October 9, 2012 part 3



Organizational Change
Research Methodology
Health Care in Canada

Organizational Change
Organisational culture and change: implementing person-centred care.
Carlstrom ED, Ekman I.
Journal of health organization and management 2012;26(2):175-191

PURPOSE: The purpose of this paper is to explore the connection between organisational cultures and the employee’s resistance to change at five hospital wards in Western Sweden. Staff had experienced extensive change during a research project implementing person-centred care (PCC) for patients with chronic heart failure. DESIGN/METHODOLOGY/APPROACH: Surveys were sent out to 170 nurses. The survey included two instruments–the Organisational Values Questionnaire (OVQ) and the Resistance to Change Scale (RTC). FINDINGS: The results indicate that a culture with a dominating focus on social competence decreases “routine seeking behaviour”, i.e. tendencies to uphold stable routines and a reluctance to give up old habits. The results indicate that a culture of flexibility, cohesion and trust negatively covariate with the overall need for a stable and well-defined framework. PRACTICAL IMPLICATIONS: An instrument that pinpoints the conditions of a particular healthcare setting can improve the results of a change project. Managers can use instruments such as the ones used in this study to investigate and plan for change processes. ORIGINALITY/VALUE: Earlier studies of organisational culture and its impact on the performance of healthcare organisations have often investigated culture at the highest level of the organisation. In this study, the culture of the production units–i.e. the health workers in different hospital wards–was described. Hospital wards develop their own culture and the cultures of different wards are mirrored in the hospital..

So you want to change practice: recognizing practice issues and channeling those ideas.
Lusardi P.
Critical care nurse 2012 Apr;32(2):55-64

Applying the best evidence to support nursing practice and generating new knowledge for use in practice are the hallmarks of excellence and allow practitioners to meet patient care quality and safety priorities. Although identifying a patient care problem comes easily to staff nurses, the process of clarifying the problem and channeling those ideas through to a practice change can be daunting for bedside nurses. This article provides guidance to staff nurses who want to identify a clinical problem and change practice..

Evidence-based practice models for organizational change: overview and practical applications.
Schaffer MA, Sandau KE, Diedrick L.
Journal of advanced nursing 2012 Aug 9

AIM: To provide an overview, summary of key features and evaluation of usefulness of six evidence-based practice models frequently discussed in the literature. BACKGROUND: The variety of evidence-based practice models and frameworks, complex terminology and organizational culture challenges nurses in selecting the model that best fits their practice setting. DATA SOURCES: The authors: (1) initially identified models described in a predominant nursing text; (2) searched the literature through CINAHL from 1998 to current year, using combinations of ‘evidence’, ‘evidence-based practice’, ‘models’, ‘nursing’ and ‘research’; (3) refined the list of selected models based on the initial literature review; and (4) conducted a second search of the literature on the selected models for all available years to locate both historical and recent articles on their use in nursing practice. DISCUSSION: Authors described model key features and provided an evaluation of model usefulness based on specific criteria, which focused on facilitating the evidence-based practice process and guiding practice change. IMPLICATIONS FOR NURSING: The evaluation of model usefulness can be used to determine the best fit of the models to the practice setting. CONCLUSION: The Johns Hopkins Model and the Academic Center for Evidence-Based Practice Star Model emphasize the processes of finding and evaluating evidence that is likely to appeal to nursing educators. Organizations may prefer the Promoting Action on Research Implementation in Health Services Framework, Advancing Research and Clinical Practice Through Close Collaboration, or Iowa models for their emphasis on team decision-making. An evidence-based practice model that is clear to the clinician and fits the organization will guide a systematic approach to evidence review and practice change. © 2012 Blackwell Publishing Ltd.

Research Methodology
Characteristics of clinical trials registered in ClinicalTrials.gov, 2007-2010.
Califf RM, Zarin DA, Kramer JM, Sherman RE, Aberle LH, Tasneem A.
JAMA : the journal of the American Medical Association 2012 May 2;307(17):1838-1847

