chronic conditions has been assessed with instruments designed to assess self-management of a single chronic illness. The instruments may not address the complexity of self-management in multiple chronic conditions. Thus, this review aimed to examine how self-management has been operationalized in the context of multiple chronic conditions. DESIGN A narrative review method was used. DATA SOURCE The online databases, Pubmed, CINAHL Plus, and PsycInfo, were searched. The search was conducted of the database from January 2006 through November 2017. REVIEW METHODS Peer-reviewed research articles which operationalized self-management in adults with at least two or more chronic illnesses were selected for review. Two reviewers read full text of selected articles and extracted data regarding operational definitions of self-management and instruments used to assess self-management. Operational definitions were categorized to conceptualize how self-management has been assessed. RESULTS A total of seven peer-reviewed research articles were selected for inclusion. This review found that self-management has been assessed through prerequisites of self-management and behaviors involved in self-management. Prerequisites of self-management included attitude, self-efficacy, perceived ability, and knowledge. Behaviors included an individuals engagement in self-management such as health-related behaviors, health service use, and medication adherence. CONCLUSIONS This review revealed that current literature does not operationalize self-management in multiple chronic conditions as a process, indicating incomplete assessments of self-management. To obtain a more comprehensive understanding of self-management in multiple chronic conditions, future studies should consider self-management as an iterative process in addition to prerequisites for self-management and behaviors. Such studies will inform the development of patient-centered self-management interventions for individuals with multiple chronic conditions.