Abstract
Introduction
Nursing homes (NH) are important settings for end-of-life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia.
Material and methods
Study design was a cross-sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial.
Results
Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff.
Conclusion
Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.
Keywords: Nursing homes, care plan team, adoption, Goals of Care communication, Diffusion of Innovation
Introduction
Dementia is a progressive incurable disease that afflicts over five million Americans; most will die in nursing homes (NH).1,2 In advanced dementia, end-of-life care issues include uncontrolled pain, diminished interest in eating, and infections.3 Communication to align overarching goals of care (GOC) with treatment plans is the recommended approach to advance care planning and decisions about end-of-life treatments.4,5 Goals of care such as prolonging life or promoting comfort are first discussed, and then aligned to choices about treatment. Family caregivers typically make decisions about resuscitation, tube feeding, hospitalization and treatment of recurrent infections for persons with dementia in the NH, since these individuals lack decision-making capacity for many years prior to death.
Nurses lead the healthcare inter-disciplinary team in NHs, which also includes social workers, therapists, nutrition and activity staff. A Care Plan nurse typically completes a federally required health assessment that guides the care plan on admission. The health assessments are updated quarterly or if the medical status of the residents changes. Health care providers deliver medical care, but are rarely present for care planning meetings or family communication. A key component of resident-centered care for nurses could be goals of care discussions, which can be initiated during the health assessment.
Families and nursing staff both report that GOC discussions are not commonly used in NHs, and care plans rarely include advance care planning content.6, 7 Limited communication between NH staff and families contributes to poor end-of-life care quality.8 Notable barriers to GOC communication in NHs include lack of nursing education, time constraints, lack of health care providers involvement, unclear nursing staff responsibility, fear of legal ramifications, and limited family involvement.8,9 Nurses may not view advance care planning discussions as a part of their job responsibilities, and time pressures result in prioritizing other tasks.10 Alternatively, nursing education and experience may facilitate acceptance of this role.11
The Goals of Care study tested the first systematic adoption of a video decision aid in the NH setting, to facilitate GOC communication. In addition to testing the intervention itself, investigators sought to understand nursing home staff perceptions that may hinder or support the adoption of this innovation in GOC communication. To use the GOC video decision aid, NH nurses and other staff must learn and adopt evidence-based practices, and do so accounting for the complex relationships and barriers to the adoption of innovations in NHs.12,13 Roger’s diffusion of innovation (DOI) framework (2003) guided the measures used in this study to examine nursing home staffs’ perceptions of the GOC approach. The DOI framework focuses on the process by which an innovation – the GOC decision aid -- is adopted. Additionally, the DOI framework includes attributes of the innovation that determine its rate of adoption: relative advantage, compatibility, complexity, trialability, and observability. 14
Characteristics of NH staff may affect readiness to adopt this innovation. Racial/ethnic disparities have been well documented in long-term care settings. 15,16,17 Previous literature has identified potential individual-level factors that contribute to racial/ethnic disparities in advance care planning, including cultural and religious beliefs,18 mistrust of the healthcare system due to historical discrimination,19 and preference for more aggressive treatment.20 Similar beliefs may be held by Black NH staff, limiting comfort with GOC discussions. The GOC intervention may thus be particularly beneficial to Black NH staff. Furthermore, nurses or other NH staff who have greater training for or experience with advance care planning may be more comfortable having GOC discussions, and also see the GOC intervention more favorably.
Investigators designed a study to examine nursing home staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia, and to examine characteristics associated with these perceptions. In addition to descriptive findings, the study tested two hypotheses: 1) that Black nursing home staff would have more positive perceptions of the GOC intervention than White staff, and 2) that nurses and staff who have experience with end-of-life training will have higher perceptions of the Goals of Care intervention.
Material and methods
Design
This study was part of a cluster randomized clinical trial testing the GOC decision aid intervention in 22 NHs. Nurses and other inter-disciplinary care planning team members from 11 NHs in the intervention arm were eligible for an in-person or telephone survey, after training on and delivering the GOC intervention for at least 10 families of residents with advanced dementia.
