Gerontological nursing research is critical for developing the science that will be needed to pro... more Gerontological nursing research is critical for developing the science that will be needed to provide the evidence base required to care for the unprecedented growth of the older adult population in the 21st century. This article describes the research initiatives of the 5 Hartford Centers of Geriatric Nursing Excellence (HCGNE), the key features that made them successful, the lessons learned, the challenges during implementation, and the outcomes; it concludes with conclusions and recommendations. The HCGNE developed highly successful initiatives to increase gerontological nursing research capacity focused on assisting faculty and students to write and conduct pilot studies. Key features of these initiatives included mentoring by senior gerontological nurse researchers over an extended period of time, dedicated time free from the demands of teaching, and financial support, either in the form of money or release time from regular responsibilities. The research initiatives described in this article can serve as models upon which other schools can build their own initiatives, based on their own strengths and resources. Ongoing strategies to increase gerontological nursing research are needed at both the national and individual school levels.
This chapter reviews 80 published research reports of pain and pain problems in older adults by n... more This chapter reviews 80 published research reports of pain and pain problems in older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) using the search terms pain, older adult, aged and pain, and dementia. Reports were included if published between 1985 to 2001, if conducted on samples age 60 or older, if conducted by nurses or relevant to nursing research, and if published in English. Descriptive, qualitative, correlational, longitudinal, and intervention studies were included. Key findings include the following: pain is widely prevalent in older adult populations; few studies have included minority groups; under-identification and undertreatment of pain in older adults is a consistent interpretation of research findings; pain intensity rating scales are as valid and reliable in older populations as in younger populations; current observat...
Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, p... more Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, particularly those caring for older adults living in long term care settings. Despite the national priority of pain management, insufficient knowledge of nurses about geriatric pain is a documented barrier to effective geriatric pain management in all long term care settings. To address this knowledge gap, a website (GeriatricPain.org) was developed by the National Geriatric Pain Collaborative with a grant from the MayDay Fund to provide a single site for evidenced-based, easy-to-use, downloadable resources on pain management. This paper describes the development of the most recent addition to the website, a set of evidence-based core geriatric pain management competencies and a geriatric pain knowledge assessment, and discusses their potential uses in improving pain care for older adults.
The PREP system of nursing interventions, designed to increase preparedness (PR), enrichment (E),... more The PREP system of nursing interventions, designed to increase preparedness (PR), enrichment (E), and predictability (P) in families providing care to older people, was pilot tested for acceptability and preliminary effectiveness. Eleven family units were assigned to the PREP group and 11 to a standard home health control group. The PREP group scored approximately one SD higher than the control group (p < .05) on the Care Effectiveness Scale, indicating greater preparedness, enrichment, and predictability. Further, on a rating of overall usefulness, the PREP group rated their assistance from PREP nurses (Ad = 9.75) as significantly higher (p i .01) than the control group rated assistance from the home health nurse or physical therapist (M = 6.57). Although not statistically significant, mean hospital costs for the PREP group ($2,775) were lower than for the control group ($6,929). Results provided support for a full intervention trial. D 1995 John Wiley 8. Sons, Inc.
b Background: Multiple studies report on symptoms or physical function in people with fibromyalgi... more b Background: Multiple studies report on symptoms or physical function in people with fibromyalgia; however, limited studies have been focused on older adults with fibromyalgia. b Objectives: The aims of this study were to describe the occurrence, frequency, severity, and distress of symptoms and to examine differences in symptoms and physical function between a middle-aged and an older group. b Method: Questionnaires were mailed to a random sample of 533 adults with fibromyalgia over 50 years of age, using a large tertiary care database. These questionnaires included an investigator-developed 29-item symptom questionnaire that measured the frequency (1Y4), severity (1Y4), and distress (0Y4) of FM symptoms. The participants also completed the Late Life Function and Disability Instrument and the Charlson Comorbidity Index. b Results: Fifty-three percent of the sample reported at least 20 symptoms in the last 7 days. The most frequent and severe symptoms were pain, nonrefreshing sleep, fatigue, stiffness, difficulty staying asleep, difficulty falling asleep, and profuse sweating. The most distressing symptoms were fear of symptoms worsening, followed by difficulty staying asleep, fatigue, nonrefreshing sleep, and restless legs. Participants reported moderate functional limitations (M T SD = 52.7 T 9.0). Comorbidities were low (1.7 T 1.5; range = 0Y7). The middle-aged group experienced a greater number of total symptoms (21.
