Journal of Gerontological Nursing

Feature Article 

Use of Direct In-Person Observation in the Care of Hospitalized Older Adults with Cognitive Impairment: A Systematic Review

Andrea L. Gilmore-Bykovskyi, PhD, RN; Haley Fuhr, BS; Yuanyuan Jin, MSN; Clark Benson, BS

Abstract

Hospitalized older adults with cognitive impairment (CI) due to dementia and/or delirium may require individualized care strategies such as direct observation to mitigate safety concerns and manage behavioral symptoms. Despite common use of direct observation as a strategy, little is known about its practice and outcomes. A systematic review was conducted to identify, appraise, and synthesize literature on direct observation among hospitalized older adults with CI. The search yielded 16 eligible studies, with four describing current practices, nine reporting quality improvement efforts to broaden direct observation, and three focusing on direct observation reduction. Strength of evidence across studies was weak, limited in scope, and lacking clarity in definitions, indications for use and discontinuation, and documentation. Overall, findings highlight differing views on direct observation and the need for future, rigorous evaluation of approaches (e.g., nursing autonomy in initiating and discontinuing observation) to better align direct observation with patient needs. [Journal of Gerontological Nursing, 46(5), 23–30.]

Abstract

Hospitalized older adults with cognitive impairment (CI) due to dementia and/or delirium may require individualized care strategies such as direct observation to mitigate safety concerns and manage behavioral symptoms. Despite common use of direct observation as a strategy, little is known about its practice and outcomes. A systematic review was conducted to identify, appraise, and synthesize literature on direct observation among hospitalized older adults with CI. The search yielded 16 eligible studies, with four describing current practices, nine reporting quality improvement efforts to broaden direct observation, and three focusing on direct observation reduction. Strength of evidence across studies was weak, limited in scope, and lacking clarity in definitions, indications for use and discontinuation, and documentation. Overall, findings highlight differing views on direct observation and the need for future, rigorous evaluation of approaches (e.g., nursing autonomy in initiating and discontinuing observation) to better align direct observation with patient needs. [Journal of Gerontological Nursing, 46(5), 23–30.]

Dementia and delirium are age-associated conditions that independently and collectively contribute to a high proportion of cognitive impairment (CI) among older adults (Inouye, 2006; Preston & Burch, 2018). Dementia and delirium exhibit multiple interrelationships and can occur simultaneously (Fick et al., 2002; Fong et al., 2019) and interactively (Inouye & Ferrucci, 2006; Fong et al., 2009).

An estimated 50% of people older than 65 admitted to hospital settings have either dementia and/or delirium (Boustani et al., 2010; Goldberg et al., 2014). Despite the high prevalence of CI among older adults and their increased risk for adverse outcomes during and following hospitalization (Fogg et al., 2018), dementia and delirium are frequently under-detected and poorly managed in hospital settings (Boustani et al., 2010; Laurila et al., 2004). Management is further complicated by the challenge of differentiating between complex and potentially interrelated etiologies and underlying symptoms associated with CI in older adults, which may exacerbate reliance on reactive management strategies (Dewing & Dijk, 2016; White et al., 2017).

A common management strategy in response to symptoms associated with cognitive impairment is the use of direct in-person observation, also referred to as sitters and 1:1 observation. Referred to hereafter as direct observation, this practice involves direct in-person observation provided by a human, distinct from robot-assisted observation, and has important implications for nursing practice (Jaworowski et al., 2008; Rochefort et al., 2011; Tzeng et al., 2008). A national survey of 102 general medical/surgical hospitals assessing direct in-person observation found that all hospitals reported some form of direct observation (Worley et al., 2000). Although direct observation is anecdotally used in response to behavioral symptoms and safety challenges presented in the care of older adults with CI, little is known about the scope and nature of this practice, including indications for use, specific care provided during observation, and relevant patient outcomes. A better understanding of direct observation among hospitalized older adults with CI is critical to comprehending the influence of this practice on nursing management of these conditions and informing targeted improvements in gerontological nursing care during hospitalization. The objective of the current systematic review was to identify, appraise, and synthesize published literature reporting the practice of direct observation among older adults with CI in hospital settings.

Method

Review Methodology and Search Strategy

Procedures for conducting database searches, reviewing articles for eligibility, and extraction of relevant information from articles were designed a priori following methodological guidance for mixed evidence synthesis from the Cochrane Collaborative (Noyes et al., 2019).

Procedures for a systematic literature review were developed with consultation from a health sciences librarian. A systematic search of published, peer-reviewed literature was conducted in January 2019. The search included any articles published after January 2007 in five databases: MEDLINE (PubMed), CINAHL (EbscoHOST), PsycINFO (Ovid), Web of Science, and Academic Search Premier (Table A, available in the online version of this article). The search timeframe was selected to reflect changes following major inpatient payment reforms issued by the Centers for Medicare & Medicaid Services (2007) that likely had a broad influence on inpatient risk management practices (Carroll, 2008).

Literature Search Strategy.

Table A.

Literature Search Strategy.

Study Selection

The current systematic review included studies that reported the use of direct observation in the care of hospitalized older adults age 65 and older with dementia and/or delirium. Studies had to focus on observation provided by hospital staff or volunteers (rather than family caregivers) and be available in English.

Studies were excluded if they: (a) did not focus on hospital care; (b) did not focus on or specifically describe care of older patients with dementia and/or delirium; or (c) only examined observation practices for patients with acute psychiatric needs, such as suicide precautions, as these individuals and conditions have distinct care requirements.

Article Screening and Data Extraction

All search results were imported into EndNote desktop software where duplicates were removed. Non-duplicate studies were then imported into Covidence systematic review software where they were screened through duplicate independent review with disagreements being arbitrated by a third reviewer. Studies were screened first by title/abstract, and subsequently through a full-text review. In addition to reviewing search results for relevant articles, a manual citation search was also conducted by reviewing reference lists from all included studies and any relevant review articles that were retrieved to increase the likelihood of identifying relevant primary evidence. Two independent reviewers extracted relevant information from included studies using a standardized data extraction template (Table B, available in the online version of this article). A third reviewer compared extracted data from both reviewers to identify and resolve areas of disagreement.

Data Extraction.

Table B.

Data Extraction.

