- Email: [email protected]
Award winning abstracts
Geriatric Nursing 35 (2014) 156e158
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
NGNA Section
Award winning abstracts 2013 Judith V. Braun Excellence in Research Award Winner
also excluded if they had been diagnosed with a major depressive disorder prior to caregiving.
Cherie Simpson, PhD, APRN, CNS-BC The Dynamic Experience of Dementia Caregiving Objectives 1) Gain knowledge about the dynamic nature of the dementia caregiving experience as evidence by change in levels of mastery, sleep quality and stress over a 2 month period. 2) Gain knowledge of how mastery, sleep quality and stress impact caregiver depression and perceived self-health over 2 months. Background Cross-sectional and longitudinal studies of dementia caregivers show that chronic exposure to the stress of caregiving results in negative health outcomes. Missing from these studies is an understanding of any intermediate changes that may occur. Understanding the dynamic changes in caregiver experiences that occur from month to month can help target interventions. The purpose of this study was to explore changes in the caregiver experience (stressors and outcomes) over a 2-month period to see what changes might occur, measure those changes, and determine how the relationships between stressors and caregiver health outcomes might be affected within this shorter period. Setting Central Texas Metropolitan area. Data was collected at a time and place convenient for the caregiver that allowed for supervision of the person with dementia. This was usually the caregiver’s home.
Procedures Data were collected via interview by a single interviewer who was an advanced practice nurse. Data collected included demographics, information about caregiving (hours per week caregiving, length of caregiving) primary stressors of the frequency of problematic behaviors by the PWD and dementia severity (Dementia Severity Rating Scale), mastery (Pearlin mastery scale, Lawton caregiver mastery scale), sleep quality (Pittsburgh Sleep Quality Index), perceived stress (Cohen Perceived Stress scale), depression (Center for Epidemiological Studies Depression Scale) and perceived self-health (Healthy Days Questions from BRFSS). Data were collected baseline, 4 weeks and 8 weeks after baseline. Descriptive statistics were performed on variables of caregiver demographics. Tests of general linear models of repeated measures were conducted for the main variables of mastery, sleep quality, perceived stress, depression, and caregiver health. Tests of general linear models of repeated measures were also conducted for the primary stressors that could contribute to outcomes (hours spent per week caregiving, problematic behaviors of the person with dementia, dementia severity). Assumption of sphericity was tested with Mauchy’s test, and if the assumption was violated, alternative change scores (GreenhouseeGeisser or HuynheFeldt) were reported. Correlations were tested for the variables of interest. Multiple regressions were performed, regressing the variables of depression and health (overall health and unhealthy days) on the hours per week caregiving, PWD problematic behaviors, dementia severity, mastery, sleep quality, and perceived stress in order to explain the variance in the outcome variables at each time point. Findings
Sample A convenience sample of 80 caregivers were enrolled and 74 completed the study. Caregivers were English speaking, over the age of 21, and self-identified as a primary caregiver of a communitydwelling person with dementia. Caregivers were excluded if they had untreated obstructive sleep apnea, a medical condition that could affect nighttime sleep and daytime function. Caregivers were 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.02.010
Global mastery remained stable (F1,73 ¼ .42, p ¼ .66) over the short time period while caregiver mastery increased (F1,73 ¼ 2.41, p ¼ .01), sleep quality improved (F1,73 ¼ 8.63, p he report of the number of unhealthy days decreased (F1,73 ¼ 4.93, p ¼ .01), but overall health eroded slightly over the 8 weeks (F1,73 ¼ 3.91, p ¼ .02). These changes in secondary stressors and outcomes coincided with the caregivers’ reports of the frequency of
NGNA Section / Geriatric Nursing 35 (2014) 156e158
