Directed Content Analysis Research Articles

A mobile telehealth program for behavioral treatment of urinary incontinence in women Veterans: Qualitative evaluation of MyHealtheBladder

Women Veterans constitute a distinctive cohort whose exposure to military service can contribute to development of bladder conditions, such as urinary incontinence (UI), as they age. Behavioral therapies are recommended as first-line treatment for incontinence, yet many VA Medical Centers do not have staff trained to administer them. The purpose of this research study was to conduct a qualitative program evaluation of MyHealtheBladder, a mobile telehealth version of an evidence-based eight‐week behavioral treatment program designed for women Veterans with incontinence. MyHealtheBladder uses mobile telehealth technology to teach pelvic floor muscle exercises, bladder control strategies, fluid management, risk factor reduction, and self‐monitoring. Eighteen women Veterans who completed a pilot study of MyHealtheBladder participated in semi-structured telephone interviews exploring their experience with the program. A directed content analysis was conducted of the transcribed interview data. Participants described ease of accessing MyHealtheBladder using smart phones and other mobile devices, emphasizing the flexibility of using the program at home, work, or while traveling. Most participants described program content as understandable, relevant, and easy to follow. They discussed how the program increased knowledge of UI, promoted consistency in practicing behavioral therapy, strengthened pelvic floor muscles, reduced urine leakage, and improved psychosocial wellbeing. Suggestions for improvement included more interaction with staff, more individualized tailoring of content to UI type, incorporating in-person clinic visits, and including supplementary material. Participants uniformly endorsed the program and recommended it for other women Veterans, as well as for those in active duty to prevent or treat UI earlier in the life course.

Abstract B048: Qualitative analysis of fieldnote and interview data for planning a food bank- based breast cancer screening intervention

Abstract Among individuals and communities with low-income, the experience of food insecurity is associated with greater delays in recommended mammography screening and late-stage breast cancer at diagnosis. Community-based interventions that address barriers to breast cancer screening in diverse communities of women with food insecurity can increase screening uptake, ultimately improving cancer health equity. In partnership with Sacramento Food Bank and Family Services (SFBFS), the largest non-profit provider of social services in Sacramento County, this study identified barriers and facilitators to implementing a breast cancer screening intervention in a food distribution setting, assessing the preliminary acceptability and logistical feasibility of the proposed intervention. Qualitative data about food bank distribution events and the clients served was collected over 24 weeks using participant observation with semi-structured fieldnotes and interviews, then analyzed via directed content analysis guided by the well-defined domains and determinants in the Consolidated Framework for Implementation Research (CFIR) and coded using Dedoose software. Fieldnotes were completed for 12 community food distribution events, and 20 stakeholder interviews were conducted with purposefully sampled food bank staff (N=10) and female clients (N=10) who regularly attend events. The results of this qualitative analysis identified barriers and facilitators to implementation in all CFIR domains, describing current workflows for food distribution events and existing health education efforts, capacity, client engagement logistics and modes of delivery, and resources available or needed to support implementation. Prominent CFIR determinants included characteristics of individuals, specifically the innovation recipients’ capability and motivation to receive a breast cancer screening intervention in this context. Participants often pointed out their awareness of important preventative behaviors such as nutrition while also acknowledging barriers such as time constraints, accessibility of breast cancer screening services, and culturally-specific health beliefs and practices. Determinants in the outer setting, inner setting, innovation characteristics, and process that relate to the overall theme of sustainability were identified as potential barriers including financing, the availability of resources, internal and external pressure to change, and the process of engaging with clients while they are at the food distribution event. Facilitators included buy-in from SFBFS leadership and staff, and the benefit of collaborating with reputable local partners. Intervention format should include tailored messaging that is culturally appropriate and empowers individuals to obtain recommended screening. Content of the intervention should provide interactive assistance that facilitates local support for screening eligibility and services. Overall, there was consensus that promoting breast cancer screening in the food distribution setting was beneficial and welcomed by all stakeholders. Citation Format: Charlotte L. Kerber, Julie HT Dang, Daniel J. Pasillas-Pablo, Jocelyn T. Canty, Laura Fejerman. Qualitative analysis of fieldnote and interview data for planning a food bank- based breast cancer screening intervention [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B048.