Appraisal of Study Quality

All studies were evaluated for quality through duplicate independent review with disagreements being arbitrated by a third reviewer. Quantitative or quasi-experimental reports that evaluated an intervention were reviewed using the Quality Assessment Tool for Quantitative Studies (Thomas et al., 2004). Qualitative studies were reviewed using the Joanna Briggs Institute (JBI; 2017) Checklist for Qualitative Research.

Data Synthesis

Following data extraction and quality appraisal, findings were synthesized thematically using a meta-summary approach (Sandelowski et al., 2007). Meta-summary techniques focus on aggregating primary study findings rather than re-interpreting primary study data as is common in thematic synthesis approaches. Procedures in the meta-summary approach include extracting relevant data, organizing these data into common topical domains, calculating descriptive statistics if appropriate, and abstracting these findings to inform conclusions.

Results

Search Results

Following removal of duplicates, database search results yielded 1,080 studies, 14 of which met criteria for inclusion. Hand-searching reference lists yielded two additional eligible articles, resulting in 16 published reports for review (Figure 1).

Study selection process.

Figure 1.

Study selection process.

Characteristics of Included Studies

Of the 16 included studies, four reported current direct observation practice, nine reported quality improvement projects focused on developing interventions or new direct observation programs, and three examined efforts to reduce the frequency of direct observation. Studies were conducted in Australia (n = 7), the United States (n = 4), United Kingdom (n = 4), and Canada (n = 1). Detailed study information can be found in Table C (available in the online version of this article).

Characteristics of Included Studies.Characteristics of Included Studies.Characteristics of Included Studies.Characteristics of Included Studies.Characteristics of Included Studies.Characteristics of Included Studies.

Table C.

Characteristics of Included Studies.

Studies Examining Current Direct Observation Practice. Four studies examined current practice regarding direct observation. One study examined relationships between direct observation costs, patient health conditions, and staffing, finding that low staffing situations and the presence of psychogeriatric conditions related to higher costs (Rochefort et al., 2011). The remaining three studies collected nursing staff perspectives regarding direct observation (Ayton et al., 2017; Grealish et al., 2019; Moyle et al., 2011). Findings highlighted diverse views regarding the purpose and effectiveness of observation, with many nursing staff identifying supervision and safety as the main purpose (Ayton et al., 2017; Grealish et al., 2019; Moyle et al., 2011). A less frequent finding was the view that observation should also include efforts to understand and address the underlying source of symptoms such as pain or agitation (Grealish et al., 2019; Moyle et al., 2011).

Findings from these studies also shed light on common concerns held by nursing staff regarding the quality of care provided during observation and the adequacy of training in preparation for the role. Staff expressed a desire for the practice to transition toward “active” rather than “passive” observation roles (Grealish et al., 2019; Moyle et al., 2011). One study also found staff expressed concern for increased fall risk due to lack of coordination between in-person observation and other technologies designed to help with supervision (Grealish et al., 2019).

Reports of Quality Improvement Efforts Focused on Development of Interventions or New Observation Programs. Of the nine studies reporting an intervention or new observation program, five focused on use of volunteers to provide observation (Bateman et al., 2016; Blair et al., 2018; Ervin & Moore, 2014; Preston & Burch, 2018; Wong Shee et al., 2014). The remaining four reports described various interventional efforts directed at improving care for patients with dementia through training or other resources to improve existing direct observation programs (Brooke & Herring, 2016; Connors & Dewing, 2017; Goodwin, 2015; Waszynski et al., 2013).

Volunteer-based programs were evaluated through various approaches, including a qualitative assessment of staff and volunteer views (Ervin & Moore, 2014; Preston & Burch, 2018; Wong Shee et al., 2014), a chart review of patient outcomes, (Blair et al., 2018), and a pre/post evaluation of patient outcomes as well as staff and volunteer views (Bateman et al., 2016). Although the methods for evaluation varied widely, all studies concluded volunteer programs were safe, effective, and inexpensive approaches for providing care for patients with dementia and/or delirium (Bateman et al., 2016; Blair et al., 2018; Ervin & Moore, 2014; Preston & Burch, 2018; Wong Shee et al., 2014). Studies further concluded the programs reduced time pressure from hospital staff (Bateman et al., 2016; Ervin & Moore, 2014) and readmissions (Blair et al., 2018). In three of these studies, staff recommended expanding volunteer programs (Ervin & Moore, 2014; Preston & Burch, 2018; Wong Shee et al., 2014). Areas for improvement were also identified and included better differentiation between volunteers and hospital staff (Preston & Burch, 2018; Wong Shee et al., 2014) and the need for policies guiding staff and volunteer communication (Preston & Burch, 2018; Wong Shee et al., 2014).

Among the four interventional reports, three described the development of a training program (Brooke & Herring, 2016; Goodwin, 2015; Waszynski et al., 2013), and one implemented guidance for the level of direct observation needed according to patients' needs (Connors & Dewing, 2017). All studies also emphasized the need for individualized resources, activities, and background information on lifestyle, hobbies, and leisure activities to inform care delivery. Two studies examined the impact of the intervention on patient outcomes, with one reporting a 50% reduction in patient falls resulting in serious harm (Brooke & Herring, 2016), and one reporting a 73% reduction in agitation during individualized activities provided in the context of direct observation (Waszynski et al., 2013).

Studies Examining Efforts to Reduce Frequency of Direct Observation. The remaining three studies evaluated interventions or policies aimed at reducing 1:1 direct observation for patients with CI (Colella et al., 2017; Laws & Crawford, 2013; Weeks, 2011). All of these studies were initiated in response to the increased reliance on direct observation and consequential high costs with little change in patient outcomes. These studies emphasized the goal of transitioning from reactive, provider-led direct observer initiatives to proactive, nurse-led initiatives. Proactive strategies included enhanced communication processes about a patient's history of dementia between physicians and nurses when developing a postoperative care plan (Laws & Crawford, 2013) and development of nurse-led procedures to initiate and discontinue direct observers (Colella et al., 2017; Weeks, 2011). All three studies reported they were successful in reducing direct observation, with one study citing a reduction in patient falls and workplace injuries (Laws & Crawford, 2013). However, across studies, the rigor of assessing practice reduction and impact on patient outcomes was lacking.