problematic behaviors decreasing in the PWD (F1,73 ¼ 10.00, p y, and stress contribute to the variance in depression and caregiver health over time, the regression models for depression were a good fit (F3,70 ¼ 20.67, p explaining the variance in depression at all 3 time points (R2 ¼ .69, .72, .69). Neither global mastery nor caregiving mastery made a significant contribution to depression at any time point in these models. On the other hand, the models for predicting overall health and unhealthy days explained less variance, and the variables of interest (mastery, sleep quality, and stress) reflected different contributions to the variance in health at different time points. For overall health the models explained 30% of the variance at Time 1 (F3,70 ¼ 4.01, p F3,70 ¼ 6.68, p lobal mastery nor caregiving mastery made a unique contribution to reports of unhealthy days, but perceived stress was significant at times. Conclusion These results of varying strengths of relationships at the three time points, the difference in the amount of variance explained in depression (70%) and overall health (30%), and fluctuation across time points suggest that the caregiving experience is dynamic and that the relationships are complex. A limitation to the present study is the acknowledgement that other possible covariates to health were not accounted for in the regression models. Interestingly, an unexpected improvement was seen in caregiver stress and sleep quality, as the behaviors of the PWD decreased in frequency without the benefit of an intervention. This is consistent with previous research identifying problematic behaviors as a correlate of depression and health. However, either the improvements in sleep quality and stress were not enough of a change or did not occur over a long enough time period, or, because the symptoms of depression were low for the sample (the mean CESD score fell below 16), the change in stress and sleep did not coincide with a change in depression. The clinical implications of the present study are two-fold. First, the study does support the dynamic nature of the caregiving experience. This sample of caregivers experienced changes in levels of caregiving mastery, stress, sleep quality, and health over a 2month period. This suggests that caregivers should be evaluated for caregiver stress and changes in sleep frequently. Furthermore, although several community-based options for caregiver interventions such as Powerful Tools for Caregivers or REACH OUT train caregivers in new skill sets over a period of several weeks, caregivers may also need “booster” or refresher sessions of skills learned as the caregiving experience changes and evolves. Emphasis on managing the problematic behaviors of the PWD, stress reduction techniques, and interventions to help caregivers sleep would be beneficial to caregivers’ health status, perhaps over the long term for their depression. Second, one must consider nursing presence as an intervention, based on the caregivers’ stress and sleep quality improving over the 2 months without other direct intervention. One might argue that the very act of observing, and in this case measuring a phenomenon like sleep quality, can effect change in the one being observed. On the other hand, one must also consider the phenomenon of healing presence and the benefits of comfort and a sense of being cared for that can be gained by the caregiver’s being in the presence of a nurse. While this was not an intended intervention, the nurse’s being present, attentive, and available or open to the caregiver and hearing about the caregiver’s experience could have provided a healing environment in which the caregivers could experience change. A nurse’s presence can be a valuable tool for the caregiver in any setting.
157
2013 Innovations in Practice Award Winner Laury Jensen Development and Implementation of the VA Coordinated Transitional Care Program: Lessons Learned and Challenges Objectives 1) Identify the limitations of existing transitional care interventions for at risk patient populations including older persons with dementia and/or in care settings with a wide geographic dispersion of patients who may not be eligible for home visits. 2) Describe the challenges and lessons learned in designing, implementing and evaluating a nurse-led, telephone based transitional care program that targets at risk patient populations, the Coordinated-Transitional Care (C-TraC) Program.