The branding pyramidical tool kit for enhancing actors’ agency in regional energy transitions within the Nordic Battery Belt

This article investigates how to enhance the agency of regional actors in the branding of the ‘Nordic Battery Belt’ (NBB), the region where the industry, considered a new green path, is emerging. Branding will enhance the attraction of skilled workforce, investment, market, and increased public awareness of the industry’s contribution to decarbonization. While national battery strategies have been developed to promote the industry, the tool kit that can enhance the implementation of the strategic branding action plan is underexplored. Firstly, this article develops a tool kit based on the directed content analysis, which ensures the use of existing branding theory and its pyramidic components: attention, awareness, associations, attitudes, and relationships. Regional actors can leverage the tool kit as it reduces oversight and increases lucidity and conciseness. Secondly, the paper develops a conceptual framework through a multidisciplinary approach to elaborate on the importance of the tool kit for enhancing actors’ agency in regional branding. The paper is relevant for regional actors, e.g., development agencies within the Nordic region that are saddled with the responsibility of place branding.

What are the barriers and facilitators for health and social care professionals accessing organizational wellbeing support services? A mixed-methods study

Recent years have seen increases in workers’ stress levels and sickness absence rates. Organizations have increased the number of wellbeing support services they offer employees, but uptake has been poor. This study investigated barriers and facilitators to accessing organizational wellbeing support services. A two-study, mixed-methods design in health and social care employees was used. Study 1 conducted a directed content analysis of qualitative interview data based on the Theoretical Domains Framework (TDF) to identify barriers and facilitators. These were translated into survey items. Study 2 conducted a quantitative cross-sectional survey to assess whether the number of barriers and facilitators was associated with the likelihood of service use. Study 1 (n = 20) created a survey list of 23 barriers and 23 facilitators. Study 2 (n = 162) found that a greater number of facilitators was associated with a greater likelihood of service access, but number of barriers was not. We concluded that increasing facilitators may increase employee uptake of wellbeing support services. Facilitators include making access routes to services simple and efficient and circulating regular information to staff about available services.

Iran’s health insurance ecosystem: challenges and strategies

IntroductionIdentifying and exploiting stewardship and financing challenges in Iran’s health insurance system as an ecosystem is essential to achieving predetermined goals. This study aimed to determine the challenges and strategies in the Iranian health insurance ecosystem to provide relevant evidence to healthcare managers and policymakers to improve its functions and perform necessary reforms.MethodThis qualitative study was conducted at the national level in Iran. Data were collected using semi-structured interviews and analyzed using the directed content analysis method. The study participants included managers and experts in health insurance and faculty of universities of medical sciences, who were selected by purposive sampling.ResultsThe challenges and strategies expressed by participants were categorized into two functions: stewardship and financing. Four main themes, ten subthemes, 22 challenges, and 24 strategies were identified in the stewardship function, along with three main themes, 12 subthemes, 17 challenges, and 16 strategies in the financing function. The major challenge in the Iranian health insurance ecosystem was the complexity and conflict of interests between multiple actors with different roles, which led to fragmentation, diverse structures, and a gap between other functions and objectives, hindering the effective functioning of the ecosystem.ConclusionIn order to deal with the challenges of the health insurance ecosystem, it is suggested to create a coherent insurance system through a single utility system, and by paying more attention to health-oriented services, the health insurance ecosystem becomes a health-oriented system instead of being treatment-oriented. In addition, in order to strengthen the governance of the country’s health insurance ecosystem, the number of actors with multiple roles should be reduced and the roles of the actors should be clarified and separated in order to prevent conflicts of interest and structural corruption in this ecosystem.

Experiences of Using a Digital Guidance and Assessment Tool (the Technology-Optimized Practice Process in Nursing Application) During Clinical Practice in a Nursing Home: Focus Group Study Among Nursing Students.