CONTEXT: Recent reports highlight gaps between guidelines-based treatment recommendations and evidence from clinical trials that supports those recommendations. Strengthened reporting requirements for studies registered with ClinicalTrials.gov enable a comprehensive evaluation of the national trials portfolio. OBJECTIVE: To examine fundamental characteristics of interventional clinical trials registered in the ClinicalTrials.gov database. METHODS: A data set comprising 96,346 clinical studies from ClinicalTrials.gov was downloaded on September 27, 2010, and entered into a relational database to analyze aggregate data. Interventional trials were identified and analyses were focused on 3 clinical specialties-cardiovascular, mental health, and oncology-that together encompass the largest number of disability-adjusted life-years lost in the United States. MAIN OUTCOME MEASURES: Characteristics of registered clinical trials as reported data elements in the trial registry; how those characteristics have changed over time; differences in characteristics as a function of clinical specialty; and factors associated with use of randomization, blinding, and data monitoring committees (DMCs). RESULTS: The number of registered interventional clinical trials increased from 28,881 (October 2004-September 2007) to 40,970 (October 2007-September 2010), and the number of missing data elements has generally declined. Most interventional trials registered between 2007 and 2010 were small, with 62% enrolling 100 or fewer participants. Many clinical trials were single-center (66%; 24,788/37,520) and funded by organizations other than industry or the National Institutes of Health (NIH) (47%; 17,592/37,520). Heterogeneity in the reported methods by clinical specialty; sponsor type; and the reported use of DMCs, randomization, and blinding was evident. For example, reported use of DMCs was less common in industry-sponsored vs NIH-sponsored trials (adjusted odds ratio [OR], 0.11; 95% CI, 0.09-0.14), earlier-phase vs phase 3 trials (adjusted OR, 0.83; 95% CI, 0.76-0.91), and mental health trials vs those in the other 2 specialties. In similar comparisons, randomization and blinding were less frequently reported in earlier-phase, oncology, and device trials. CONCLUSION: Clinical trials registered in ClinicalTrials.gov are dominated by small trials and contain significant heterogeneity in methodological approaches, including reported use of randomization, blinding, and DMCs.

T-Tests, Non-Parametric Tests, and Large Studies-a Paradox of Statistical Practice?
Fagerland MW.
BMC medical research methodology 2012 Jun 14;12:78

BACKGROUND: During the last 30 years, the median sample size of research studies published in high-impact medical journals has increased manyfold, while the use of non-parametric tests has increased at the expense of t-tests. This paper explores this paradoxical practice and illustrates its consequences. METHODS: A simulation study is used to compare the rejection rates of the Wilcoxon-Mann-Whitney (WMW) test and the two-sample t-test for increasing sample size. Samples are drawn from skewed distributions with equal means and medians but with a small difference in spread. A hypothetical case study is used for illustration and motivation. RESULTS: The WMW test produces, on average, smaller p-values than the t-test. This discrepancy increases with increasing sample size, skewness, and difference in spread. For heavily skewed data, the proportion of p<0.05 with the WMW test can be greater than 90% if the standard deviations differ by 10% and the number of observations is 1000 in each group. The high rejection rates of the WMW test should be interpreted as the power to detect that the probability that a random sample from one of the distributions is less than a random sample from the other distribution is greater than 50%. CONCLUSIONS: Non-parametric tests are most useful for small studies. Using non-parametric tests in large studies may provide answers to the wrong question, thus confusing readers. For studies with a large sample size, t-tests and their corresponding confidence intervals can and should be used even for heavily skewed data.

Investigating clinical heterogeneity in systematic reviews: a methodologic review of guidance in the literature.
Gagnier JJ, Moher D, Boon H, Beyene J, Bombardier C.
BMC medical research methodology 2012 Jul 30;12(1):111

BACKGROUND: While there is some consensus on methods for investigating statistical and methodological heterogeneity, little attention has been paid to clinical aspects of heterogeneity. The objective of this study is to summarize and collate suggested methods for investigating clinical heterogeneity in systematic reviews. METHODS: We searched databases (Medline, EMBASE, CINAHL, Cochrane Library, and CONSORT, to December 2010) and reference lists and contacted experts to identify resources providing suggestions for investigating clinical heterogeneity between controlled clinical trials included in systematic reviews. We extracted recommendations, assessed resources for risk of bias, and collated the recommendations. RESULTS: One hundred and one resources were collected, including narrative reviews, methodological reviews, statistical methods papers, and textbooks. These resources generally had a low risk of bias, but there was minimal consensus among them. Resources suggested that planned investigations of clinical heterogeneity should be made explicit in the protocol of the review; clinical experts should be included on the review team; a set of clinical covariates should be chosen considering variables from the participant level, intervention level, outcome level, research setting, or others unique to the research question; covariates should have a clear scientific rationale; there should be a sufficient number of trials per covariate; and results of any such investigations should be interpreted with caution. CONCLUSIONS: Though the consensus was minimal, there were many recommendations in the literature for investigating clinical heterogeneity in systematic reviews. Formal recommendations for investigating clinical heterogeneity in systematic reviews of controlled trials are required.