Background/purpose There is a need to improve care coordination of hospitalized veterans discharged to the community. Has the study been approved by the IRB? Yes Study/project design Pre/post-test comparison comparing outcomes for patients enrolled in C-TraC to a baseline period. Setting William S. Middleton Memorial Veterans Hospital; an 87 bed hospital with 4400 admissions annually and a geographically dispersed patient population. Sample The Coordinated-Transitional Care Program (C-TraC) targeted community dwelling veterans at high risk of poor post hospital outcomes. Veterans hospitalized on medical or surgical wards and discharged to non-institutional community settings were eligible for participation provided they had access to a telephone. Eligible veterans were also required to have a diagnosis of dementia, delirium and/or cognitive impairment, or alternatively, to be at least 65 years old and either live alone or have a hospitalization in the previous twelve months. Procedure A nurse-case manager with specialized geriatric and transitional care training provides inpatient and post-discharge transitional care support by (1) educating and empowering the veteran (and/or the veteran’s caregiver) in medication management, (2) ensuring the veteran has medical follow-up in place and is ready and able to actively participate in that follow-up, (3) educating the veteran/ caregiver regarding the signs of a worsening medical condition and how to respond to such signs and (4) ensuring the veteran/caregiver knows whom to contact (generally the C-TraC nurse) if questions or concerns arise during the period after hospital discharge but before the first outpatient follow-up. Post-discharge
158
NGNA Section / Geriatric Nursing 35 (2014) 156e158
support is provided via telephone and emphasizes patient-led medication reconciliation. Findings C-TraC was developed and piloted from 2008 to 2010 by an interdisciplinary team of clinicians, researchers, and hospital leadership. The program underwent several PDCA cycles to identify at risk hospitalized veterans, improve coordination with existing hospital services, enhance the effectiveness of follow-up telephone protocols in identifying medication discrepancies and reinforcing patient education. Lessons learned included the critical role of hospital administration support, early communication with inpatient/outpatient administration and frontline stakeholders, the need for patient-driven medication reconciliation post-discharge, and integrating (not duplicating) existing discharge processes. Primary challenges involved raising awareness of the importance of
dedicated transitional care support, and developing approaches to effectively help veterans/caregivers prioritize medical information. Strategies used in C-TraC protocols to overcome these challenges will be discussed. Conclusions/implications Implementation of C-TraC required multiple, iterative phases and widespread stakeholder engagement. Lessons learned and challenges to implementation may be informative in anticipating needs for similar transitional care interventions. C-TraC demonstrated favorable outcomes (1/3 fewer rehospitalizations among C-TraC patients compared to a baseline group and a net savings cost avoidance of $1273/patient enrolled) and may represent a viable alternative for transitional care in VA, rural or other settings challenged by distance, constrained resources and patient vulnerability.
NGNA Section of Geriatric Nursing Looking for Authors and Articles The co-editors of the NGNA section, Elizabeth (Ibby) Tanner ([email protected]) and Alyce Ashcraft ([email protected]), invite authors to submit scholarly manuscripts including research, systematic reviews, evidence based practice, quality improvement, policy implementation and evaluation, and program implementation and evaluation. The editors will also consider reflection pieces on the art and science of gerontological nursing that compel us to stop and think about the meaning of growing old. In addition, this section will showcase NGNA activities.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
NGNA Section
Award winning abstracts 2013 Judith V. Braun Excellence in Research Award Winner
also excluded if they had been diagnosed with a major depressive disorder prior to caregiving.
Cherie Simpson, PhD, APRN, CNS-BC The Dynamic Experience of Dementia Caregiving Objectives 1) Gain knowledge about the dynamic nature of the dementia caregiving experience as evidence by change in levels of mastery, sleep quality and stress over a 2 month period. 2) Gain knowledge of how mastery, sleep quality and stress impact caregiver depression and perceived self-health over 2 months. Background Cross-sectional and longitudinal studies of dementia caregivers show that chronic exposure to the stress of caregiving results in negative health outcomes. Missing from these studies is an understanding of any intermediate changes that may occur. Understanding the dynamic changes in caregiver experiences that occur from month to month can help target interventions. The purpose of this study was to explore changes in the caregiver experience (stressors and outcomes) over a 2-month period to see what changes might occur, measure those changes, and determine how the relationships between stressors and caregiver health outcomes might be affected within this shorter period. Setting Central Texas Metropolitan area. Data was collected at a time and place convenient for the caregiver that allowed for supervision of the person with dementia. This was usually the caregiver’s home.