Nursing students' learning during clinical practice is largely influenced by the quality of the guidance they receive from their nurse preceptors. Students that have attended placement in nursing home settings have called for more time with nurse preceptors and an opportunity for more help from the nurses for reflection and developing critical thinking skills. To strengthen students' guidance and assessment and enhance students' learning in the practice setting, it has also been recommended to improve the collaboration between faculties and nurse preceptors. This study explores first-year nursing students' experiences of using the Technology-Optimized Practice Process in Nursing (TOPP-N) application in 4 nursing homes in Norway. TOPP-N was developed to support guidance and assessment in clinical practice in nursing education. Four focus groups were conducted with 19 nursing students from 2 university campuses in Norway. The data collection and directed content analysis were based on DeLone and McLean's information system success model. Some participants had difficulties learning to use the TOPP-N tool, particularly those who had not attended the 1-hour digital course. Furthermore, participants remarked that the content of the TOPP-N guidance module could be better adjusted to the current clinical placement, level of education, and individual achievements to be more usable. Despite this, most participants liked the TOPP-N application's concept. Using the TOPP-N mobile app for guidance and assessment was found to be very flexible. The frequency and ways of using the application varied among the participants. Most participants perceived that the use of TOPP-N facilitated awareness of learning objectives and enabled continuous reflection and feedback from nurse preceptors. However, the findings indicate that the TOPP-N application's perceived usefulness was highly dependent on the preparedness and use of the app among nurse preceptors (or absence thereof). This study offers information about critical success factors perceived by nursing students related to the use of the TOPP-N application. To develop similar learning management systems that are usable and efficient, developers should focus on personalizing the content, clarifying procedures for use, and enhancing the training and motivation of users, that is, students, nurse preceptors, and educators.

Does the decision to disclose non-suicidal self-injury align with decision-making frameworks of personal information disclosure? A directed content analysis.

Non-suicidal self-injury (NSSI) is the deliberate damage caused to one's own body tissue, without the intent to die. Voluntary disclosure of one's NSSI can catalyze help-seeking and provision of support, although what informs the decision to disclose NSSI is not yet well understood. There is currently no existing framework specific to the process of NSSI disclosure, and the aim of this study was to assess the fit between factors involved in the decision to disclose NSSI and two broader frameworks of disclosure: the Disclosure Decision-Making and Disclosure Processes models. A directed content analysis was used to code interview transcripts from 15 participants, all of whom were university students aged between 18 and 25 (M = 20.33, SD = 1.88), with 11 identifying as female. All participants had lived experience of NSSI which they had previously disclosed to at least one other person. All codes within the coding matrix, which were informed by the disclosure models, were identified as being present in the data. Of the 229 units of data, 95.63% were captured in the existing frameworks with only 10 instances being unique to NSSI disclosure. Though factors that inform the decision to disclose NSSI largely align with the aforementioned models of disclosure, there are aspects of disclosure decision-making that may be specific to NSSI.

Integrating the sustainable development goals into health professions’ curricula: using the nominal group technique to guide their contextualisation

BackgroundTo embed the Sustainable Development Goals in health profession education, educators must contextualise them to their profession and geographical region. This study used the nominal group technique to contextualise the SDGs for Australian nutrition and dietetics tertiary education programs by determining the specific knowledge, skills, and values required for graduating dietitians to practise sustainably.MethodsIn 2022, 23 experts in food and sustainability attended a group session that employed the nominal group technique to discuss the Sustainable Development Goals knowledge, skills, and values Australian dietetic students should develop. After the group session, participants ranked the Sustainable Development Goals according to their perceived level of importance for student dietitians. These data were analysed using multi-methods, including a summation of the rankings, directed qualitative content analysis and reflexive thematic analysis.ResultsThe three highest-priority Sustainable Development Goals identified were (1) Zero Hunger, (2) Good Health and Well-Being, and (3) Responsible Consumption and Production, which were then considered with the qualitative findings. The main categories that were generated from the content analysis reflected the broad knowledge, skills, and values student dietitians should develop. The preliminary codes provided specific details for each of the main categories. The thematic analysis generated two additional themes: the importance of Indigenous ways of knowing, being and doing, and authentic experiential learning activities.ConclusionsThe method employed for this study provides a useful framework for health professions to contextualise the Sustainable Development Goals to their profession and geographical region. For this study, the ranking process and the qualitative data analysis enabled the Sustainable Development Goals to be reframed in a way that would be meaningful for dietetic educators and students and demonstrate the interrelatedness of the goals. The direct qualitative content analysis and reflexive thematic analysis identified the knowledge, skills, and values student dietitians should develop.