Goals of Care Decision Aid and Care Plan Intervention
The parent study was a cluster randomized trial to test whether a GOC video decision aid is effective to improve the quality of GOC communication for nursing home residents with advanced dementia. Family decision-makers in intervention NHs experienced the GOC intervention: a video decision aid about GOC in advanced dementia followed by a structured NH care plan meeting with the Care Plan nurse and other members of the inter-disciplinary NH team for a GOC discussion. Three overarching goals were presented in the 20-minute video: prolonging life, supporting function, and improving comfort, and treatment options consistent with each of the goals. In addition, personal stories were presented to depict the selection of goals. Family decision-makers were provided a copy of the decision aid video and a print discussion guide to use with NH providers. Subsequently, family decision-makers were asked to participate in a care plan meeting scheduled by and with the NH interdisciplinary team.
Care plan staff – nurses, social works, therapists and nutritionists -- viewed the video prior to use with families, during a 1- hour training on how to use the GOC discussion guide with family-decision makers. The training session consisted of staff viewing the GOC decision-aid, discussion of the VALUE principles for family discussions, (value family comments, address comments, listen, understand the patient as a person, and elicit family questions) and a short role-play of a GOC discussion. 11,21
Staff Interviews
Purposive sampling was used to seek representation of staff from different disciplines, including medical, nursing, social work, physical therapy, and activities personnel. A site liaison identified NH staff members who were eligible after participation in care plan meetings. The majority of nursing homes staff that participated in the study were from various disciplines, one facility had only a nurse and a social worker complete the survey. A total of 65 care plan members were eligible to participate in the study, and 49 (75%) selected to complete the survey. Participants were enrolled from July 2012 through July 2015, consistent with the timeline of the GOC study. Institutional Review Boards (IRBs) at the University of North Carolina and the University of Central Florida approved this research.
Measures
Diffusion of Innovation
Staff perceptions of the GOC intervention were measured by adapting the supervisory staff version of the Duke Diffusion of Innovation (DOI)-Long-Term Care (LTC) battery.22 The adapted version of the DOI-LTC battery survey used for this study excluded the following subscales: trialability, image, and voluntariness. Working with Dr. McConnell, the developer of the DOI-LTC, we determined these subscales were not applicable for the context of GOC innovation. Furthermore, wording for some of the items were changed to relate to goals of care discussions. Subscales for attributes of the innovation measure included: relative advantage, compatibility, complexity and observability. Relative advantage describes how an innovation is better than what is currently being done. Compatibility relates to the degree to which the innovation is consistent with values of the adopters. Complexity addresses adopters’ ease of use of the innovation. Observability is the extent to which the innovation is evident to others. The 25 items are rated on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). After negative items are reverse coded, higher scores indicate a positive perception of the GOC innovation. The intraclass coefficient (ICC) was low for the overall DOI measures (ICC=.12) and for the DOI subscales, ranging from ICC=0.01 to 0.16.
Sustainability of the Innovation
Investigators developed 3 Likert-scale items to measure sustainability of the innovation, each ranging from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicate higher perceptions of sustainability. Sustainability items were: 1) “the care plan team will continue to use the GOC approach to discuss advance care planning after the study has been completed;” 2) “the care plan team has the knowledge and communication needed to continue to use the GOC intervention;” and 3) “the GOC approach will replace how we previously conducted advance care planning.”
Potential Correlates
Staff characteristics were examined for correlation with perceptions of the GOC intervention. These variables included gender, race, clinical discipline, formal training for end-of-life discussions, experience discussing end-of-life care, involvement with the GOC approach, and preference for the GOC approach. Responses for involvement with and preference for the GOC intervention ranged from always to never on a 6-point Likert scale.
Analysis
Because the DOI measure was adapted, its internal consistency for this population was examined using Cronbach alpha statistic. Internal consistency for the adapted DOI overall measure was high (α=0.88), and the internal consistency for the DOI subscales was moderate to high, ranging from α=0.61 to α=0.90. We also calculated the Cronbach alpha for the sustainability items, but due to low internal consistency we did not aggregate them.
Univariate analyses were used to describe NH staff demographics, training, and perceptions of the GOC intervention. Means and standard deviations (SDs) of the DOI measure and its subscales were calculated to describe the overall perception of adopting the GOC intervention, and analysis of variance (ANOVA) models were conducted to examine the relationship between each of the DOI subscales (dependent variables) and NH staff characteristics, with a focus on the hypothesized relationships with race and experience. The same was done for the sustainability items.
Results
Sixty-five care plan staff were eligible to participate, and we enrolled 49 NH staff members. Thirty-nine percent of participating staff members were nurses, 31% were social workers, and 31% had other roles (Table 1). More than half reported they had formal training in end-of-life care, and 86% reported experience discussing end-of-life care with residents/families. In relation to the GOC intervention, 49% of NH staff indicated they were always or very frequently involved in the GOC intervention, and 69% reported they always or very frequently liked utilizing the GOC intervention.