Do incentives, reminders or reduced burden improve healthcare professional response rates in postal questionnaires? two randomised controlled trials.
Glidewell LD, Thomas RD, Maclennan GM, Bonetti DD, Johnston MP, Eccles MP P, et al.
BMC health services research 2012 Aug 14;12(1):250

BACKGROUND: Healthcare professional response rates to postal questionnaires are declining and this may threaten the validity and generalisability of their findings. Methods to improve response rates do incur costs (resources) and increase the cost of research projects. The aim of these randomised controlled trials (RCTs) was to assess whether 1) incentives, 2) type of reminder and/or 3) reduced response burden improve response rates; and to assess the cost implications of such additional effective interventions. METHODS: Two RCTs were conducted. In RCT A general dental practitioners (dentists) in Scotland were randomised to receive either an incentive; an abridged questionnaire or a full length questionnaire. In RCT B non-responders to a postal questionnaire sent to general medical practitioners (GPs) in the UK were firstly randomised to receive a second full length questionnaire as a reminder or a postcard reminder. Continued non-responders from RCT B were then randomised within their first randomisation to receive a third full length or an abridged questionnaire reminder. The cost-effectiveness of interventions that effectively increased response rates was assessed as a secondary outcome. RESULTS: There was no evidence that an incentive (52% versus 43%, Risk Difference (RD) -8.8 (95%CI [MINUS SIGN]22.5, 4.8); or abridged questionnaire (46% versus 43%, RD [MINUS SIGN]2.9 (95%CI [MINUS SIGN]16.5, 10.7); statistically significantly improved dentist response rates compared to a full length questionnaire in RCT A. In RCT B there was no evidence that a full questionnaire reminder statistically significantly improved response rates compared to a postcard reminder (10.4% versus 7.3%, RD 3 (95%CI [MINUS SIGN]0.1, 6.8). At a second reminder stage, GPs sent the abridged questionnaire responded more often (14.8% versus 7.2%, RD [MINUS SIGN]7.7 (95%CI [MINUS SIGN]12.8, -2.6). GPs who received a postcard reminder followed by an abridged questionnaire were most likely to respond (19.8% versus 6.3%, RD 8.1%, and 9.1% for full/postcard/full, three full or full/full/abridged questionnaire respectively). An abridged questionnaire containing fewer questions following a postcard reminder was the only cost-effective strategy for increasing the response rate ([POUND SIGN]15.99 per response). CONCLUSIONS: When expecting or facing a low response rate to postal questionnaires, researchers should carefully identify the most efficient way to boost their response rate. In these studies, an abridged questionnaire containing fewer questions following a postcard reminder was the only cost-effective strategy. An increase in response rates may be explained by a combination of the number and type of contacts. Increasing the sampling frame may be more cost-effective than interventions to prompt non-responders. However, this may not strengthen the validity and generalisability of the survey findings and affect the representativeness of the sample.

A systematic mapping review of Randomized Controlled Trials (RCTs) in care homes.
Gordon AL, Logan PA, Jones RG, Forrester-Paton C, Mamo JP, Gladman JR.
BMC geriatrics 2012 Jun 25;12(1):31

BACKGROUND: A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes. METHODS: A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results. RESULTS: 3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health. CONCLUSIONS: This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas – influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

What is the most appropriate knowledge synthesis method to conduct a review? Protocol for a scoping review.
Kastner M, Tricco AC, Soobiah C, Lillie E, Perrier L, Horsley T, et al.
BMC medical research methodology 2012 Aug 3;12(1):114

