Latent transition analysis is a method of modeling change over time in categorical variables. It has been used in the social sciences for many years, but not in nursing research.The purposes of this study were to illustrate the utility of latent transition analysis for nursing research by presenting a case example (a secondary analysis of data from a previously conducted randomized control trial testing the effectiveness of a tailored psychoeducational intervention to decrease patient-related attitudinal barriers to cancer pain management) and to understand for whom and in what direction the tailored intervention resulted in change with respect to attitudinal barriers and pain symptoms.The model was developed by (a) defining a class structure on the basis of individuals' barrier patterns, (b) adding demographic predictors and distal pain outcomes, and (c) modeling and testing transitions across classes.There were two classes of individuals: Low Barriers and High Barriers. Older, less educated individuals were more likely to be in the High Barriers class at Time 1. Individuals in either class did not have different pain outcomes at the end of the study. Of those individuals that transitioned across classes, those who received the intervention were statistically more likely to move in a favorable direction (to the Low Barriers class). Furthermore, there is evidence that some individuals in the control group had unfavorable outcomes.The results from the example provide useful information about for whom and in what direction the intervention resulted in change. Latent transition analysis is a valuable procedure for nurse researchers because it collapses large arrays of categorical data into meaningful patterns. It is a flexible modeling procedure with extensions allowing further understanding of a change process.
Abstract The Moving Forward Nursing Home Quality Coalition advances the goals outlined by the 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report aimed at improving nursing home (NH) quality. Over two years, Coalition committee members – along with a network of national leaders, nursing home residents, and the general public – will develop, test and promote action plans that will improve the way the United States finances, delivers, and regulates care in Nursing Homes. The Coalition is comprised of a steering committee and working committees that align with and advance the seven NASEM goals including; 1) advancing delivery of person-centered care; 2) ensuring a well-prepared and compensated workforce; 3) increasing financial transparency and accountability; 4) creating a rational and robust financing system; 5) designing more effective and responsive quality assurance; 6) expanding quality measurement and continuous quality improvement; and 7) adopting health information technology. Coalition committees have engaged in three of four phases of their two-year work plan including convening stakeholders to prioritize and develop action plans to test and promote change. Throughout the work, committee collaboration has ensured action plans are refined and expanded in synergistic ways to shape state and national policy. This presentation will provide an overview of the broader Coalition work and give context for the other presentations which provide an example of collaborative work leading to proposed recommendations for critical policy and regulatory change around person-centered care planning.
Increasing use of daily chlorhexidine gluconate (CHG) bathing can potentially lead to selection for organisms with reduced susceptibility to CHG, limiting the utility of CHG. We examined reduced susceptibility to CHG of fluoroquinolone-resistant gram-negative bacilli and methicillin-resistant Staphylococcus . No evidence suggested reduced susceptibility to CHG. Infect Control Hosp Epidemiol 2017;38:729–731
Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital.We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made.Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers.Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.
Abstract NASEM’s first recommendation to reform nursing home (NH) care is to deliver comprehensive, person-centered, equitable care that ensures residents’ health, quality of life, and safety, promotes autonomy, and manages risks. The NH Code of Federal Regulations requires person-centered care (PCC). However, while there are existing structures (i.e. MDS 3.0) to support care planning clinical needs, most NHs lack tools and procedures to systematically identify and provide care that aligns with resident goals, priorities, and preferences (GPPs). This is especially true for GPPs that reflect personhood and the human desire for autonomy. Our subcommittee aims to change the culture of care planning in NHs to integrate residents and families in co-developing holistic, person-centered care plans that centralize residents’ GPPs in ways that promote and support personhood. Our subcommittee will develop and test a) a standardized GPP care planning process that includes enhanced approaches to identification, documentation, communication, and implementation of resident GPPs; b) a repository of tools to support identification and documentation of resident GPPs; and c) training to prepare staff to understand and recognize resident GPPs. We will collaborate with other Moving Forward Committees to develop approaches to evaluating and measuring quality in care planning with inclusion of health information technology . When completed, the proposed work will provide evidence of successful and feasible quality improvement approaches to care planning resident GPPs that can augment existing federal requirements and can inform future policy changes or guidance to surveyors.
Stress-Susceptible (Judge et al., 1968) animals frequently die during transport or handling. In less severe cases these animals suffer substantially when made anoxic; this response is reflected in the production of large quantities (50 to 100 µM/g tissue) of lactic acid in their muscles. A similar response can be noted during the development of anoxia in the muscle after excision or exsanguination (Lister et al., 1970; Sair et al., 1970). The accumulation of high levels of lactate near body temperature results in the development of pale, soft, exudative (PSE) characteristics in the musculature (Judge et al., 1968; Briskey, 1964). Stress-resistant animals show only a slight response to anoxia, have a slow rate of glycolysis and lactic acid accumulation and do not develop PSE characteristics in their musculature. Bendall (1966) postulated that the rapid rate of glycolysis was due to intense nervous stimuli reaching the muscle. Lippold (1952) and Bigland and Lippold (1954) have indicated that electromyograph (EMG) electrical activity should be a good measure of the amount of muscular activity during and after exsanguination.
Abstract Self-determination is a core value of person-centered care. Research has shown residents and families want to be involved in decisions about care. Care conferences are one existing structure where residents and families can engage in decision-making about care goals. However, there are few tools to support effective engagement. To inform future tool development, this study sought to understand what resident and family stakeholders value about engaging in care conferences. In virtual meetings, 16 stakeholders identified 3 key areas of engagement: being informed about health/well-being, influencing care goals, and advocating for needs. They indicated current approaches do not achieve these engagement goals, which is particularly problematic during COVID when families cannot engage in person. Stakeholders offered ideas for supporting engagement such as provision of data before the conference. The study has implications for individualizing care conferences and encouraging resident and family engagement in decision-making both during and beyond COVID.
Abstract Identifying nursing home (NH) residents’ goals, priorities, and preferences is a critical step in the delivery of person-centered care. While numerous instruments and tools exist to measure resident preferences, it remains unclear how psychometrically validated instruments used in research may be feasibly applied in practice. In this review, we aimed to identify instruments for assessing residents’ goals, priorities, and preferences and develop recommendations for application in practice. We searched MEDLINE, CINAHL, and PsycINFO databases to identify instruments that assessed quality of life, satisfaction, person-centered care, psychosocial needs and goals, and preferences and were validated in US NHs. We also surveyed experts in the field to identify assessment tools from grey literature. We identified a total of 28 validated tools from 23 peer-reviewed articles and 12 additional tools from 35 grey literature sources. These tools varied in structure (e.g. open vs closed questions), content (e.g. domains covered), and length (e.g. few to many items). Tools could be grouped into two major types: generative and evaluative. Generative tools assessed specific resident goals, priorities, and preferences that could inform care planning particularly upon admission, but also throughout the resident’s stay. Evaluative tools required residents to evaluate aspects of care and may be most appropriate beyond admission. NH staff may find different benefits to various assessment approaches and may need to make local decisions about which to use and which will integrate into existing workflows effectively.
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.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.Qualitative study using grounded dimensional analysis.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.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.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.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.
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