Table 1.
Descriptive Statistics of Demographic, Training, and Goals of Care Involvement Characteristics of Nursing Home Staff Participants (N=49)
| Variables | Mean (SD) or / Frequency (%) |
|---|---|
| Demographics | |
| Sex | |
| Female | 44 (89.8%) |
| Male | 5 (10.2%) |
| Race | |
| White | 32 (66.7%) |
| Black | 16 (33.3%) |
| Training | |
| Discipline | |
| Nurse | 19 (38.8%) |
| Social worker | 15 (30.6%) |
| Other | 15 (30.6%) |
| Job tenure (years) | 5.02 (4.6) |
| EOL Experience | |
| Formal training in EOL care | |
| Yes | 28 (57.1%) |
| No | 21 (42.9%) |
| Experience discussing EOL care | |
| Yes | 42 (85.7%) |
| No | 7 (14.3%) |
| GOC Use | |
| Involvement in GOC approach | |
| Always/Very Frequently | 24 (49.0%) |
| Occasionally through never | 25 (51.0%) |
| Like to use the GOC approach | |
| Always/Very Frequently | 34 (69.4%) |
| Occasionally through never | 15 (30.6%) |
NH staff reported high ratings for adoption and sustainability of the GOC intervention. (Table 2). On a scale from 1–6, staff perceived the GOC intervention as relatively advantageous (mean 5.09), compatible with practice (mean 5.01) and easy to use (mean 5.16), indicating strong potential for adoption. On sustainability items, staff reported they would continue to use the GOC intervention (mean 4.89) and had the knowledge to do so (mean 5.08); however, they only somewhat agreed that the GOC intervention would replace their current practices (mean 3.94).
Table 2.
Perceptions of the Innovation and Sustainability of the Goals of Care Intervention (N=49)
| Variables | Mean (SD) |
|---|---|
| Diffusion of Innovation (DOI) Attributes of Innovation Scale | |
| Subscales | |
| Relative Advantage | 5.09 (0.69) |
| Complexity (Ease of Use) | 5.16 (0.68) |
| Compatibility | 5.01 (0.73) |
| Observability | 4.52 (0.94) |
| Sustainability Items | |
| Care plan team will continue to use the GOC intervention. | 4.89 (0.81) |
| The care plan team has the knowledge and communication needed to continue to use the GOC intervention. | 5.08 (0.70) |
| The GOC approach will replace how we previously conducted advance care planning. | 3.94 (1.21) |
Note: Scale ranges from 1-strongly disagree to 6-strongly agree.
Compatibility and Complexity negative items have been reversed coded, higher scores indicate greater agreement
Table 3 describes the relationships found between NH staff characteristics and the DOI scale, DOI subscales, and sustainability items. NH staff characteristics did not have strong or consistent correlations with measures of adoption and sustainability; most statistically significant correlations were isolated to a single subscale. Specifically, compared to Whites, Blacks found GOC more observable and more likely to replace their current practices but other DOI subscales did not show associations of adoption and sustainability perceptions by race. Training was not associated with staff perceptions of adoption and sustainability, but those with greater experience in end-of-life communication found this innovation compatible with their practice. Furthermore, nurses perceived the GOC intervention has being more compatible with current practices compared to other nursing home staff.
Table 3.