BACKGROUND: A knowledge synthesis attempts to summarize all pertinent studies on a specific question, can improve the understanding of inconsistencies in diverse evidence, and can identify gaps in research evidence to define future research agendas. Knowledge synthesis activities in healthcare have largely focused on systematic reviews of interventions. However, a wider range of synthesis methods has emerged in the last decade addressing different types of questions (e.g., realist synthesis to explore mediating mechanisms and moderators of interventions). Many different knowledge synthesis methods exist in the literature across multiple disciplines, but locating these, particularly for qualitative research, present challenges. There is a need for a comprehensive manual for synthesis methods (quantitative/qualitative or mixed), outlining how these methods are related, and how to match the most appropriate knowledge synthesis method to answer a research question. The objectives of this scoping review are to: 1) conduct a systematic search of the literature for knowledge synthesis methods across multi-disciplinary fields; 2) compare and contrast the different knowledge synthesis methods; and, 3) map out the specific steps to conducting the knowledge syntheses to inform the development of a knowledge synthesis methods manual/tool. METHODS: We will search relevant electronic databases (e.g., MEDLINE, CINAHL), grey literature, and discipline-based listservs. The scoping review will consider all study designs including qualitative and quantitative methodologies (excluding economic analysis or clinical practice guideline development), and identify knowledge synthesis methods across the disciplines of health, education, sociology, and philosophy. Two reviewers will pilot-test the screening criteria and data abstraction forms, and will independently screen the literature and abstract the data. A three-step synthesis process will be used to map the literature to our objectives. DISCUSSION: This project represents the first attempt to broadly and systematically identify, define and classify knowledge synthesis methods (i.e., less traditional knowledge synthesis methods). We anticipate that our results will lead to an accepted taxonomy for less traditional knowledge synthesis methods, and to the development and implementation of a methods manual for these reviews which will be relevant to a wide range of knowledge users, including researchers, funders, and journal editors.

Evaluation of the propensity score methods for estimating marginal odds ratios in case of small sample size.
Pirracchio R, Resche Rigon M, Chevret S.
BMC medical research methodology 2012 May 30;12(1):70

BACKGROUND: Propensity score (PS) methods are increasingly used, even when sample sizes are small or treatments are seldom used. However, the relative performance of the two mainly recommended PS methods, namely PS-matching or inverse probability of treatment weighting (IPTW), have not been studied in the context of small sample sizes. METHODS: We conducted a series of Monte Carlo simulations to evaluate the influence of sample size, prevalence of treatment exposure, and strength of the association between the variables and the outcome and/or the treatment exposure, on the performance of these two methods. RESULTS: Decreasing the sample size from 1,000 to 40 subjects did not substantially alter the Type I error rate, and led to relative biases below 10 %. The IPTW method performed better than the PS-matching down to 60 subjects. When N was set at 40, the PS matching estimators were either similarly or even less biased than the IPTW estimators. Including variables unrelated to the exposure but related to the outcome in the PS model decreased the bias and the variance as compared to models omitting such variables. Excluding the true confounder from the PS model resulted, whatever the method used, in a significantly biased estimation of treatment effect. These results were illustrated in a real dataset. CONCLUSION: Even in case of small study samples or low prevalence of treatment, PS-matching and IPTW can yield correct estimations of treatment effect unless the true confounders and the variables related only to the outcome are not included in the PS model.

Writing usable qualitative health research findings.

Sandelowski M, Leeman J.

Qualitative health research 2012 Oct;22(10):1404-1413

Scholars in diverse health-related disciplines and specialty fields of practice routinely promote qualitative research as an essential component of intervention and implementation programs of research and of a comprehensive evidence base for practice. Remarkably little attention, however, has been paid to the most important element of qualitative studies-the findings in reports of those studies-and specifically to enhancing the accessibility and utilization value of these findings for diverse audiences of users. The findings in reports of qualitative health research are too often difficult to understand and even to find owing to the way they are presented. A basic strategy for enhancing the presentation of these findings is to translate them into thematic statements, which can then in turn be translated into the language of intervention and implementation. Writers of qualitative health research reports might consider these strategies better to showcase the significance and actionability of findings to a wider audience.
Mapping the Mixed Methods–Mixed Research Synthesis Terrain. 
Sandelowski M, Voils CI, Leeman J, Crandell JL. 
Journal of Mixed Methods Research 2012 October 01;6(4):317-331 
Mixed methods–mixed research synthesis is a form of systematic review in which the findings of qualitative and quantitative studies are integrated via qualitative and/or quantitative methods. Although methodological advances have been made, efforts to differentiate research synthesis methods have been too focused on methods and not focused enough on the defining logics of research synthesis—each of which may be operationalized in different ways—or on the research findings themselves that are targeted for synthesis. The conduct of mixed methods–mixed research synthesis studies may more usefully be understood in terms of the logics of aggregation and configuration. Neither logic is preferable to the other nor tied exclusively to any one method or to any one side of the qualitative/quantitative binary.