We mailed a questionnaire to nurses and social workers who care for patients enrolled in hospice ... more We mailed a questionnaire to nurses and social workers who care for patients enrolled in hospice programs in Oregon. All 50 Medi-· www.nejm.org · 583 65 3.0 (1.0-4.5) Confusion or fear of confusion 67 3.0 (1.0-4.0) Experience of witnessing bad deaths 44 2.0 (1.0-3.75) Perception of self as financial drain on others or fear of becoming financial drain 60 2.0 (1.0-3.0) Depression or other psychiatric disorder 59 2.0 (1.0-3.0) Nausea or fear of worsening nausea 67 2.0 (1.0-3.0) Lack of social support 65 1.0 (1.0-2.0) 42
Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted su... more Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted suicide for terminally ill patients who wish to hasten death. There are few reports of patients who have made this choice. We mailed a questionnaire to all nurses employed by hospice programs in Oregon and analyzed the results. Of 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, and considered their quality of life poor. The survey showed that 85 percent of patients died within 15 days after stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8. On the basis of the hospice nurses&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; reports, the patients who stopped eating and drinking were older than 55 patients who died by physician-assisted suicide (74 vs. 64 years of age, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), less likely to want to control the circumstances of their death (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), and less likely to be evaluated by a mental health professional (9 percent vs. 45 percent, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). On the basis of reports by nurses, patients in hospice care who voluntarily choose to refuse food and fluids are elderly, no longer find meaning in living, and usually die a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;good&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; death within two weeks after stopping food and fluids.
Regulatory agencies, researchers, and clinicians have identified improving pain assessment and ma... more Regulatory agencies, researchers, and clinicians have identified improving pain assessment and management in nursing homes as a high priority, but there is no consensus regarding the best strategies to change pain management practices in nursing homes. The goal of this article is to present a synthesis of published literature of process-level pain management improvement projects in nursing homes and identify and describe the role and necessary skills of various clinicians and nursing leaders in successful interventions. This literature synthesis is limited to research in nursing homes. Reports of research or reports of evaluation of quality improvement programs and descriptions of process interventions that targeted pain assessment and management were reviewed. Studies that focused primarily on the efficacy of pain treatment (e.g., analgesic trials or nonpharmacological therapies) were excluded. Of the original 472 articles, 53 were kept for a full text review. Of these, 10 were included in the final synthesis. Findings from this synthesis suggest that pain management practices may improve with the adoption of systematic implementation models, clinical decision-making algorithms, an interdisciplinary approach, continuous evaluation of outcomes, and use of on-site resource consultants. Clinician leaders in nursing homes require adept pain assessment and management skills and working knowledge of organizational change practices, including quality improvement processes, team building, collaborative decision-making, and assessing and solving system-level problems.
... Fit with MDS 3.0 and F-Tag requirements Does not fit all MDS 3.0 indicators of pain Recor... more ... Fit with MDS 3.0 and F-Tag requirements Does not fit all MDS 3.0 indicators of pain Records change in behavior if adminis-tered frequently Lacks gait change and vital sign param-eters associated with pain in F-Tag screen Does not focus on functional status or ...