Staff Characteristics Correlated with Perceptions of the Goals of Care Intervention (N=49)
| Diffusion of Innovation (DOI) Scale Measuring Attributes of the Innovation | Sustainability | |||||||
|---|---|---|---|---|---|---|---|---|
| DOI Scale | Relative Advantage Subscale |
Compatibility Subscale* |
Complexity Subscale* |
Observability Subscale |
Continue to Use± |
Knowledge to Use± |
Replace Current Practice± |
|
| Staff Variables | ||||||||
| Sex | ||||||||
| Male | 3.99 (0.42) | 5.50 (0.44) | 5.64 (0.43)*** | 5.50 (0.40) | 5.18 (0.43) | 5.50 (0.58) | 5.14 (0.63) | 3.40 (1.52) |
| Female (reference) | 3.93 (0.51) | 5.05 (0.70) | 4.94 (0.72) | 5.12 (0.70) | 4.43 (0.96) | 4.83 (0.81) | 4.60 (1.14) | 4.00 (1.18) |
| Race | ||||||||
| White | 3.83 (0.54) | 5.01 (0.74) | 5.13 (0.66) | 5.18 (0.70) | 4.36 (1.03)** | 4.80 (0.76) | 5.06 (0.72) | 3.71 (1.25)* |
| Black (reference) | 4.12 (0.37) | 5.28 (0.55) | 4.78 (0.85) | 5.13 (0.65) | 4.80 (0.72) | 5.06 (0.93) | 5.13 (0.72) | 4.38 (1.09) |
| Clinical Discipline | ||||||||
| Nurse | 4.04 (0.31) | 5.23 (0.51) | 5.07 (0.67)* | 5.25 (0.56) | 4.71 (0.78) | 4.89 (0.66) | 5.26 (0.56) | 3.94 (1.17) |
| Social Work | 3.75 (0.64)* | 4.89 (0.89) | 5.11 (0.77) | 5.03 (0.85) | 4.01 (0.93) | 4.71 (1.07) | 4.93 (0.80) | 3.67 (1.11) |
| Other (reference) | 3.98 (0.52) | 5.12 (0.64) | 4.83 (0.77) | 5.17 (0.64) | 4.77 (1.00) | 5.07 (0.73) | 5.00 (0.76) | 4.20 (1.37) |
| Formal training in EOL care | ||||||||
| Yes | 3.88 (0.53) | 5.10 (0.72) | 5.16 (0.59) | 5.22 (0.59) | 4.38 (0.99) | 4.81 (0.88) | 5.00 (0.77) | 3.79 (1.10) |
| No | 3.99 (0.45) | 5.09 (0.65) | 4.81 (0.85) | 5.07 (0.78) | 4.70 (0.87) | 5.00 (0.73) | 5.19 (0.60) | 4.14 (1.35) |
| Experience discussing EOL care | ||||||||
| Yes | 3.89 (0.50) | 5.05 (0.72) | 5.10 (0.64)* | 5.17 (0.66) | 4.45 (0.97) | 4.88 (0.87) | 5.10 (0.73) | 4.02 (1.16) |
| No (reference) | 4.14 (0.47) | 5.39 (0.31) | 4.51 (1.06) | 5.07 (0.80) | 4.92 (0.66) | 5.00 (0.00) | 5.00 (0.58) | 3.43 (1.51) |
| Involvement in GOC approach | ||||||||
| Always/Very Frequently | 3.88 (0.62) | 5.21 (0.51) | 5.11 (0.73) | 5.09 (0.57) | 4.61 (0.99) | 5.21 (0.60)** | 5.33 (0.70)*** | 4.17 (1.17) |
| Occasionally to never (reference) | 3.99 (0.33) | 4.98 (0.81) | 4.92 (0.73) | 5.23 (0.77) | 4.42 (0.91) | 4.58 (0.88) | 4.84 (0.62) | 3.72 (1.24) |
| Like to use the GOC approach | ||||||||
| Always/Very Frequently | 3.77 (0.70) | 5.21 (0.52) | 5.06 (0.67) | 5.14 (0.72) | 4.58 (0.93) | 5.03 (0.70) | 5.15 (0.70)* | 3.60 (1.35) |
| Occasionally to never (reference) | 4.00 (0.37) | 4.83 (0.93) | 4.89 (0.86) | 5.20 (0.57) | 4.37 (0.99) | 4.57 (1.01) | 4.93 (0.70) | 4.09 (1.14) |
Note: Scale ranges from 1-strongly disagree to 6-strongly agree; Compatibility and Complexity (ease of use) negative items were reversed coded, higher scores indicate a more positive perception of the GOC intervention;
p<.05;
p<.01,
p<.001;
Linear mixed effects models were conducted, in addition to the ANOVA, to account for intraclass correlation to obtain robust statistical tests.
Discussion
This study addressed the systematic adoption of a decision aid in nursing homes, or any similar innovation in end-of-life communication skills. Nursing home staff responded positively to experience with the Goals of Care video decision aid intervention, endorsing its relative advantage over prior end-of-life communication, compatibility with nursing home practice, and ease of use. These findings indicate staff support for adoption and use of the GOC intervention. Participating nursing home staff also saw the intervention as sustainable, particularly if they had been more involved with its use. Perceptions were somewhat correlated with experience, suggesting that experience with an innovative approach may ultimately help to promote improved GOC communication in nursing homes.