Research data collection methods: from paper to tablet computers.
Wilcox AB, Gallagher KD, Boden-Albala B, Bakken SR.
Medical care 2012 Jul;50 Suppl:S68-73

BACKGROUND: Primary data collection is a critical activity in clinical research. Even with significant advances in technical capabilities, clear benefits of use, and even user preferences for using electronic systems for collecting primary data, paper-based data collection is still common in clinical research settings. However, with recent developments in both clinical research and tablet computer technology, the comparative advantages and disadvantages of data collection methods should be determined. OBJECTIVE: To describe case studies using multiple methods of data collection, including next-generation tablets, and consider their various advantages and disadvantages. MATERIALS AND METHODS: We reviewed 5 modern case studies using primary data collection, using methods ranging from paper to next-generation tablet computers. We performed semistructured telephone interviews with each project, which considered factors relevant to data collection. We address specific issues with workflow, implementation and security for these different methods, and identify differences in implementation that led to different technology considerations for each case study. RESULTS AND DISCUSSION: There remain multiple methods for primary data collection, each with its own strengths and weaknesses. Two recent methods are electronic health record templates and next-generation tablet computers. Electronic health record templates can link data directly to medical records, but are notably difficult to use. Current tablet computers are substantially different from previous technologies with regard to user familiarity and software cost. The use of cloud-based storage for tablet computers, however, creates a specific challenge for clinical research that must be considered but can be overcome.

Mining the Management Literature for Insights into Implementing Evidence-Based Change in Healthcare.
Karen Harlos, Jacqueline Tetroe, Ian D Graham, Madeleine Bird and Nicole Robinson.
Healthcare Policy 2012 08/21;8(1):33-48

Objective: We synthesized the management and health literatures for insights into implementing evidence-based change in healthcare drawn from industry-specific data. Because change principles based on evidence often fail to be translated into organizational practice or policy, we sought studies at the nexus of organizational change and knowledge translation.
Methods: We reviewed five top management journals to identify an initial pool of 3,091 studies, which yielded a final sample of 100 studies. Data were abstracted, verified by the original authors and revised before entry into a database. We employed a systematic narrative synthesis approach using words and text to distill data and explain relationships. We categorized studies by varying levels of relevance for knowledge translation as (1) primary, direct; (2) intermediate; and (3) secondary, indirect. We also identified recurring categories of change-related organizational factors. The current analysis examines these factors in studies of primary relevance to knowledge translation, which we also coded for intervention readiness to reflect how readily change can be implemented. Preliminary Results and Conclusions: Results centred on five change-related categories: Tailoring the Intervention Message; Institutional Links/Social Networks; Training; Quality of Work Relationships; and Fit to Organization. In particular, networks across institutional and individual levels appeared as prominent pathways for changing healthcare organizations. Power dynamics, positive social relations and team structures also played key roles in implementing change and translating it into practice. We analyzed journals in which first authors of these studies typically publish, and found evidence that management and health sciences remain divided. Bridging these disciplines through research syntheses promises a wealth of evidence and insights, well worth mining in the search for change that works in healthcare transformation.

Decisions about lumping vs. splitting of the scope of systematic reviews of complex interventions are not well justified: a case study in systematic reviews of health care professional reminders.
Weir MC, Grimshaw JM, Mayhew A, Fergusson D.
Journal of clinical epidemiology 2012 Jul;65(7):756-763

OBJECTIVES: Lumping and splitting refer to the scope of a systematic review question, where lumped reviews are broad and split are narrow. The objective was to determine the frequency of lumping and splitting in systematic reviews of reminder interventions, assess how review authors justified their decisions about the scope of their reviews, and explore how review authors cited other systematic reviews in the field. STUDY DESIGN AND SETTING: A descriptive approach involving a content analysis and citation bibliometric study of an overview of 31 systematic reviews of reminder interventions. RESULTS: Twenty-four of 31 reminder reviews were split, most frequently across one category (population, intervention, study design, outcome). Review authors poorly justified their decisions about the scope of their reviews and tended not to cite other similar reviews. CONCLUSION: This study demonstrates that for systematic reviews of reminder interventions, splitting is more common than lumping, with most reviews split by condition or targeted behavior. Review authors poorly justify the need for their review and do not cite relevant literature to put their reviews in the context of the available evidence. These factors may have contributed to a proliferation of systematic reviews of reminders and an overall disorganization of the literature.