Patient-, Staff-, and Health System–Related Outcomes. All 16 studies reviewed included some form of assessment of patient, staff, and/ or health system outcomes, which included qualitative and quantitative measures. Of these studies, 13 evaluated patient outcomes, 12 evaluated staff outcomes, and six reported health systems outcomes. Of the 13 studies evaluating patient outcomes, three used at least one validated pre/ post measurement (Colella et al., 2017; Connors et al., 2017; Wasynski et al., 2013). Common patient outcomes reported included patient falls, length of stay, patient mood/agitation, medication use, and patient care (Table D, available in the online version of this article). Staff outcomes included perceptions of patient safety, perceptions of patient well-being, and work satisfaction. Health systemrelated outcomes included a change in the rate of direct observation or a change in the cost of care related to direct observation (Table E, available in the online version of this article).

Patient Outcomes Reported in Included Studies and Use of Standardized Measures.

Table D.

Patient Outcomes Reported in Included Studies and Use of Standardized Measures.

Staff and Health System-Related Outcomes.

Table E.

Staff and Health System-Related Outcomes.

Patient and Family Perspectives. One study reported findings from patients regarding direct observation (Wong Shee et al., 2014), and two studies included informal caregivers in their evaluation of direct observation (Preston & Burch, 2018; Wong Shee et al., 2014), reporting that patients and caregivers were overall supportive of a volunteer direct observation program. However, detailed description regarding the perspectives of patients and families in these reports was minimal.

Consistency of Definitions, Indications, and Delivery of Direct Observation Across Studies

Definitions of Direct Observation. Various terms were used across and within studies to describe direct observation, including sitter, constant observer, and special/specialling, among others (Table C). Studies lacked explicit or detailed conceptual definitions of direct observation. Descriptions of the individual providing observation and his/her training was generally limited and included various terminology including babysitter, observer, and therapeutic companion. One study found that nursing staff defined direct observation in terms of the frequency and degree of focus of the activity, “they [direct observers] need to be able to observe that patient 24/7. In the toilet, not have them behind closed doors…” (Moyle et al., 2011, p. 423). The remaining articles did not describe the frequency or duration.

Specific Care Practices and Activities in Delivery of Direct Observation. Fourteen studies detailed the provision of specific cares/activities in direct observation. Activities varied across studies and were characterized as either active or passive practices (Table 1). Common active observation practices included engaging in meaningful activities and conversation. Common passive observation tended to be more reactionary and included monitoring patient, communicating with staff, and “verbally or physically redirecting patient behaviors” (Colella et al., 2017, p. 2). Only one study reported guidelines for clinical documentation of observation or reliance on standard policies or procedures to inform observation practices in routine care (Colella et al., 2017).

Descriptions of Care and Activities Provided Through Direct Observation

Table 1:

Descriptions of Care and Activities Provided Through Direct Observation

Quality Appraisal

Of the 10 studies evaluated using the Quality Assessment Tool for Quantitative Studies (Thomas et al., 2004), eight received a global rating of weak and two were moderate (Table F, available in the online version of this article). The JBI (2017) Checklist for Qualitative Research does not produce uniform ratings; however, no studies met all quality criteria and two of the six studies met eight of the 10 quality criteria (Table G, available in the online version of this article).

Quality Rating of the Included Studies According to Effective Public Health Practice Project's Qualitative Assessment Tool for Quantitative Studies.

Table F.

Quality Rating of the Included Studies According to Effective Public Health Practice Project's Qualitative Assessment Tool for Quantitative Studies.

Joanna Brigg's Institute Checklist for Qualitative Research Results.

Table G.

Joanna Brigg's Institute Checklist for Qualitative Research Results.

Discussion

The results of the current systematic review highlight the substantially limited scope and quality of existing evidence on the use of direct observation practices among older adults with CI in hospital settings. Most available evidence is derived from small, single-site studies and efforts toward quality improvement, many of which lack features of rigorous scientific design that would aid in interpreting outcomes purported to be associated with various facets of observation practices.

Findings from the current systematic review demonstrate that available evidence on direct observation practices is insufficient to guide gerontological nursing practice and is hindered by vague, inconsistent, and sometimes absent data clarifying indications for the use of observation and specific activities that take place during observation. Findings highlight that direct observation practices often include multiple components, such as delivery of multimodal activities, that necessitate consistent measurement and documentation of actual care delivered to ascertain which components of observation care may lead to different patient outcomes. Furthermore, evaluation of direct observation practice among hospitalized older adults with CI is heterogeneous, with many studies only evaluating perspectives about the practice and few applying validated or standardized measures to evaluate outcomes associated with observation. Although the use of direct observation in acute care settings is common and costly, only one study quantified cost or resource requirements. Collectively, these findings suggest that there is a substantial disconnect between lack of evidence regarding direct in-person observation in hospitalized care of older adults with CI and the high use of this practice.

Given the limited scope and quality of evidence, there is limited guidance for frontline providers engaged in or overseeing direct observation practices among hospitalized older adults with CI. However, the reviewed studies suggest that concentrated efforts to evaluate and consider the benefits, drawbacks, and potential unintended consequences of local direct observation practices is a worthwhile endeavor to inform site-specific practices well-suited to nursing's scope of practice.

Despite the limitations of existing evidence, the studies reviewed provide preliminary insights into aspects of direct observation practice that merit further investigation. In general, studies that reported direct observation programs incorporating dementia-specific and active or person-centered approaches led to improvements in patient outcomes, with some citing reduction in patient falls in addition to subjective improvements in care quality. Across studies the importance of specific training in dementia and delirium-specific care approaches was highlighted as an important component of effective observation programs. Another major theme was a preference for use of active rather than passive approaches to direct observation, with active approaches generally being characterized as person-centered in nature and identified as one of the most rewarding aspects of fulfilling observer roles.

Findings also suggest that with lack of structured guidance regarding appropriate use of direct observation, there may be unintended negative consequences for cost and care delivery. Although several studies focused on implementing new observation practices, three studies had the goal of reducing direct in-person observation due to high costs of the practice and other consequences, such as strain on nurse staffing. These studies found no increase in falls with reduction in observation, and perceived improvements in care delivery through better distribution and engagement of patients with CI across the entire care team. These conclusions are consistent with findings from other studies that suggest increased nurse autonomy in decision making regarding nursing interventions can be appropriate, particularly when accompanied by structured guidelines (Labrague et al., 2019; Weston, 2010). Although preliminary in nature, these studies challenge the assumption that hospitalized older adults with CI inevitably require observation to ensure their safety or to address symptoms. These studies also shed light on potential unintended consequences of reliance on direct in-person observation to meet the needs of hospitalized older adults with CI that have not been systematically investigated—including reduced accountability for caring for cognitively vulnerable patients across the care team, staff burden and stress due to staffing strains imposed by observation requirements, and financial consequences related to use of direct observation practice.