Nurses and staff who have experience discussing end-of-life care perceived the GOC intervention to be compatible with current practices to discuss treatment goals. Furthermore, NH staff who participated in the GOC intervention frequently expressed greater confidence in its sustainability than staff who had limited experience with the GOC intervention. Experienced nursing or social work staff may be able to champion innovative approaches that promote GOC discussions in nursing homes.
Various factors have been identified as potential contributors of racial/ethnic disparities in advance care planning, such as, religious belief, 18 mistrust of the healthcare system,19 and preference for aggressive care treatment. 20 Black nursing home staff may have similar perceptions regarding advance care planning, which may hinder treatment preference discussions Black nursing home staff have with residents/families. Consequently, Black nursing home staff may also benefit from the GOC intervention. Furthermore, Black staff agreed the GOC approach would replace how they currently discuss treatment goals with residents.
Another finding of this study indicates social work staff perceptions regarding the novelty of the GOC intervention were rated low. Social work staff in nursing homes may be responsible for discussing treatment preferences on a continuous basis with residents and families. 23,24 Therefore, social work staff may perceive the GOC intervention as less beneficial to them. However, the GOC intervention can be a beneficial tool to assist social work staff to educate residents and families regarding treatment options to improve the concordance of treatment goals between NH staff and family decision-makers. Additionally, the GOC intervention can be useful for nursing home staff that have less involvement with GOC discussions.
Conclusions
Evidence-based best practices evolve in response to research, but have little impact unless practicing clinicians can adopt these new approaches. Understanding staff perceptions of innovations in nursing home care is necessary in order to facilitate the adoption and sustainability of new best practices.25.26 With the need to improve advance care planning discussions in nursing homes, administrators will need to identify strategies for nursing home staff that promote the adoption of evidence-based practices in long-term care. Nursing home clinicians and administrators may use findings from this study when attempting to implement a new approach to advanced care planning communication. Furthermore, nurse engagement in a person-centered practice, like the GOC decision aid intervention, can help educate and empower other staff.27 Some NH staff may need additional training and education to have GOC discussions with family-decision makers, while more experienced NH staff, such as nurses, may become effective champions for new methods to promote GOC discussions in nursing homes.
Acknowledgments
This work was supported by the National Institutes of Health/National Institute of Aging (grant NIA R01AG037483). We thank the staff and families participating in the Goals of Care Project for their time and commitment to understanding and informing care in nursing homes.
Footnotes
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References
- 1.Alzheimer’s Association. Alzheimer’s Disease Facts and Figures. 2017 http://www.alz.org/facts/ viewed March 2017.
- 2.Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470–477. doi: 10.1001/jama.2012.207624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mitchell SL, Teno JM, Kiely D, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529–1538. doi: 10.1056/NEJMoa0902234. (2009) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Arcand M. End-of-life issues in advance dementia: Part 1: Goals of care, decision-making process, and family education. Can Fam Physician. 2015;61:330–4. [PMC free article] [PubMed] [Google Scholar]
- 5.Gramling R, Sanders M, Ladwig S, et al. Goal communication in palliative care decision-making consultation. Journal of Pain and Symptom Management. 2015;50(5):701–706. doi: 10.1016/j.jpainsymman.2015.05.007. [DOI] [PubMed] [Google Scholar]
- 6.Givens JL, Kiley DK, Carey K, Mitchell SL. Healthcare proxies of nursing home residents with advanced dementia: Decisions they confront and their satisfaction with decision-making. J Am Geriatr Soc. 2009;57:1149–1155. doi: 10.1111/j.1532-5415.2009.02304.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Towsley G, Hirschman K, Madden C. Conversations about end-of-life: Perspectives of nursing home residents, family, and staff. J Palliat Med. 2015;18(5):421–428. doi: 10.1089/jpm.2014.0316. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Furman C, Kelly S, Knapp K, et al. Eliciting goals of care in nursing homes. J Am Med Dir Assoc. 2007;8(3 Suppl 2):e35–41. doi: 10.1016/j.jamda.2006.12.006. [DOI] [PubMed] [Google Scholar]