The Journal of Continuing Education in Nursing, 2010
This article describes a faculty development initiative implemented by baccalaureate school of nu... more This article describes a faculty development initiative implemented by baccalaureate school of nursing faculty to address the urgent need for education and development in gerontological nursing. The Gerontological Nursing Education Curriculum (G-NEC) project was implemented in five states between 2006 and 2009 to (a) increase faculty knowledge of gerontological nursing, and (b) increase gerontological content in participating schools of nursing. A 4-hour workshop presented at 11 schools introduced key concepts and instructional activities related to care of older adults. Participants rated content and format highly; follow-up reports indicated that many made curriculum changes to incorporate gerontological content. The authors describe workshop content and teaching strategies, curriculum changes participants made to incorporate gerontological content, and implications for faculty development.
American Journal of Alzheimer's Disease and Other Dementias, 2007
Significant contact between nursing staff and nursing home residents with dementia occurs during ... more Significant contact between nursing staff and nursing home residents with dementia occurs during assistance with activities of daily living during morning care; however, the content and process of morning care have received little attention in the scientific literature. To better understand the morning care process and its role in generation of pain symptoms, 51 videotaped episodes of morning care involving 17 nursing home residents from 3 long-term care facilities were coded and analyzed; each resident had a diagnosis of dementia and concern about possible pain during assistance with activities of daily living. The typical morning care episode involved performance of multiple activities of daily living during a short period of time, during which pain stimulation and expression occurred frequently. Much could be done to make morning care more an activity to be enjoyed rather than a task to be completed.
Background / Purpose: Up to 80% of Nursing home (NH) residents suffer from unrecognized and under... more Background / Purpose: Up to 80% of Nursing home (NH) residents suffer from unrecognized and undertreated pain problems and pain contributes to significant impairment in physical, psychological and social function and diminishes overall quality of life for NH residents. Additionally the use of evidence-based practices (EBP) by nurses in NHs is sporadic at best, despite the existence of EBP guidelines. Main conclusion: Developed and launched a web resource for the dissemination of best practice tools and resources for use in NHs, The Geriatric Pain Web site is a one-stop site that shares best-practice tools and resources that support recommendations for good pain assessment and management in older adults.
Gerontological nursing research is critical for developing the science that will be needed to pro... more Gerontological nursing research is critical for developing the science that will be needed to provide the evidence base required to care for the unprecedented growth of the older adult population in the 21st century. This article describes the research initiatives of the 5 Hartford Centers of Geriatric Nursing Excellence (HCGNE), the key features that made them successful, the lessons learned, the challenges during implementation, and the outcomes; it concludes with conclusions and recommendations. The HCGNE developed highly successful initiatives to increase gerontological nursing research capacity focused on assisting faculty and students to write and conduct pilot studies. Key features of these initiatives included mentoring by senior gerontological nurse researchers over an extended period of time, dedicated time free from the demands of teaching, and financial support, either in the form of money or release time from regular responsibilities. The research initiatives described in this article can serve as models upon which other schools can build their own initiatives, based on their own strengths and resources. Ongoing strategies to increase gerontological nursing research are needed at both the national and individual school levels.
This chapter reviews 80 published research reports of pain and pain problems in older adults by n... more This chapter reviews 80 published research reports of pain and pain problems in older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) using the search terms pain, older adult, aged and pain, and dementia. Reports were included if published between 1985 to 2001, if conducted on samples age 60 or older, if conducted by nurses or relevant to nursing research, and if published in English. Descriptive, qualitative, correlational, longitudinal, and intervention studies were included. Key findings include the following: pain is widely prevalent in older adult populations; few studies have included minority groups; under-identification and undertreatment of pain in older adults is a consistent interpretation of research findings; pain intensity rating scales are as valid and reliable in older populations as in younger populations; current observat...
Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, p... more Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, particularly those caring for older adults living in long term care settings. Despite the national priority of pain management, insufficient knowledge of nurses about geriatric pain is a documented barrier to effective geriatric pain management in all long term care settings. To address this knowledge gap, a website (GeriatricPain.org) was developed by the National Geriatric Pain Collaborative with a grant from the MayDay Fund to provide a single site for evidenced-based, easy-to-use, downloadable resources on pain management. This paper describes the development of the most recent addition to the website, a set of evidence-based core geriatric pain management competencies and a geriatric pain knowledge assessment, and discusses their potential uses in improving pain care for older adults.