Limitations

There are limitations to the current systematic review. The literature search was restricted to studies written in English, and it is possible that the search terms did not capture all relevant articles. Because the review focused on peer-reviewed literature, reports of other quality improvement efforts that may shed light on other practices related to direct observation for older adults with CI were not incorporated. However, findings from this review provide a comprehensive summary of the current state of the science regarding direct in-person observation practices and their use among hospitalized older adults with CI.

Conclusion

To address existing scientific gaps and ultimately inform evidence-based gerontological nursing practices in applying direct observation, future scholarship on direct observation practices in hospital settings will first necessitate the development of standardized definitions, measurements, and outcomes. Findings further highlight the need for additional, more rigorous research to quantify the extent of this practice, clarify indications for its use and discontinuation, and comprehensively document specific features of care delivered through direct observation and associated care costs. Finally, to fully understand the true impact of direct observation practices, greater partnership with and integration of the perspectives of patients and family caregivers is needed.

References

  • Ayton, D., O'Brien, P., Treml, J., Soh, S. E., Morello, R. & Barker, A. (2017). Nurses' perceptions of preventing falls for patients with dementia in the acute hospital setting. Australasian Journal on Ageing, 36(4), E70–E72 doi:10.1111/ajag.12474 [CrossRef] PMID:29171133
  • Bateman, C., Anderson, K., Bird, M. & Hungerford, C. (2016). Volunteers improving person-centred dementia and delirium care in a rural Australian hospital. Rural and Remote Health, 16(2), 3667 PMID:27303861
  • Blair, A., Anderson, K. & Bateman, C. (2018). The “Golden Angels”: Effects of trained volunteers on specialling and readmission rates for people with dementia and delirium in rural hospitals. International Psychogeriatrics, 30(11), 1707–1716 doi:10.1017/S1041610218000911 [CrossRef] PMID:30099973
  • Boustani, M., Baker, M. S., Campbell, N., Munger, S., Hui, S. L., Castelluccio, P., Farber, M., Guzman, O., Ademuyiwa, A., Miller, D. & Callahan, C. (2010). Impact and recognition of cognitive impairment among hospitalized elders. Journal of Hospital Medicine, 5(2), 69–75 doi:10.1002/jhm.589 [CrossRef] PMID:20104623
  • Brooke, J. & Herring, S. (2016). Development of an activities care crew to support patients. Nursing Older People, 28(8), 20–25 doi:10.7748/nop.2016.e835 [CrossRef] PMID:27682386
  • Carroll, R. (2008). Implications of the inpatient prospective payment system final rules. Journal of Healthcare Risk Management, 28(4), 13–17, 19–21. doi:10.1002/jhrm.5600280404 [CrossRef] PMID:20200922
  • Centers for Medicare & Medicaid Services. (2007). FY 2008 inpatient prospective payment system final rule. https://www.cms.gov/newsroom/fact-sheets/fy-2008-inpatient-prospective-payment-system-final-rule
  • Colella, J., Aroh, D., Douglas, C., Van-Buitenen, N., Galesi, J., Castro, A., Tank, L., Parulekar, M. & Menacker, M. (2017). Managing delirium behaviors with one-to-one sitters. Nursing, 47(8), 1–5 doi:10.1097/01.NURSE.0000521038.27830.b4 [CrossRef] PMID:28746110
  • Connors, D., Beverley, & Dewing, J. (2017). ‘More than a sitter’: A practice development project on special observations in acute general hospital care. East Sussex Healthcare NHS Trust. https://www.fons.org/Resources/Documents/Special-Observations-in-Acute-General-Hospital-Care-PBDR-East-Sussex-.pdf
  • Dewing, J. & Dijk, S. (2016). What is the current state of care for older people with dementia in general hospitals? A literature review. Dementia (London), 15(1), 106–124 doi:10.1177/1471301213520172 [CrossRef] PMID:24459188
  • Ervin, K. & Moore, S. (2014). Rural nurses' perceptions of a volunteer program in an acute setting: Volunteers delivering person-centred care for patients with dementia and delirium. Open Journal of Nursing, 04(01), 27–33 doi:10.4236/ojn.2014.41005 [CrossRef]
  • Fick, D. M., Agostini, J. V. & Inouye, S. K. (2002). Delirium superimposed on dementia: A systematic review. Journal of the American Geriatrics Society, 50(10), 1723–1732 doi:10.1046/j.1532-5415.2002.50468.x [CrossRef] PMID:12366629
  • Fogg, C., Griffiths, P., Meredith, P. & Bridges, J. (2018). Hospital outcomes of older people with cognitive impairment: An integrative review. International Journal of Geriatric Psychiatry, 33(9), 1177–1197 doi:10.1002/gps.4919 [CrossRef] PMID:29947150
  • Fong, T. G., Jones, R. N., Shi, P., Marcantonio, E. R., Yap, L., Rudolph, J. L., Yang, F. M., Kiely, D. K. & Inouye, S. K. (2009). Delirium accelerates cognitive decline in Alzheimer disease. Neurology, 72(18), 1570–1575 doi:10.1212/WNL.0b013e3181a4129a [CrossRef] PMID:19414723
  • Fong, T. G., Vasunilashorn, S. M., Libermann, T., Marcantonio, E. R. & Inouye, S. K. (2019). Delirium and Alzheimer disease: A proposed model for shared pathophysiology. International Journal of Geriatric Psychiatry, 34(6), 781–789 doi:10.1002/gps.5088 [CrossRef] PMID:30773695
  • Goldberg, S. E., Whittamore, K. H., Pollock, K., Harwood, R. H. & Gladman, J. R. (2014). Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist medical and mental health unit and standard care wards. International Journal of Nursing Studies, 51(10), 1332–1343 doi:10.1016/j.ijnurstu.2014.02.002 [CrossRef] PMID:24613652
  • Goodwin, C. (2015). Enhancing health-care assistants' dementia role. https://www.nursingtimes.net/clinical-archive/neurology/enhancing-healthcare-assistants-dementia-role-23-02-2015/