An analysis of existing publications to explore the use of the diffusion of innovations theory and innovation attributes.
Kapoor K, Williams M, Dwivedi Y, Lal B.
2011 World Congress On Information & Communication Technologies (WICT)

‘Diffusion of Innovations’ is a theory that explicates the process of introducing new ideas (i.e. technological innovation) into a system via varied channels of communication. The purpose of this paper is to undertake a systematic review of the available literature to examine the current advances in the Diffusion Of Innovations (DOI) theory. The focus remains more inclined towards the diffusion attributes. ISI Web of Knowledge ® and Google Scholar were the two rigorously used search engines for our study. These engines fectched a total of 2073 published records that cited Rogers’ Diffusion of Innovation theory. Some of these publications were found to be available for download. Upon conducting a further search, 1145 published records were found to have used the 28 innovation attributes that were identified in a previous article on this subject. Statistical filtering then showed complexity to be the highly used attribute with 834 records having cited this attribute. Further review showed that all the five attributes adopted from Rogers’ work of study, represented the most frequently employed attributes for examining the rate of innovation adoption. © 2011 IEEE.

Health Care in Canada
Development of an interactive model for planning the care workforce for Alberta: case study.
Bloom J, Duckett S, Robertson A. 
Human resources for health 2012 Aug 20;10(1):22

INTRODUCTION: In common with other jurisdictions, Alberta faces challenges in ensuring a balance in health worker supply and demand. As the provider organization with province-wide responsibility, Alberta Health Services needed to develop a forecasting tool to inform its position on key workforce parameters, in the first instance focused on modeling the situation for Registered Nurses, Licensed Practical Nurses and health care aides. This case study describes the development of the model, highlighting the choices involved in model development. Case description A workforce planning model was developed to test the effect of different assumptions (for instance about vacancy rates or retirement) and different policy choices (for example about the size of intakes into universities and colleges, different composition of the workforce). This case study describes the choices involved in designing the model. The workforce planning model was used as part of a consultation process and to develop six scenarios (based on different policy choices). Discussion and evaluation The model outputs highlighted the problems with continuation of current workforce strategies and the impact of key policy choices on workforce parameters. CONCLUSIONS: Models which allow for transparency of the underlying assumptions, and the ability to assess the sensitivity of assumptions and the impact of policy choices are required for effective workforce planning.

Saskatchewan: improving patient, nursing and organizational outcomes utilizing formal nurse-patient ratios.
Rozdilsky J, Alecxe A.
Nursing leadership (Toronto, Ont.) 2012 Mar;25 Spec No 2012:103-113

The issue of nurse-to-patient ratios has been of significant interest to nurses in Saskatchewan. A commitment to a nurse-to-patient pilot project was articulated in a letter of understanding in the 2005 to 2008 contract between the Saskatchewan Union of Nurses (SUN) and the Saskatchewan Association of Health Organizations. The SUN, the Saskatoon Health Region and the Saskatchewan Ministry of Health formed a partnership to engage in the pilot project, which lasted from November 2008 to March 2011. The project involved the creation of a flexible, dynamic and real-time staffing tool to inform day-to-day nurse staffing decisions on a hospital unit and was based on an adaptation of Curley’s Synergy Model. A medical unit at St. Paul’s Hospital in Saskatoon was selected for implementation, and all front-line nursing staff as well as unit nursing leaders were involved. A project working group adapted the Synergy-based Patient Scoring Tool (PST), which had been utilized for a recent project in British Columbia, to its own patient population. In April 2010, nurses began assessing each patient on every shift with the goal of determining the most suitable care provider. Patient assignment became based on the holistic assessment of patient needs according to the PST results rather than “geography” (for example, one nurse assigned to a multi-bed unit regardless of the acuity/capability of patients in the unit). Whenever possible, staffing on the unit was increased according to tool calculations.Positive impacts in patient outcomes began to be noted during the final data collection period for the project – nosocomial infection rates showed improvement, and the number of falls per patient-days decreased. As well, patient needs were made more visible through use of the PST, which created non-threatening opportunities for dialogue related to legislated scopes of practice. While longer timelines and larger sample size are needed to measure impacts on retention and recruitment of nurses, nurses in the project demonstrated increased engagement over the study period. The tools and processes developed in this project are adaptable to other patient populations and care settings.