Developing community-based physical activity interventions and recreational programming for children in rural and smaller urban centres: a qualitative exploration of service provider and parent experiences

BackgroundChildren’s physical inactivity is a persisting international public health concern. While there is a large body of literature examining physical activity interventions for children, the unique physical activity context of low-density communities in rural areas and smaller urban centres remains largely underexplored. With an influx of families migrating to rural communities and small towns, evaluations of health promotion efforts that support physical activity are needed to ensure they are meeting the needs of the growing populations in these settings. The aim of this community-based research was to explore service providers’ and parents’ perspectives on physical activity opportunities available in their community and recommendations toward the development and implementation of efficacious physical activity programming for children in rural communities and smaller urban centres.MethodsThree in-person community forums with recreation service providers (n = 37 participants) and 1 online community forum with the parents of school-aged children (n = 9 participants) were hosted. An online survey and Mentimeter activity were conducted prior to the community forums to gather participants’ views on the barriers and facilitators to physical activities and suggestions for activity-promoting programs. The service provider and parent discussions were audio-recorded, transcribed verbatim, and analyzed following a deductive approach guided by Hseih and Shannon’s (2005) procedure for direct content analysis. A code list developed from the responses to the pre-forum survey and Mentimeter activity was used to guide the analysis and category development.ResultsSeven distinct categories related to the existing physical activity opportunities and recommendations for programs in rural communities and smaller urban centres were identified during the analysis: (1) Recovery from Pandemic-Related Measures, (2) Knowledge and Access to Programs, (3) Availability, (4) Personnel Support, (5) Quality of Programs and Facilities, (6) Expenses and Subsidies, and (7) Inclusivity and Preferences.ConclusionTo improve the health and well-being of children who reside in low-density areas, the results of this study highlight service provider and parent recommendations when developing and implementing community-based physical activity programs and interventions in rural and smaller urban settings, including skill development programs, non-competitive activity options, maximizing existing spaces for activities, and financial support.

FABLE: A New Horizon in Digital Learning and Serious Game Design

Serious games have stood out as a new pedagogical format capable of motivating students through interactive learning. The lack of standards in the conception of these video games has led to the creation of different models, where the ludic aspects often prevail over the educational ones. This research analyzes the models present in the literature to identify those key elements in the design of serious games and to determine the presence of ludic-pedagogical elements. A systematic review is carried out following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement to identify the existing models for creating serious games. A qualitative analysis of the selected models is carried out to extract the key elements that should be present when creating a guide for designing serious games and to evaluate a ludic-pedagogical approach. Finally, a directed content analysis is performed to evaluate the presence of ludic-pedagogical elements in the selected models. The results show a lack of attention paid to the elements of the pedagogical dimension of the game in the studies reviewed. Other elements, such as the format or the audience, are not specified, and most models prove incomplete. From this study emerges FABLE (Fun And Balanced Learning Experience), a model that incorporates both the playful and pedagogical dimensions of the serious game.

School-Based Occupational Therapists' Roles Supporting Transitions Into and Throughout Kindergarten to Grade 12: A Scoping Review.

Large educational transitions occur when students enter and exit school or move between grades or divisions within the kindergarten to Grade 12 (K-12) school system. For students with disabilities, the quality of large educational transitions affects academic and postschool outcomes, which is germane to school-based occupational therapists. To explore the school-based occupational therapy literature to describe the roles of occupational therapists in supporting large educational transitions and to identify relevant terminology. We searched six databases (CINAHL, EMCare, Embase, ERIC, MEDLINE, and PsycINFO) for peer-reviewed publications in English with no date limitations. We included articles focused on children and youth with disabilities and school-based occupational therapy services supporting large transitions within K to 12 education. Using directed content analysis, we reported on publication characteristics, occupational therapy roles, and terminology. We included 46 publications spanning 37 yr that addressed transitions into school (n = 3), within K to 12 grades or divisions (n = 10), or to exit secondary education (n = 33). Occupational therapists assumed many roles in supporting large transitions, some much more frequently than others; 125 transition terms were used across included articles with few terms explicitly defined. School-based occupational therapists' involvement in educational transitions is extensive, with potential for expansion. Consistency in terminology would support future research and practice. Plain-Language Summary: A large educational transition occurs when students move between a school, grade, or division as part of their K to 12 education. For students with disabilities, the quality of a large educational transition affects their academic and postschool outcomes. This review provides an understanding of how school-based occupational therapists support educational transitions for youth with disabilities. The review found that occupational therapists took on many roles, with the potential for expanding their roles. The review also identified 125 transition terms that were used across the literature review and found that few terms were explicitly defined. Consistency in terminology would support future research and expanded occupational therapy practice in this area.