  • Grealish, L., Chaboyer, W., Darch, J., Real, B., Phelan, M., Soltau, D., Lunn, M., Brandis, S., Todd, J. & Cooke, M. (2019). Caring for the older person with cognitive impairment in hospital: Qualitative analysis of nursing personnel reflections on fall events. Journal of Clinical Nursing, 28(7–8), 1346–1353 doi:10.1111/jocn.14724 [CrossRef] PMID:30520196
  • Inouye, S. K. (2006). Delirium in older persons. The New England Journal of Medicine, 354(11), 1157–1165 doi:10.1056/NEJMra052321 [CrossRef] PMID:16540616
  • Inouye, S. K. & Ferrucci, L. (2006). Elucidating the pathophysiology of delirium and the interrelationship of delirium and dementia. The Journals of Gerontology, Series A, Biological Sciences and Medical Sciences, 61(12), 1277–1280 doi:10.1093/gerona/61.12.1277 [CrossRef] PMID:17234820
  • Jaworowski, S., Raveh, D., Lobel, E., Fuer, A., Gropp, C. & Mergui, J. (2008). Constant observation in the general hospital: A review. The Israel Journal of Psychiatry and Related Sciences, 45(4), 278–284 PMID:19439833
  • Joanna Briggs Institute. (2017). Checklist for qualitative research. https://joannabriggs.org/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Qualitative_Research2017_0.pdf
  • Labrague, L. J., McEnroe-Petitte, D. M. & Tsaras, K. (2019). Predictors and outcomes of nurse professional autonomy: A cross-sectional study. International Journal of Nursing Practice, 25(1), e12711 doi:10.1111/ijn.12711 [CrossRef] PMID:30426592
  • Laurila, J. V., Pitkala, K. H., Strandberg, T. E. & Tilvis, R. S. (2004). Detection and documentation of dementia and delirium in acute geriatric wards. General Hospital Psychiatry, 26(1), 31–35 doi:10.1016/j.genhosppsych.2003.08.003 [CrossRef] PMID:14757300
  • Laws, D. & Crawford, C. L. (2013). Alternative strategies to constant patient observation and sitters: A proactive approach. The Journal of Nursing Administration, 43(10), 497–501 doi:10.1097/NNA.0b013e3182a3e83e [CrossRef] PMID:24061581
  • Moyle, W., Borbasi, S., Wallis, M., Olorenshaw, R. & Gracia, N. (2011). Acute care management of older people with dementia: A qualitative perspective. Journal of Clinical Nursing, 20(3–4), 420–428 doi:10.1111/j.1365-2702.2010.03521.x [CrossRef]
  • Noyes, J., Booth, A., Cargo, M., Flemming, K., Harden, A., Harris, J., Garside, R., Hannes, K., Pantoja, T. & Thomas, J. (2019). Chapter 21: Qualitative evidence. In Higgins, J. P. T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M. J. & Welch, V. A. (Eds.). Cochrane handbook for systematic reviews of interventions (version 6.0). Cochrane. https://training.cochrane.org/handbook/current/chapter-21
  • Preston, C. & Burch, S. (2018). Dementia buddying as a vehicle for person-centred care? The performance of a volunteer-led pilot on two hospital wards. Journal of Health Services Research & Policy, 23(3), 139–147 doi:10.1177/1355819618767944 [CrossRef] PMID:29661033
  • Rochefort, C. M., Ward, L., Ritchie, J. A., Girard, N. & Tamblyn, R. M. (2011). Registered nurses' job demands in relation to sitter use: Nested case-control study. Nursing Research, 60(4), 221–230 doi:10.1097/NNR.0b013e318221b6ce [CrossRef] PMID:21691242
  • Sandelowski, M., Barroso, J. & Voils, C. I. (2007). Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings. Research in Nursing & Health, 30(1), 99–111 doi:10.1002/nur.20176 [CrossRef] PMID:17243111
  • Thomas, B. H., Ciliska, D., Dobbins, M. & Micucci, S. (2004). A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions. Worldviews on Evidence-Based Nursing, 1(3), 176–184 doi:10.1111/j.1524-475X.2004.04006.x [CrossRef] PMID:17163895
  • Tzeng, H. M., Yin, C. Y. & Grunawalt, J. (2008). Effective assessment of use of sitters by nurses in inpatient care settings. Journal of Advanced Nursing, 64(2), 176–183 doi:10.1111/j.1365-2648.2008.04779.x [CrossRef] PMID:18990098
  • Waszynski, C., Veronneau, P., Therrien, K., Brousseau, M., Massa, A. & Levick, S. (2013). Decreasing patient agitation using individualized therapeutic activities. The American Journal of Nursing, 113(10), 32–39 doi:10.1097/01.NAJ.0000435345.23040.42 [CrossRef] PMID:24037247
  • Weeks, S. K. (2011). Reducing sitter use: Decision outcomes. Nursing Management, 42(12), 37–38 doi:10.1097/01.NUMA.0000407582.12602.21 [CrossRef] PMID:22124299
  • Weston, M. (2010). Strategies for enhancing autonomy and control over nursing practice. Online Journal of Issues in Nursing, 15(1). doi:10.3912/OJIN.Vol15No01Man02 [CrossRef]
  • White, N., Leurent, B., Lord, K., Scott, S., Jones, L. & Sampson, E. L. (2017). The management of behavioural and psychological symptoms of dementia in the acute general medical hospital: A longitudinal cohort study. International Journal of Geriatric Psychiatry, 32(3), 297–305 doi:10.1002/gps.4463 [CrossRef] PMID:27019375
  • Wong Shee, A., Phillips, B., Hill, K. & Dodd, K. (2014). Feasibility and acceptability of a volunteer-mediated diversional therapy program for older patients with cognitive impairment. Geriatric Nursing, 35(4), 300–305 doi:10.1016/j.gerinurse.2014.03.005 [CrossRef] PMID:24755195
  • Worley, L. L., Kunkel, E. J., Gitlin, D. F., Menefee, L. A. & Conway, G. (2000). Constant observation practices in the general hospital setting: A national survey. Psychosomatics, 41(4), 301–310 doi:10.1176/appi.psy.41.4.301 [CrossRef] PMID:10906352

Descriptions of Care and Activities Provided Through Direct Observation

ActivitiesSpecific Examples of Care Provided
Active Observation Care Practices
  Engaging in conversation

Talking to patients about current events and surroundings (Bateman et al., 2016)

Engaging patients in conversations (Wong Shee et al., 2014)