Procedures Data were collected via interview by a single interviewer who was an advanced practice nurse. Data collected included demographics, information about caregiving (hours per week caregiving, length of caregiving) primary stressors of the frequency of problematic behaviors by the PWD and dementia severity (Dementia Severity Rating Scale), mastery (Pearlin mastery scale, Lawton caregiver mastery scale), sleep quality (Pittsburgh Sleep Quality Index), perceived stress (Cohen Perceived Stress scale), depression (Center for Epidemiological Studies Depression Scale) and perceived self-health (Healthy Days Questions from BRFSS). Data were collected baseline, 4 weeks and 8 weeks after baseline. Descriptive statistics were performed on variables of caregiver demographics. Tests of general linear models of repeated measures were conducted for the main variables of mastery, sleep quality, perceived stress, depression, and caregiver health. Tests of general linear models of repeated measures were also conducted for the primary stressors that could contribute to outcomes (hours spent per week caregiving, problematic behaviors of the person with dementia, dementia severity). Assumption of sphericity was tested with Mauchy’s test, and if the assumption was violated, alternative change scores (GreenhouseeGeisser or HuynheFeldt) were reported. Correlations were tested for the variables of interest. Multiple regressions were performed, regressing the variables of depression and health (overall health and unhealthy days) on the hours per week caregiving, PWD problematic behaviors, dementia severity, mastery, sleep quality, and perceived stress in order to explain the variance in the outcome variables at each time point. Findings
Sample A convenience sample of 80 caregivers were enrolled and 74 completed the study. Caregivers were English speaking, over the age of 21, and self-identified as a primary caregiver of a communitydwelling person with dementia. Caregivers were excluded if they had untreated obstructive sleep apnea, a medical condition that could affect nighttime sleep and daytime function. Caregivers were 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.02.010
Global mastery remained stable (F1,73 ¼ .42, p ¼ .66) over the short time period while caregiver mastery increased (F1,73 ¼ 2.41, p ¼ .01), sleep quality improved (F1,73 ¼ 8.63, p he report of the number of unhealthy days decreased (F1,73 ¼ 4.93, p ¼ .01), but overall health eroded slightly over the 8 weeks (F1,73 ¼ 3.91, p ¼ .02). These changes in secondary stressors and outcomes coincided with the caregivers’ reports of the frequency of
NGNA Section / Geriatric Nursing 35 (2014) 156e158
problematic behaviors decreasing in the PWD (F1,73 ¼ 10.00, p y, and stress contribute to the variance in depression and caregiver health over time, the regression models for depression were a good fit (F3,70 ¼ 20.67, p explaining the variance in depression at all 3 time points (R2 ¼ .69, .72, .69). Neither global mastery nor caregiving mastery made a significant contribution to depression at any time point in these models. On the other hand, the models for predicting overall health and unhealthy days explained less variance, and the variables of interest (mastery, sleep quality, and stress) reflected different contributions to the variance in health at different time points. For overall health the models explained 30% of the variance at Time 1 (F3,70 ¼ 4.01, p F3,70 ¼ 6.68, p lobal mastery nor caregiving mastery made a unique contribution to reports of unhealthy days, but perceived stress was significant at times. Conclusion These results of varying strengths of relationships at the three time points, the difference in the amount of variance explained in depression (70%) and overall health (30%), and fluctuation across time points suggest that the caregiving experience is dynamic and that the relationships are complex. A limitation to the present study is the acknowledgement that other possible covariates to health were not accounted for in the regression models. Interestingly, an unexpected improvement was seen in caregiver stress and sleep quality, as the behaviors of the PWD decreased in frequency without the benefit of an intervention. This is consistent with previous research identifying problematic behaviors as a correlate of depression and health. However, either the improvements in sleep quality and stress were not enough of a change or did not occur over a long enough time period, or, because the symptoms of depression were low for the sample (the mean CESD score fell below 16), the change in stress and sleep did not coincide with a change in depression. The clinical implications of the present study are two-fold. First, the study does support the dynamic nature of the caregiving experience. This sample of caregivers experienced changes in levels of caregiving mastery, stress, sleep quality, and health over a 2month period. This suggests that caregivers should be evaluated for caregiver stress and changes in sleep frequently. Furthermore, although several community-based options for caregiver interventions such as Powerful Tools for Caregivers or REACH OUT train caregivers in new skill sets over a period of several weeks, caregivers may also need “booster” or refresher sessions of skills learned as the caregiving experience changes and evolves. Emphasis on managing the problematic behaviors of the PWD, stress reduction techniques, and interventions to help caregivers sleep would be beneficial to caregivers’ health status, perhaps over the long term for their depression. Second, one must consider nursing presence as an intervention, based on the caregivers’ stress and sleep quality improving over the 2 months without other direct intervention. One might argue that the very act of observing, and in this case measuring a phenomenon like sleep quality, can effect change in the one being observed. On the other hand, one must also consider the phenomenon of healing presence and the benefits of comfort and a sense of being cared for that can be gained by the caregiver’s being in the presence of a nurse. While this was not an intended intervention, the nurse’s being present, attentive, and available or open to the caregiver and hearing about the caregiver’s experience could have provided a healing environment in which the caregivers could experience change. A nurse’s presence can be a valuable tool for the caregiver in any setting.