The PREP system of nursing interventions, designed to increase preparedness (PR), enrichment (E),... more The PREP system of nursing interventions, designed to increase preparedness (PR), enrichment (E), and predictability (P) in families providing care to older people, was pilot tested for acceptability and preliminary effectiveness. Eleven family units were assigned to the PREP group and 11 to a standard home health control group. The PREP group scored approximately one SD higher than the control group (p < .05) on the Care Effectiveness Scale, indicating greater preparedness, enrichment, and predictability. Further, on a rating of overall usefulness, the PREP group rated their assistance from PREP nurses (Ad = 9.75) as significantly higher (p i .01) than the control group rated assistance from the home health nurse or physical therapist (M = 6.57). Although not statistically significant, mean hospital costs for the PREP group ($2,775) were lower than for the control group ($6,929). Results provided support for a full intervention trial. D 1995 John Wiley 8. Sons, Inc.
b Background: Multiple studies report on symptoms or physical function in people with fibromyalgi... more b Background: Multiple studies report on symptoms or physical function in people with fibromyalgia; however, limited studies have been focused on older adults with fibromyalgia. b Objectives: The aims of this study were to describe the occurrence, frequency, severity, and distress of symptoms and to examine differences in symptoms and physical function between a middle-aged and an older group. b Method: Questionnaires were mailed to a random sample of 533 adults with fibromyalgia over 50 years of age, using a large tertiary care database. These questionnaires included an investigator-developed 29-item symptom questionnaire that measured the frequency (1Y4), severity (1Y4), and distress (0Y4) of FM symptoms. The participants also completed the Late Life Function and Disability Instrument and the Charlson Comorbidity Index. b Results: Fifty-three percent of the sample reported at least 20 symptoms in the last 7 days. The most frequent and severe symptoms were pain, nonrefreshing sleep, fatigue, stiffness, difficulty staying asleep, difficulty falling asleep, and profuse sweating. The most distressing symptoms were fear of symptoms worsening, followed by difficulty staying asleep, fatigue, nonrefreshing sleep, and restless legs. Participants reported moderate functional limitations (M T SD = 52.7 T 9.0). Comorbidities were low (1.7 T 1.5; range = 0Y7). The middle-aged group experienced a greater number of total symptoms (21.
We mailed a questionnaire to nurses and social workers who care for patients enrolled in hospice ... more We mailed a questionnaire to nurses and social workers who care for patients enrolled in hospice programs in Oregon. All 50 Medi-· www.nejm.org · 583 65 3.0 (1.0-4.5) Confusion or fear of confusion 67 3.0 (1.0-4.0) Experience of witnessing bad deaths 44 2.0 (1.0-3.75) Perception of self as financial drain on others or fear of becoming financial drain 60 2.0 (1.0-3.0) Depression or other psychiatric disorder 59 2.0 (1.0-3.0) Nausea or fear of worsening nausea 67 2.0 (1.0-3.0) Lack of social support 65 1.0 (1.0-2.0) 42
Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted su... more Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted suicide for terminally ill patients who wish to hasten death. There are few reports of patients who have made this choice. We mailed a questionnaire to all nurses employed by hospice programs in Oregon and analyzed the results. Of 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, and considered their quality of life poor. The survey showed that 85 percent of patients died within 15 days after stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8. On the basis of the hospice nurses&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; reports, the patients who stopped eating and drinking were older than 55 patients who died by physician-assisted suicide (74 vs. 64 years of age, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), less likely to want to control the circumstances of their death (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), and less likely to be evaluated by a mental health professional (9 percent vs. 45 percent, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). On the basis of reports by nurses, patients in hospice care who voluntarily choose to refuse food and fluids are elderly, no longer find meaning in living, and usually die a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;good&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; death within two weeks after stopping food and fluids.