Building a strong and supportive friendship (Preston & Burch, 2018)

Gaining information about the patient's background and personal preferences from the person or his/her family member (Bateman et al., 2016; Blair et al., 2018)

Emotional support (Ayton et al., 2017; Blair et al., 2018)

  Engaging in meaningful activities

Distraction therapies, for example, the care crew purchased a tool box and wooden tools for a man who had been a carpenter (Brooke & Herring, 2016)

Activities such as singing, no-cook baking, art therapy (Brooke & Herring, 2016)

Supporting activities patients enjoy (e.g., reading to them) (Bateman et al., 2016)

Playing cards (Bateman et al., 2016; Waszynski et al., 2013)

Individualized activities tailored to patients' interests and preferences (Bateman et al., 2016; Brooke & Herring, 2016; Kaye & Sharon, 2014; Preston & Burch, 2018; Waszynski et al., 2013)

Activity box with games, cards, magazines, a CD player, crayons, coloring books, and drawing pads (Connors & Dewing, 2017)

Listening to, singing, and discussing music (Brooke & Herring, 2016)

  Comfort measures

Adjusting pillows (Bateman et al., 2016)

Providing warm drinks (Bateman et al., 2016)

Hand massage (Bateman et al., 2016; Brooke & Herring, 2016)

  Actively ensuring patient safety

Making sure patients were wearing glasses and hearing aids and checking that these were clean and working properly (Bateman et al., 2016; Blair et al., 2018)

Providing mobilization assistance (Ayton et al., 2017; Blair et al., 2018; Waszynski et al., 2013)

Encouraging and accompanying walking as advised by nurses (Bateman et al., 2016; Blair et al., 2018)

Assisting with eating and drinking (Ayton et al., 2017; Bateman et al., 2016; Blair et al., 2018)

Passive Observation Activities
  Prevent patient behaviors

Limited to verbally or physically redirecting patient behaviors (Colella et al., 2017)

Before the intervention, sitters were “observing the patient and intervening if the patient exhibits dangerous behaviors” (Waszynski et al., 2013)

  Monitoring

Watch over patients by adopting a custodial rather than a caring and therapeutic stance (Connors & Dewing, 2017)

Watch patients (Weeks, 2011)

Excessive or unnatural monitoring of patients (Moyle et al., 2011)

Attempt to ensure patient safety through the provision of continuous surveillance (Rochefort et al., 2012)

  Communication with staff

Communicating any concerns that may arise to hospital staff (Bateman et al., 2016)

Writing down and communicating to staff any changes that are noticed in patient behavior (Bateman et al., 2016)

Literature Search Strategy.

Databases searched
MEDLINE (PubMed), CINAHL (EbscoHOST), and PsycINFO (Ovid) Web of Science, and Academic Search Premier
Direct Observation Practice
direct observation OR constant observation OR continuous observation OR 1:1 observation OR special observation OR superv* OR sitter* OR aide OR volunteer OR assistant OR attendant OR companion
Patient Population
alzheimer OR dementia OR lewy OR multi-infarct dementia OR vascular dementia OR aids dementia complex OR creutzfeldt jakob syndrome OR Korsakoff* OR Binswanger* OR pick's disease OR Wernicke* OR deliri*
Location
hospital OR acute OR inpatient OR “extended stay”
Inclusions

Included studies must explicitly describe or examine the practice of direct in-person observation defined as provision of 1:1 continuous in-person observation, which may also be referred to as “personal safety attendant, sitter, or direct/constant/continuous observation” relevant to the care of hospitalized older adults (age 65 +) with dementia and/or delirium.

The practice of direct in-person observation in the study must be provided by an individual who is not a family (i.e. informal) caregiver, but may be a member of paid staff or formal hospital volunteers

Included studies must be written in the English language.

Exclusions

Data Extraction.

1Title
2First author
3Study design
4Intervention and control groups (if applicable)
5Setting
6Number of participants
7Definitions provided for direct observation
8Indications specified for implementing direct observation
9Role/training of individual(s) providing direct observation
10Specific care practices and activities in provision of direct observation
11Guidelines for clinical documentation of observation
12Policies and procedures around direct observation
13Evaluation of patient/family outcomes
14Staff outcomes
15Health system or financial outcomes

Characteristics of Included Studies.

