As an undergraduate nursing student at Duke, I vividly recall preparing for “the dreaded nursing home rotation:” an experience that was widely heralded as involving a LOT of hard work with little reward–the antithesis of the high-tech Duke we all embraced. Our preparation was a combination of “handoffs” from other nursing students regarding the idiosyncrasies of the residents in our care, and, pivotally, a guest lecture from Dr. Virginia Stone about age-related changes in the sensory system and how we could use that knowledge to improve our ability to communicate with these vulnerable older adults. Our predictions about the effort required by the rotation were well-founded; however, no one could have predicted the tremendous impact of that experience on my clinical and research career. For a young health professional-in-training, the nursing home held a treasure trove of lessons about complex chronic illness, family dynamics, and health care policy, and showcased the vital influence of nursing practice on outcomes of care for frail older adults. A student-led elective on successful aging, to which Dr. George Maddox contributed, and a community health rotation in the United Kingdom exposed me to important alternative models of care for frail elders that opened up the possibility of a career in geriatrics where I could make a difference.
After holding a series of clinical positions in both residential long-term care and geriatric community mental health, I joined the faculty of the fledgling Program on Aging at University of North Carolina at Chapel Hill (UNC-CH). There I learned the power of interdisciplinary team collaboration with medicine, social work, and rehabilitation professionals, who worked together to infuse geriatrics content into health professions curricula, provide clinical consultations in primary care, and engage with community partners to provide alternatives to nursing home care – work that I pursue to this day as co-leader of Duke’s newly funded Geriatric Workforce Enhancement Project (GWEP). I launched my research career with Drs. Virginia Neelon and Mary Champagne, as we led the first NIH-funded study at UNC-CH School of Nursing, focused on describing the natural history of acute confusion (delirium) in hospitalized elders. The NEECHAM scale, one of the first clinical measures of delirium was developed during this study, along with additional important insights such as the vulnerability of delirious patients to under-nutrition while hospitalized. Under the mentorship of Dr. Carol Clarke Hogue, I completed my PhD in nursing examining the combined effects of cognitive and physical impairment on disability among nursing homes residents with dementia. During this time, I returned to the “Duke orbit” by accepting a position with Dr. Stephanie Studenski, as a Clinical Nurse Specialist on an inpatient rehabilitation service at the Durham Veterans Affairs (VA) Medical Center, later transitioning to a position within the Durham VA’s Geriatric Research, Education and Clinical Center (GRECC). Today I continue my work at the Durham GRECC as a core investigator. I also serve as a tenured Associate Professor at the Duke University School of Nursing, and Director of the Duke Geriatric Nursing Center of Excellence, a member of the John A. Hartford national CGNE network, a focal point for integrating scholarship in research, education, and clinical practice in nursing care of older adults at Duke. One of the signature accomplishments of the Duke CGNE has been the development of the Duke NICHE (Nurses Improving Care of Health System Elders) programs, in partnership with colleagues in the Duke University Health System.
Two overarching aims drive my current research program: (1) How best to design, implement, and evaluate care approaches to improve the quality of life of older adults who have major neurocognitive disorders, and (2) How best to accelerate the process of implementing scientific discoveries in residential long-term care to improve resident outcomes. To address those aims, I am engaged in a variety of interprofessional research and education teams. Three ongoing studies illustrate how my program of research is unfolding. One study I currently lead focuses on establishing the feasibility of preparing master trainers to teach direct care staff Adaptive Dementia Care skills in governmentally-run nursing homes in the US and in China. Funded by the School of Nursing’s NIH-funded ADAPT Center, this study examines the amount of time required to teach registered nurses how to observe behavior sequences and adapt their care approach based on patient behavioral responses to specific approach and cueing techniques during basic care. Ultimately, the goal is to develop a scalable approach to teaching caregivers essential person-centered dementia care skills, taking into account cultural differences in the dementia care experience. Key collaborators on this study include Cheng Yun, Chief Nursing Officer at Huadong Hospital, one of the top geriatric hospitals in China, and Dr. Bei Wu, Director of International Research at the Duke School of Nursing. This project is helping to lay the foundation for ongoing collaborations between the School of Nursing and other key academic partners, including Duke Kunshan University (DKU) in China.
A second ongoing study, funded by the VA’s Health Services Research and Development (HSR&D) Quality Improvement Research Initiative (QUERI), for which I serve as site-principal investigator, involves a mixed-method, multi-center study, to examine the processes required to implement a home safety toolkit (HST) for Veterans who have dementia. Disciplines involved include advanced practice geriatric nursing, neurology, occupational therapy, and systems engineering. In a prior randomized trial, the HST was effective in improving caregiver self-efficacy and reducing caregiver burden. We are now examining clinical processes to promote rapid dissemination of this toolkit among primary care providers within two regions in the Veterans Health Administration (VHA). The ultimate goal of this work is to understand processes that support rapid adoption of evidence-based dementia care practices within large, integrated health care systems.
A third line of research, conducted in collaboration with Duke School of Nursing faculty colleagues Drs. Kirsten Corazzini and Lisa Day, concerns strengthening nursing practice in nursing homes at the clinical microsystem-level, to prevent avoidable hospitalizations. Building on work supported with funding from the Health Resources and Services Administration (HRSA) that supported a Dementia Grand Challenge to motivate improvements in care of people with dementia by linking continuing education learners, pre-professional learners, and faculty, we were approached by a nursing home corporate leader to assist with teaching nursing staff assessment skills to increase their capacity to prevent avoidable hospitalization among their residents with dementia. Dr. Day, who is an expert in situated learning, developed a continuing education series, using narrative pedagogy and unfolding cases to teach nursing home staff how to more effectively use approaches from INTERACT-II: a national program to prevent avoidable hospitalization. Early results are promising, and have led to a recent NIH submission by Drs. Corazzini and Vogelsmeier (University of Missouri) to study these approaches in a multi-state trial.
My colleagues and I welcome the opportunity to work with undergraduate students, graduate students, post-doctoral fellows, and faculty from a variety of professions and disciplines who share our passion for generating and implementing research-based approaches to address the many challenges facing older adults who live with major neurocognitive disorders and other complex chronic illnesses that lead to a need for long-term care.