How best to support parents in the management of standing frame usage in home settings: A mixed methods study.

An improved understanding of the current practice of standing frame use may have implications for supporting parents in managing standing frames. We aimed to investigate how parents of children with cerebral palsy perceive and manage standing frame use in home settings. We conducted a mixed methods study with an explanatory sequential design, first collecting and analysing quantitative questionnaire data and then using these results to inform a qualitative follow-up phase to explain them. The questionnaire was answered by 103 parents of children with cerebral palsy across five countries, Denmark, Norway, Great Britain, Canada and the United States, and 12 Danish families participated in the subsequent interviews. A descriptive analysis was conducted using the questionnaire data. The qualitative data were analysed using a directed content analysis, enabling integration of the quantitative and qualitative data. The quantitative analysis showed that 89% of the parents felt confident with their child's standing frame, and 82% felt they had sufficient knowledge about how their child's standing frame could/should be used. However, the qualitative analysis showed that even when feeling confident, the parents experienced insecurity regarding whether their child was positioned correctly, and being responsible for positioning was challenging. Our study implies a need for providing educational materials to assist the parents in ensuring optimal positioning of their child in the standing frame to decrease insecurity. Additionally, our study suggests a need to provide more thorough information about the benefits of using a standing frame and ensure alignment of expectations in relation to the child's prognosis of functional independence.

Successes and Shortcomings of COVID-19 Vaccine Access for Older Americans.

To understand perceived facilitators and barriers older adults experienced in accessing coronavirus disease 2019 (COVID-19) vaccines. An electronic survey was distributed to older adults and those familiar with experiences of older adults accessing COVID-19 vaccines. Analysis included descriptive statistics and directed content analysis of open-ended responses, guided by the National Institute on Aging Health Disparities Research Framework. Most participants (n = 294) identified as White (79.5%), 33.8% identified as Hispanic, 8.1% identified as Black, and 12.4% identified as Other. Two thirds of respondents were male (68.6%), and the median age was 67 years. Five key themes emerged: Availability and Accessibility, Information, Cost, Safety and Side Effects, and Sense of Security. Barriers and facilitators to accessing COVID-19 vaccines for older populations paralleled those seen in other demographics. Similar needs likely exist for access to other vaccines and health care in general. Vaccine rollouts, particularly in public health emergencies, must be carried out with care and an awareness of the barriers faced by vulnerable groups. [Journal of Gerontological Nursing, 50(9), 12-17.].

Child health-friendly neighbourhood: a qualitative study to explore the perspectives and experiences of experts and mothers of children under 6 years of age in Tehran, Iran

ObjectivesCreating health-supportive environments is one of the key strategies for health promotion. The WHO launched the Healthy Cities Initiative which has inspired other international organisations to develop settings-based health initiatives,...

Weathering the storm when the end of the road is near: A qualitative analysis of supportive care needs during CAR T-cell therapy in pediatrics.