Study/YearSettingStudy TypeStudy DesignStudy ObjectivesParticipantsDefinition of Direct Observation UsedMajor Conclusion(s)
Studies Examining Current Direct Observation Practice
Ayton et al., 20176 hospitals in New South Wales and Victoria in AustraliaEvaluation of current direct observation practiceQualitative; secondary analysis of focus group data.To explore nurses' perspectives regarding fall prevention for patients with dementia in an acute care setting.96 nurses working on participating wardsOne-to-one supervision in the form of specially trained patient sitters (also termed constant observer or patient watch).Nurses report that one-to-one supervision is required to keep patients safe.
Grealish et al., 20191 subacute and 2 acute wards within two hospitals of a tertiary level health service in southeast Queensland in AustraliaEvaluation of current direct observation practiceQualitative; Analysis of semi-structured interviews.To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall.11 registered and 2 enrolled nurses and 4 assistants in nursingCasual Assistants in nursing (AIN) were employed to provide continuous observation.Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy. Clinical practice should reconsider the sitter role from simple observer to assistant, focused on ambulation and support independence in activities of daily living.
Moyle et al., 2011A large South East Queensland Hospital in AustraliaEvaluation of current direct observation practiceQualitative; Analysis of semi-structured interviews.(1) To describe the staff perspectives of current practice in the care of older people with dementia in the acute care setting; and (2) to critically evaluate the current care management in this setting in relation to the available literature.4 senior staff, 9 ward staff on acute medical or surgical wards.‘Specialling’, a practice whereby one staff member, usually the most junior, is assigned to spend their shift observing the patient.Using untrained staff to sit and observe people with dementia as a risk management strategy does not encourage an evidence-based approach. Staff education and environmental resources may improve the current situation so that people with dementia receive care that takes into account their individual needs and human dignity.
Rochefort et al., 20124 adult care hospitals in Montreal, CanadaEvaluation of current direct observation practiceQuantitative Prospective study; Analysis of collected dataTo estimate the relationships between patient health conditions, nurse staffing characteristics and high sitter use costs.1151 patients who received a sitterSitters are paid unlicensed assistive healthcare providers; once ordered, they are contracted through external private agencies.Circumstances of understaffing and patients having psychogeriatric conditions are associated with high sitter use costs. Improving staffing and providing additional resources to support the care of psychogeriatric patients may lower these expenses.
Reports of Quality Improvement Efforts Focused on Development of Interventions or New Observation Programs
Bateman et al., 201663-bed rural acute hospital located in New South Wales in AustraliaEvaluation of new volunteer direct observer programQuasi-experimental pre-post design and qualitative assessments of the acceptability and feasibility of the intervention.To assess the effectiveness, acceptability and feasibility of the use of volunteers for patients with dementia and/or delirium.64 patients, 18 nurses, 18 volunteersVolunteers sitting with patients individually or in group activity sessions.It is feasible to introduce and sustain a relatively inexpensive volunteer program to improve quality of care for patients with dementia and/or delirium.
Blair et al., 20187 acute hospitals in rural AustraliaEvaluation of new volunteer direct observer programNon-randomized controlled trial; Analysis of medical record audits.To evaluate the clinical outcomes for patients with dementia, delirium, or at risk for delirium supported by the person-centered volunteer program in rural acute hospitals.Intervention group (n=270), control group (n=188)1:1 supervision (specialized) volunteers to provide person- centered practical assistance.The volunteer intervention is a safe, effective, and replicable way to support older acute patients with dementia, delirium, or risk factors for delirium in rural hospitals.
Brooke & Herring, 20164 older people's care wards in Royal Berkshire Hospital in the UKTraining program implementationEvidence-based practice; Analysis of routinely collected data.To support ward staff to become more involved and proactive in providing appropriate stimulation and interaction for patients with dementia.1 assistant practitioner, 4 HCAsCare crew provide one-to-one care and group activities for patients.The care crew initiatives have reduced the number of falls with serious harm, improved the experience of people with dementia and their families, and supported partnership working with patients, families and multidisciplinary teams.
Connors et al., 2017Acute General Hospital in UKTraining program implementationQuality improvement project; Analysis of Survey.To explore the area of special observation within nursing practice on busy acute medical wards in a general hospital.2 healthcare assistants, 2 registered nurses and 2 ward sisters from the trial ward formed the implementation group. 12 respondents.Special observations provided by trained nursing staff who adopt a caring and therapeutic stance.Staff experiences of specialling on the trial ward following the implementation of the project have been very positive. All ward staff have now had experience of specialling a patient and feedback from staff following the introduction of the special observation quick reference chart suggests that staff are more confident about what is involved.
Ervin & Moore, 2014Acute hospital setting in AustraliaEvaluation of new volunteer direct observer programQualitative; Analysis of semi-structured interviews.To explore nursing staff's opinions after the implementation of the volunteer program.15 nurses, 10 volunteersVolunteers were utilized to provide person-centered care for patients.Findings revealed strong benefits from the perspectives of the nursing staff. These benefits included overall improved patient care and improved time management for nursing tasks.
Goodwin, 2015Royal Stroke University Hospital in UKTraining program implementationEvidence-based practice; Analysis of survey.To introduce an enhanced dementia care role for healthcare assistants, offering training in how to recognize dementia and providing one-to-one support.18 Healthcare Assistants (HCAs)HCAs offer one-to-one support, linking with families and carers and reporting to the named nurses.This enhanced dementia care course has enabled a group of staff members to support patients with dementia, as well as their families or carers.
Preston et al., 2018Two adjacent mental health hospital wards in EnglandEvaluation of new volunteer direct observer programQualitative; Analysis of semi-structured interviews.To understand and explain whether a dementia buddies pilot introduced into two adjacent mental health hospital was achieving its aim of enhancing person-centered care.3 key informant interviews and 20 (9 clinical and support staff, 7 carers/relatives, and 4 buddies) in-depth interviewsDementia buddies (volunteers), the extra one-to-one time buddies spent with patients.This finding underlines the benefit of focusing on workplace culture to understand the performance of volunteer-led initiatives. It also shows that existing ward culture is a determining factor in the capacity for dementia buddy schemes to act as vehicles for culture change.
Wasynski et al., 2013Large, inner-city, urban level 1 trauma center in USEvaluation of change to current direct observation programQuality improvement project; Pre-post interventionTo evaluate the effectiveness of an individualized therapeutic activities program and assess patients' perspectives toward this program.2 nursing staff and 13 nursing assistantsTrain direct observers (nursing staff and nursing assistant) to use individualized activities with patients and complete personalized approach form with patient.The intervention appeared effective in reducing levels of agitation in selected patients who were receiving continuous observation on non-psychiatric units at a large, urban level 1 trauma center. Many patients expressed gratitude for the diversion from their health issues.
Wong Shee et al., 201430 bed inpatient rehabilitation unit in a large regional health service in AustraliaEvaluation of new volunteer direct observer programQualitative; Analysis of structured interviews and focused groups.To evaluate the feasibility and acceptability for the patients and their families/carers, volunteers and staff, of a volunteer diversional therapy program for older patients with cognitive impairment in a sub-acute hospital ward.10 volunteers, 30 patients, 3 carers, 6 nursing staffVolunteers working on a one-to-one basis with patient participants.Overall, patients, carers, staff and volunteers were satisfied with the volunteer program and perceived benefits for quality of care. The volunteer diversional therapy pilot program for patients with cognitive impairment on a sub-acute ward was acceptable and feasible for patients, carers, staff and volunteers.
Studies Examining Efforts to Reduce Frequency of Direct Observation
Colella et al., 2017Acute care setting in USEvaluation of change to current direct observation programEvidence-based practice/project; Analysis of routinely collected dataTo translate a clinical assessment bundle of best practices for prevention and treatment of delirium into an innovative safety risk stop-light stratification tool designed for nurses to use when making clinical judgements to appropriately initiate or discontinue one-to-one sitters.Patients in all adult inpatient unitsConstant observation by one-to-one sitters to manage patients with signs of delirium.Care costs significantly declined and sitter utilization decreased while quality indicators for falls and restraints were maintained. We've successfully transitioned from a reactive provider-led initiative to a proactive nurse-led sitter initiative empowering nurses to practice at the top of their license.
Laws & Crawford, 2013Kaiser Permanente Santa Rosa Medical Center in USEvaluation of change to current direct observation programEvidence-based intervention; Analysis of routinely collected data.To design and implement proactive strategies to identify patients at risk for behavioral issues.Number of patient charts included not clearly specifiedA multidisciplinary performance improvement group aimed to reduce sitter use.The process an approach of a multidisciplinary team using a proactive approach proved effective. The organization and nurse leaders have realized a more appropriate use of sitters, Constant Observers (CO), and CO alternatives while still providing a safe environment for patients.
Weeks, 2011Pardee Hospital in USEvaluation of change to current direct observation programEvidence-based practice; Analysis of data from online safety incident reports.To evaluate the effectiveness of the “no sitter order”.Nursing leadership councilSitters, or therapeutic companions, have been hired for years to help look after patients who have difficulty caring for themselves.Hired companions or nursing staff. Empowering nurses to decide on proper patient care has helped lower hospital costs and staff frustration. The “no sitter order” had positive results, compelling evidence for all facilities to limit the use of therapeutic companions. Nursing staffs are well equipped to handle safe patient care.