- 9.Flo E, Huesbo B, Bruuggard P, et al. A review of the implementation and research strategies of advance care planning in nursing homes. BMC Geriatrics. 2016;16:24. doi: 10.1186/s12877-016-0179-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ampe S, Sevenants A, Smets T, et al. Advance care planning for nursing home residents with dementia: Influence of ‘we DECide’ on policy and practice. Patient Educ Couns. 2017;100:139–146. doi: 10.1016/j.pec.2016.08.010. [DOI] [PubMed] [Google Scholar]
- 11.Hanson LC, Song MK, Zimmerman S, et al. Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia. Clinical Trials. 2016;13:599–604. doi: 10.1177/1740774516650863. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Low L, Fletcher J, Goodenough B, et al. A systematic review of interventions to change staff care practices in order to improve resident outcomes in nursing homes. PLoS One. 2015;10(11):e0140711. doi: 10.1371/journal.pone.0140711. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rahman A, Applebaum R, Schnelle J, Simmons S. Translating research into practice in nursing homes: Can we close the gap? The Gerontologist. 2012;52(5):597–606. doi: 10.1093/geront/gnr157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Rogers EM. Diffusion of Innovation. 5th. New York, NY: Free Press; 2003. [Google Scholar]
- 15.Degenholtz H, Arnold R, Meisel A, Lave J. Persistence of racial disparities in advance care plan documents among nursing home residents. J Am Geriatr Soc. 2002;50(2):378–81. doi: 10.1046/j.1532-5415.2002.50073.x. [DOI] [PubMed] [Google Scholar]
- 16.Frahm K, Brown L, Hyer K. Racial disparities in end-of-life planning and services for deceased nursing home residents. JAMDA. 2012;13(9):819–e7. doi: 10.1016/j.jamda.2012.07.021. [DOI] [PubMed] [Google Scholar]
- 17.Rich S, Gruber-Baldini A, Quinn C, Zimmerman S. Discussion as a factor in the racial disparity in advance directive completion at nursing home admission. J Am Geriatr Soc. 2009;57(1):146–152. doi: 10.1111/j.1532-5415.2008.02090.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Carr D. Racial differences in end-of-life planning: Why don’t Blacks and Latinos prepare for the inevitable? OMEGA. 2011;63(1):1–20. doi: 10.2190/OM.63.1.a. [DOI] [PubMed] [Google Scholar]
- 19.Krakauer EL, Crenner C, Fox K. Barriers to optimum end of life care for minority patients. Journal of the American Geriatrics Society. 2002;56(10):1953–1958. doi: 10.1046/j.1532-5415.2002.50027.x. [DOI] [PubMed] [Google Scholar]
- 20.O’Brien LA, Grisso JA, Maislin, et al. Nursing home residents’ preferences for life-sustaining treatments. JAMA. 1995;274(22):1775–1779. [PubMed] [Google Scholar]
- 21.Hanson LC, Zimmerman S, Song MK, Lin FC, Rosemond C, Carey TS, Mitchell SL. Effect of the Goals of Care intervention for advanced dementia: a randomized clinical trial. JAMA Internal Medicine. 2017;177:24–31. doi: 10.1001/jamainternmed.2016.7031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.McConnell E, Corazzini K, Lekan D, et al. Diffusion of innovation in long-term carae (DOI-LTC) measurement batter. Res Gerontol Nurs. 2012;5:64–76. doi: 10.3928/19404921-20110602-04. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Lacey D. Predictors of social service staff involvement in selected palliative care tasks in nursing homes: An exploratory model. American Journal of Hospice & Palliative Medicine. 2005;22(4):269–276. doi: 10.1177/104990910502200407. [DOI] [PubMed] [Google Scholar]
- 24.Lacey D. End-of-life decision making for nursing home residents with dementia: A survey of nursing home social services staff. Health and Social Work. 2006;31(3):189–199. doi: 10.1093/hsw/31.3.189. [DOI] [PubMed] [Google Scholar]
- 25.Low L, Fletcher J, Goodenough B, et al. A systematic review of interventions to change staff care practices in order to improve resident outcomes in nursing homes. PLoS One. 2015;10(11):e0140711. doi: 10.1371/journal.pone.0140711. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Rahman A, Applebaum R, Schnelle J, Simmons S. Translating research into practice in nursing homes: Can we close the gap? The Gerontologist. 2012;52(5):597–606. doi: 10.1093/geront/gnr157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Crandall L, White D, Schuldheis S, Talerico K. Initiating person-centered care practices: long-term facilities. Journal of Gerontological Nursing. 2007;33(11):47–56. doi: 10.3928/00989134-20071101-08. [DOI] [PubMed] [Google Scholar]