Chimeric antigen receptor (CAR) T-cell therapy provides promising outcomes in relapsed/refractory B acute lymphoblastic leukemia (ALL), yet still carries high toxicity rates and relatively poor long-term survival. Efficacy has yet to be demonstrated in other diagnoses while toxicity and risk profiles remain formidable. To date, treatment-related symptom burden is gleaned from clinical trial toxicity reports; the patient perspective remains understudied. English- or Spanish-speaking patients (ages 8-25years) undergoing CAR T-cell therapy for any malignancy and their primary caregivers were recruited from Seattle Children's Hospital (SCH), St. Jude Children's Research Hospital (SJCRH), and the Pediatric Oncology Branch of the National Cancer Institute (NCI). Both patient and caregiver completed semi-structured dyadic interviews 3months post treatment. We used directed content analysis for codebook development and thematic network analysis for inductive qualitative analysis. Twenty families completed interviews (13 patients, 15 parents). Patients were a median age 16.5years, predominantly female (65%), White (75%), and diagnosed with ALL (75%). Global themes included "A clear decision," "Coping with symptoms," and "Unforeseen psychosocial challenges." When families were asked to describe the "most challenging part of treatment," most described "the unknown." Most reported "the symptoms really weren't that bad," even among patients hospitalized for severe toxicity events. Fatigue, pain, and nausea were the most prevalent symptoms. Importantly, only one family would have chosen a different therapy, if given another opportunity. Although physical symptoms were largely tolerable, recognizing supportive care opportunities remains imperative, particularly psychosocial concerns.

Barriers and enablers to bowel cancer screening participation in remote Tasmania: A qualitative study using the theoretical domains framework.

Identify barriers and enablers for remote Tasmanians participating in bowel cancer screening through the National Bowel Cancer Screening Program. A small remote Tasmanian community. Tasmanian remote community members aged 50 years and over. A qualitative study conducted 16 semi-structured interviews. Two researchers conducted in-person and telephone interviews. Questions were directed by an interview guide developed using the Theoretical Domains Framework for behaviour change and Behaviour Change Wheel. Two researchers analysed data using directed content analysis with a flexible inductive approach. Four themes related to barriers and enablers to completing the National Bowel Cancer Screening Program screening kit in remote Tasmania. Themes included the subject of screening, physical screening kit, the process and outcome of the kit. Several barrier and enabler sub-themes overlapped or were linked, as many enablers mitigated barriers. For example, social influences, awareness level, steps in completing screening, and planning and timing to screen. Social support and discussing screening with others were key enablers, whereas lack of these were barriers. For remote communities, taking the kit to the post office was a barrier from often knowing the post officer. A bowel bus providing screening and information support services may reduce the travel burden of follow-up diagnostic tests and support low-literacy individuals to screen. Barriers and enablers exist within each stage of the screening process, from what influences an individual decision to screen, through to the outcome. To improve screening rates in rural/remote Tasmania, barriers and enablers to screening must be considered.

Re-imagining the Factors Influencing the Choice of Project Management Tools and Techniques in Tanzanian Infrastructure Projects: Elicitation of Practitioners’ Perspectives

Construction project Management tools and Techniques (CPMTT) are vital for the success of construction projects. Nonetheless, there is a paucity of studies that examined the factors influencing the choice of CPMTT in developing countries, particularly, Tanzania. The objective of the study was to analyze the factors influencing the choice of CPMTT in Tanzanian public infrastructure projects, with the aim to fill the knowledge gap. The study was descriptive in nature and employed a mixed method approach. Using purposive and snowball sampling techniques, data was collected from 60 out of 70 Project management practitioners including Consultants and project Coordinators within Dar-es-salaam Metropolitan Development Projects (DMDP) and similar infrastructure projects. Fifty valid responses were received equivalent to 83% response rate and interviews were done. Quantitative data from respondents was analyzed using IBM SPSS v25. The directed content analysis method was employed for qualitative data from 10 Resident Engineers to supplement the quantitative results. Using factor analysis, four groups of organization support, ease of access and usefulness of tools, fulfilment of project objectives, and project environment and idea generation were determined to influence the choice of CPMTT. Project managers frequently choose tools that are easily accessible without considering the organization's project objectives or resource commitment. The findings could be used as a guide for project practitioners to critically assess the areas of weakness and select CPMTT that can help address those weaknesses and hence improve project delivery in Tanzania, an unexplored context. Project managers are called to re-imagine project needs based on priority and select the CPMTT that satisfies the needs based on experience, skills and project objectives as crucial factors in the selection of CPMTT rather than using their discretion. This would improve the delivery of infrastructure projects and, hence, performance outcomes in the construction sector in Tanzania and other emerging countries. This study was limited to DMDP public infrastructure projects in Tanzania. Keywords: Construction Project Management Tools and Techniques (CPMTT), Decision analysis, mixed-methods, Tanzania

Nurses' Beliefs About Pain Assessment in Dementia: A Qualitative Study Informed by the Theory of Planned Behaviour.