Patient Outcomes Reported in Included Studies and Use of Standardized Measures.

Outcome CategoryPapersStaff PerceptionsPatient PerceptionsEvaluation of Single Time FramePre-Post MeasuresStandardized Measures/Instruments
FallsAyton et al., 2017X---N/A
Bateman et al., 2016---XN/A
Blair et al., 2018--X-N/A
Brooke & Herring, 2016---XN/A
Colella et al., 2017---XHendrich Fall Risk Assessment, Get Up & Go
Connors et al., 2017--X-Risk Assessment adapted from the National Patient Safety Agency
Grealish et al., 2019X---N/A
Laws & Crawford, 2013---XN/A
Weeks, 2011---XN/A
Length of StayBateman et al., 2016---XN/A
Blair et al., 2018---XN/A
Mood/AgitationWaszynski et al., 2013X-XXAgitated Behavior Scale
Wong Shee et al., 2014X---N/A
Medication UseBateman et al., 2016--X-N/A
Blair et al., 2018---XN/A
Improved Patient CareBateman et al., 2016X--XN/A
Blair et al., 2018---XN/A
Brooke et al., 2016---XN/A
Connors et al., 2017X---N/A
Ervin & Moore, 2014X---N/A
Preston & Burch, 2018X---N/A
Waszynski et al., 2013X---N/A
Wong Shee et al., 2014XX--N/A

Staff and Health System-Related Outcomes.

Outcome CategoryPapersStaff PerceptionsEvaluation of Intervention/ProgramEvaluation of Single Time FramePre-Post Measures
Staff-Related Outcomes
Perceptions of Patient SafetyAyton et al., 2017X---
Ervin & Moore, 2014XX--
Grealish et al., 2019X---
Moyle et al., 2011X---
Wasynski et al., 2013X---
Perceptions of Patient Well-BeingBateman et al., 2016-X-X
Connors et al., 2017X---
Moyle et al., 2011X---
Preston & Burch, 2018X---
Staff Work SatisfactionBrooke & Herring, 2016XX--
Colella et al., 2017-X-X
Connors et al., 2017X---
Ervin & Moore, 2014XXX-
Goodwin, 2015--X-
Moyle et al., 2011X---
Preston & Burch, 2018XX--
Waszynski et al., 2013X---
Wong Shee et al., 2014XX--
Health System-Related Outcomes
Change in Rate of Direct ObservationaBlair et al., 2018--X-
aBrooke & Herring, 2016-X-X
bColella et al., 2017---X
bLaws & Crawford, 2013X--X
bWeeks, 2011---X
Change in Care CostsColella et al., 2017---X
Rochefort et al., 2011--X-

Quality Rating of the Included Studies According to Effective Public Health Practice Project's Qualitative Assessment Tool for Quantitative Studies.

Selection BiasStudy DesignConfoundersBlindingData CollectionWithdrawal and DropoutsIntervention IntegrityAnalysisGlobal Rating
Bateman et al., 2016ModerateModerateWeakModerateStrongWeakModerateModerateWeak
Blair et al., 2018ModerateModerateWeakModerateModerateWeakModerateModerateWeak
Brooke & Herring, 2016ModerateWeakN/AWeakWeakWeakModerateModerateWeak
Colella et al., 2017ModerateWeakN/AWeakModerateWeakWeakModerateWeak
Connors et al., 2017ModerateWeakN/AWeakWeakWeakWeakModerateWeak
Goodwin, 2015ModerateWeakN/AWeakWeakWeakWeakModerateWeak
Laws & Crawford, 2013ModerateWeakN/AModerateWeakModerateWeakModerateWeak
Rochefort et al., 2012ModerateModerateN/AModerateStrongN/AModerateModerateModerate
Wasynski et al., 2013ModerateModerateWeakModerateStrongStrongModerateModerateModerate
Weeks, 2011ModerateWeakN/AModerateWeakN/AWeakWeakWeak

Joanna Brigg's Institute Checklist for Qualitative Research Results.

Is there congruity between the stated philosophical perspective and the research methodology?Is there congruity between the research methodology and the research question or objectives?Is there congruity between the research methodology and the methods used to collect data?Is there congruity between the research methodology and the representation and analysis of data?Is there congruity between the research methodology and the interpretation of results?Is there a statement locating the researcher culturally or theoretically?Is the influence of the researcher on the research, and vice versa, addressed?Are participants, and their voices, adequately represented?Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?Score
Ayton, 2017???6
Ervin, 2014??7
Grealish, 2019??8
Moyle, 2010?7
Preston, 20188
Wong Shee, 2014???5
Authors

Dr. Gilmore-Bykovskyi is Assistant Professor, Ms. Fuhr is Research Assistant, Ms. Jin is Program Assistant, and Mr. Benson is Research Specialist, School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin. Dr. Gilmore-Bykovskyi is also Assistant Professor, Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, and Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by the National Institute on Aging of the National Institutes of Health (NIH) (award number K76AG060005 [Gilmore-Bykovskyi]). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The authors acknowledge the contributions of Laura Block for assistance with study review and manuscript formatting.

Address correspondence to Andrea L. Gilmore-Bykovskyi, PhD, RN, Assistant Professor, School of Nursing, University of Wisconsin-Madison, 3173 Cooper Hall, 701 Highland Avenue, Madison, WI 53705; e-mail: algilmore@wisc.edu.

Received: October 16, 2019
Accepted: December 09, 2019

10.3928/00989134-20200313-02

Sign up to receive

Journal E-contents