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Although context is important, managers can also influence turnover by addressing climate and communication patterns and by encouraging stable nursing leadership.

Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.

In a nursing home case study using observation and interview data, we described two mental models that guided certified nurse assistants (CNAs) in resident care. The Golden Rule guided CNAs to respond to residents as they would want someone to do for them. Mother wit guided CNAs to treat residents as they would treat their own children. These mental models engendered self-control and affection. We found limits to the models in that they led to actions such as infantalization and misinterpretations about potentially undiagnosed conditions such as depression or pain. Further, we found that CNAs were isolated from clinicians; little resident information was exchanged. We suggest ways to alter CNA mental models to give them a better basis for action and strategies for connecting NIH Public Access CNAs and clinical professionals to improve information flow about residents. Study results highlight a critical need for registered nurses (RNs) to be involved in frontline care.

Background We hypothesized that an intervention which improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS). Design Cluster randomized trial. Setting Community (n=4) and VA NHs (n=4) Participants Staff in any role with resident contact (n=497). Intervention NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3-months. CONNECT used story-telling, relationship mapping, mentoring, self-monitoring and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit/feedback. Measurements NH staff completed surveys about interactions at baseline, 3 months (immediately following CONNECT or control period), and 6 months (immediately following FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning. Results Significant improvements in staff perceptions of communication quality, participation in decision making, safety climate, care giving quality, and use of local interaction strategies were observed in intervention community NHs (treatment by time effect p=.01), but not in VA NHs where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (2.61 and 2.64 falls/bed/yr), but decreased by 12% in intervention facilities (2.34 to 2.06 falls/bed/yr); the effect of treatment on rate of change was 0.81 (0.55, 1.20). Conclusion CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.

OBJECTIVES-To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs). DESIGN-Qualitative analysis. SETTING-Four randomly selected community nursing homes.PARTICIPANTS-NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs). MEASUREMENTS-Interviews(n = 35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers' Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.RESULTS-None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were ''checklists'' to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.CONCLUSION-Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.Address corresponding to Cathleen Colon-Emeric, MD,

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical "chain of command" between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

on behalf of the WE-THRIVE Group Authorship Statement: The following are members of WE-THRIVE (Worldwide Elements to Harmonize Research in Long Term Care Living Environments): [To insert all participants in domain discussions and IAGG-GSA session who wish to be included; we are following the ICMJE guidelines for consortium authorship, as operationalized by BMJ Special articles do not involve original research but instead provide novel interpretation or synthesis of information in 1 an area of general interest to readers of the journal. Examples of special articles include consensus statements, 2 clinical tools, practice guidelines, and discussion of new policies or regulations. Manuscripts may be solicited by the 3 editors or submitted at the initiative of authors. The body of the submission (excluding abstract and references) 4should generally be limited to 3,000 words; it can include 3 tables or figures, and 50 references. An unstructured 5 abstract of up to 300 words is required, and specific headings to organize the text are not prescribed; however, the 6 text should conclude with a section entitled "Implications for Practice, Policy, and/or Research." 7 8 ABSTRACT 9To support person-centered, residential long-term care internationally, a consortium of 10 researchers in medicine, nursing, behavioral and social sciences from 21 geographically and 11 economically diverse countries have launched the WE-THRIVE initiative to develop a common 12 data infrastructure. The consortium aims to identify measurement domains that are 13 internationally relevant, including in low and middle income countries, prioritize concepts to 14 operationalize domains, and specify a set of data elements to measure concepts that can be used (CDEs) initiative. Four domains were identified, including organizational context; workforce and 21 staffing; person-centered care; and care outcomes. Using a nominal group process, WE-22 103 who facilitated domain-specific discussions. Domain-specific discussions focused on potential 104 concepts in each domain that were common to LTC settings across represented countries. The 105 domain committee chairs met in monthly WE-THRIVE steering committee meetings to report 106 updates and share challenges and ideas across subgroups. Figure 1 summarizes the 107 developmental timeline of WE-THRIVE's work, totaling 8 steering committee meetings and 9 108 domain committee meetings that occurred in preparation for IAGG 2017. 109Because of the group's commitment to global inclusiveness, a standing item for the 110 steering committee and the domain committee meetings was to identify new WE-THRIVE 111 members, especially those from low and middle-income countries (LMICs), to vet the work to 112 date. We built an inclusive, flexible network of researchers with ongoing participation through 113 face-to-face or distance-based technology that was not limited to researchers who could attend 114 IAGG 2017. This approach is consistent with the ESSENCE on Health Research initiative's 115 principle of building collaborativ...