157
2013 Innovations in Practice Award Winner Laury Jensen Development and Implementation of the VA Coordinated Transitional Care Program: Lessons Learned and Challenges Objectives 1) Identify the limitations of existing transitional care interventions for at risk patient populations including older persons with dementia and/or in care settings with a wide geographic dispersion of patients who may not be eligible for home visits. 2) Describe the challenges and lessons learned in designing, implementing and evaluating a nurse-led, telephone based transitional care program that targets at risk patient populations, the Coordinated-Transitional Care (C-TraC) Program.
Background/purpose There is a need to improve care coordination of hospitalized veterans discharged to the community. Has the study been approved by the IRB? Yes Study/project design Pre/post-test comparison comparing outcomes for patients enrolled in C-TraC to a baseline period. Setting William S. Middleton Memorial Veterans Hospital; an 87 bed hospital with 4400 admissions annually and a geographically dispersed patient population. Sample The Coordinated-Transitional Care Program (C-TraC) targeted community dwelling veterans at high risk of poor post hospital outcomes. Veterans hospitalized on medical or surgical wards and discharged to non-institutional community settings were eligible for participation provided they had access to a telephone. Eligible veterans were also required to have a diagnosis of dementia, delirium and/or cognitive impairment, or alternatively, to be at least 65 years old and either live alone or have a hospitalization in the previous twelve months. Procedure A nurse-case manager with specialized geriatric and transitional care training provides inpatient and post-discharge transitional care support by (1) educating and empowering the veteran (and/or the veteran’s caregiver) in medication management, (2) ensuring the veteran has medical follow-up in place and is ready and able to actively participate in that follow-up, (3) educating the veteran/ caregiver regarding the signs of a worsening medical condition and how to respond to such signs and (4) ensuring the veteran/caregiver knows whom to contact (generally the C-TraC nurse) if questions or concerns arise during the period after hospital discharge but before the first outpatient follow-up. Post-discharge
158
NGNA Section / Geriatric Nursing 35 (2014) 156e158
support is provided via telephone and emphasizes patient-led medication reconciliation. Findings C-TraC was developed and piloted from 2008 to 2010 by an interdisciplinary team of clinicians, researchers, and hospital leadership. The program underwent several PDCA cycles to identify at risk hospitalized veterans, improve coordination with existing hospital services, enhance the effectiveness of follow-up telephone protocols in identifying medication discrepancies and reinforcing patient education. Lessons learned included the critical role of hospital administration support, early communication with inpatient/outpatient administration and frontline stakeholders, the need for patient-driven medication reconciliation post-discharge, and integrating (not duplicating) existing discharge processes. Primary challenges involved raising awareness of the importance of
dedicated transitional care support, and developing approaches to effectively help veterans/caregivers prioritize medical information. Strategies used in C-TraC protocols to overcome these challenges will be discussed. Conclusions/implications Implementation of C-TraC required multiple, iterative phases and widespread stakeholder engagement. Lessons learned and challenges to implementation may be informative in anticipating needs for similar transitional care interventions. C-TraC demonstrated favorable outcomes (1/3 fewer rehospitalizations among C-TraC patients compared to a baseline group and a net savings cost avoidance of $1273/patient enrolled) and may represent a viable alternative for transitional care in VA, rural or other settings challenged by distance, constrained resources and patient vulnerability.
NGNA Section of Geriatric Nursing Looking for Authors and Articles The co-editors of the NGNA section, Elizabeth (Ibby) Tanner ([email protected]) and Alyce Ashcraft ([email protected]), invite authors to submit scholarly manuscripts including research, systematic reviews, evidence based practice, quality improvement, policy implementation and evaluation, and program implementation and evaluation. The editors will also consider reflection pieces on the art and science of gerontological nursing that compel us to stop and think about the meaning of growing old. In addition, this section will showcase NGNA activities.