To explore registered nurses' beliefs regarding pain assessment in people living with dementia. A descriptive exploratory qualitative study informed by the Theory of Planned Behaviour. Online semi-structured in-depth interviews were conducted from January to April 2023 with a purposive sample of 15 registered nurses caring for people with dementia. Following transcription, data were analysed using direct content analysis. Registered nurses believe pain assessment improves the well-being of people with dementia and informs and evaluates practice. However, there is a possibility of misdiagnosing pain as agitation or behavioural problems, leading to inaccurate pain management. Interpersonal factors, such as registered nurses' knowledge and experience, beliefs and motivation to improve care provision, were the primary facilitators of pain assessment. Physical and behavioural dimensions of the pain of the dementia syndrome were the most reported barriers to pain assessment. Registered nurses reported that multidisciplinary team members expect them to do pain assessments. Most did not experience disapproval when performing pain assessments. Registered nurses hold beliefs about pain assessment benefits, consequences, enablers, barriers, approvals and disapprovals regarding dementia. The findings could inform interventions to enhance pain assessment practices. Policymakers should provide education opportunities for registered nurses to improve their knowledge, skills and beliefs about pain assessment in dementia. Future research should develop and implement multidisciplinary, multifaceted pain assessment protocols to enhance the accuracy of pain assessment practices. Pain is underassessed in dementia, and this could stem from registered nurses' beliefs about pain assessment in dementia. The findings could inform interventions to enhance pain assessment beliefs and practices. This study adhered to the COREQ criteria. Registered nurses caring for people living with dementia participated as interview respondents.

Navigating a "Good Death" During COVID-19: Understanding Real-Time End-of-Life Care Structures, Processes, and Outcomes Through Clinical Notes.

The coronavirus disease 2019 (COVID-19) pandemic severely disrupted hospice care, yet there is little research regarding how widespread disruptions affected clinician and family decision-making. We aimed to understand how the pandemic affected structures, processes, and outcomes of end-of-life care. Retrospective narrative chart review of electronic health records of 61 patients referred and admitted to hospice from 3 New York City geriatrics practices who died between March 1, 2020, and March 31, 2021. We linked longitudinal, unstructured medical, and hospice electronic health record notes to create a real-time, multiperspective trajectory of patients' interactions with providers using directed content analysis. Most patients had dementia and were enrolled in hospice for 11 days. Care processes were shaped by structural factors (staffing, supplies, and governmental/institutional policies), and outcomes were prioritized by care teams and families (protecting safety, maintaining high-touch care, honoring patient values, and supporting patients emotionally and spiritually). Processes used to achieve these outcomes were decision-making, care delivery, supporting a "good death," and emotional and spiritual support. Care processes were negotiated throughout the end of life, with clinicians and families making in-the-moment decisions. Some adaptations were effective but also placed extraordinary pressure on paid and family caregivers. Healthcare teams' and families' goals to meet patients' end-of-life priorities can be supported by ongoing assessment of patient goals and process changes needed to support them, stronger structural supports for paid and family caregivers, incentivizing relationships across primary care and hospice teams, and extending social work and spiritual care.

Leveraging Higher Education in Our Age-Friendly World

ABSTRACT There is increasing interest in better understanding the connection between higher education and age-friendly community efforts. The global age-friendly community (AFC) movement calls for multi-sectoral engagement in a multi-year model encompassing four core phases (engage, plan, act, measure) to improve livability in domains of community life pertaining to the built, social, and service environment. However, there is limited empirical knowledge regarding the involvement of higher education and how it supports AFC efforts. We used qualitative inquiry to assess the engagement of U.S. institutions as reported by 80 AFCs that completed a five-year cycle of participation. We conducted directed content analysis using paired AFC action plans and progress reports (n = 56) and classified engagement using a priori indicators by higher educational core activities (teaching, research, and service), core phases (e.g. measure), and clustered domain areas (e.g. built environment). Results reveal engagement across all core activities of higher education with most efforts in research, in all areas of the AFC model with most reported in the action phase, and across all clustered domains of practice with the greatest amount identified in the social environment. We identify opportunities for greater engagement and leadership through higher education in our age-friendly world.