Regulatory agencies, researchers, and clinicians have identified improving pain assessment and ma... more Regulatory agencies, researchers, and clinicians have identified improving pain assessment and management in nursing homes as a high priority, but there is no consensus regarding the best strategies to change pain management practices in nursing homes. The goal of this article is to present a synthesis of published literature of process-level pain management improvement projects in nursing homes and identify and describe the role and necessary skills of various clinicians and nursing leaders in successful interventions. This literature synthesis is limited to research in nursing homes. Reports of research or reports of evaluation of quality improvement programs and descriptions of process interventions that targeted pain assessment and management were reviewed. Studies that focused primarily on the efficacy of pain treatment (e.g., analgesic trials or nonpharmacological therapies) were excluded. Of the original 472 articles, 53 were kept for a full text review. Of these, 10 were included in the final synthesis. Findings from this synthesis suggest that pain management practices may improve with the adoption of systematic implementation models, clinical decision-making algorithms, an interdisciplinary approach, continuous evaluation of outcomes, and use of on-site resource consultants. Clinician leaders in nursing homes require adept pain assessment and management skills and working knowledge of organizational change practices, including quality improvement processes, team building, collaborative decision-making, and assessing and solving system-level problems.
... Fit with MDS 3.0 and F-Tag requirements Does not fit all MDS 3.0 indicators of pain Recor... more ... Fit with MDS 3.0 and F-Tag requirements Does not fit all MDS 3.0 indicators of pain Records change in behavior if adminis-tered frequently Lacks gait change and vital sign param-eters associated with pain in F-Tag screen Does not focus on functional status or ...
The Journal of Continuing Education in Nursing, 2010
This article describes a faculty development initiative implemented by baccalaureate school of nu... more This article describes a faculty development initiative implemented by baccalaureate school of nursing faculty to address the urgent need for education and development in gerontological nursing. The Gerontological Nursing Education Curriculum (G-NEC) project was implemented in five states between 2006 and 2009 to (a) increase faculty knowledge of gerontological nursing, and (b) increase gerontological content in participating schools of nursing. A 4-hour workshop presented at 11 schools introduced key concepts and instructional activities related to care of older adults. Participants rated content and format highly; follow-up reports indicated that many made curriculum changes to incorporate gerontological content. The authors describe workshop content and teaching strategies, curriculum changes participants made to incorporate gerontological content, and implications for faculty development.
American Journal of Alzheimer's Disease and Other Dementias, 2007
Significant contact between nursing staff and nursing home residents with dementia occurs during ... more Significant contact between nursing staff and nursing home residents with dementia occurs during assistance with activities of daily living during morning care; however, the content and process of morning care have received little attention in the scientific literature. To better understand the morning care process and its role in generation of pain symptoms, 51 videotaped episodes of morning care involving 17 nursing home residents from 3 long-term care facilities were coded and analyzed; each resident had a diagnosis of dementia and concern about possible pain during assistance with activities of daily living. The typical morning care episode involved performance of multiple activities of daily living during a short period of time, during which pain stimulation and expression occurred frequently. Much could be done to make morning care more an activity to be enjoyed rather than a task to be completed.
Background / Purpose: Up to 80% of Nursing home (NH) residents suffer from unrecognized and under... more Background / Purpose: Up to 80% of Nursing home (NH) residents suffer from unrecognized and undertreated pain problems and pain contributes to significant impairment in physical, psychological and social function and diminishes overall quality of life for NH residents. Additionally the use of evidence-based practices (EBP) by nurses in NHs is sporadic at best, despite the existence of EBP guidelines. Main conclusion: Developed and launched a web resource for the dissemination of best practice tools and resources for use in NHs, The Geriatric Pain Web site is a one-stop site that shares best-practice tools and resources that support recommendations for good pain assessment and management in older adults.
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Papers by Lois Miller