Eliminating the shortage of registered nurses in Canada: an exercise in applied needs-based planning.
Tomblin Murphy G, Birch S, MacKenzie A, Alder R, Lethbridge L, Little L.
Health policy (Amsterdam, Netherlands) 2012 May;105(2-3):192-202

OBJECTIVE: To demonstrate the application of a needs-based framework for health human resources (HHR) planning to illustrate the potential effects of policies on the shortage of Registered Nurses (RNs) in Canada. METHODS: A simulation model was developed to simultaneously estimate the supply of and requirements for RNs based on data on the health needs of Canadians with current service delivery patterns and levels of productivity as a baseline scenario. The potential individual and cumulative effects of various policy scenarios on the ‘gap’ between these were simulated. RESULTS: A baseline scenario estimated a shortage of about 11,000 RN FTEs in 2007 for Canada, increasing to over 60,000 by 2022. However, multifaceted approaches have the potential to eliminate the estimated shortage. CONCLUSIONS: Estimating the requirements for health human resources must explicitly consider population health needs, levels of service delivery and HHR productivity while changing supply to meet requirements involves consideration of a broad range of comprehensive interventions. Investments in improved data collection and planning tools are needed to support more effective HHR planning. The estimated Canadian shortage of RNs based on current circumstances can be resolved in the short to medium tern through modest improvements in RN retention, activity and productivity. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Living well in care homes: a systematic review of qualitative studies.
Bradshaw SA, Playford ED, Riazi A.
Age and Ageing 2012 Jul;41(4):429-440

BACKGROUND: research in care home settings is often negatively focused, portraying life as sterile and devoid of meaningful experiences. Care homes have the potential to influence people’s lives socially, physically and psychologically. It is important to understand what factors contribute to this. OBJECTIVE: to conduct a systematic qualitative review of care home life and provide practical recommendations to enhance residents’ quality of life. METHODS: the following databases were searched: PsycINFO, Medline, Web of Science, EMBASE, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature. References from appropriate journals and individual articles were checked. Papers that fitted our selection criteria were selected. Two independent reviewers assessed methodological study quality. Thematic analysis and meta-ethnographic methods were adapted to synthesise findings. RESULTS: thirty-one studies were identified. People in care homes voiced concerns about lack of autonomy and difficulty in forming appropriate relationships with others. Four key themes were identified: (i) acceptance and adaptation, (ii) connectedness with others, (iii) a homelike environment, (iv) caring practices. CONCLUSION: positive experiences in care homes can occur and are important for residents’ quality of life. The review supports literature highlighting the need for relationship-centred approaches to care and emphasises the importance of understanding the resident’s attitude towards living in care homes.

Resident-to-Resident Abuse in Nursing Homes as Reported by Nurse Aides.
Castle NG.
Journal of Elder Abuse & Neglect 2012 Oct;24(4):340-356

Information on the scale and scope of resident-to-resident abuse, including verbal, physical, material, psychological, and sexual abuse, is presented. Nursing homes (n = 249) from ten states were used, with a total of 4,451 nurse aides in these facilities returning the questionnaire. Most nursing homes experienced verbal, physical, material, and psychological abuse, but sexual abuse was less common. Our findings clearly show that both the scale and scope of resident-to-resident abuse is high in nursing homes. Resident-to-resident abuse is common enough to be considered an issue of concern impacting the quality of life and safety of many residents.

A pilot randomized controlled trial to improve geriatric frailty.
Chan DC, Tsou HH, Yang RS, Tsauo JY, Chen CY, Hsiung CA, et al.
BMC geriatrics 2012 Sep 25;12(1):58

BACKGROUND: Few randomized controlled trials (RCTs) report interventions targeting improvement of frailty status as an outcome. METHODS: This RCT enrolled 117 older adults (65-79 years of age) in Toufen, Taiwan who scored 3-6 on The Chinese Canadian Study of Health and Aging Clinical Frailty Scale Telephone Version and then score >=1 on the Cardiovascular Health Study Phenotypic Classification of Frailty (CHS_PCF). With a two by two factorial design, subjects were randomly assigned to interventions (Exercise and nutrition, EN, n = 55 or problem solving therapy, PST, n = 57) or controls (non-EN, n = 62 or non-PST, n = 60). Educational booklets were provided to all. EN group subjects received nutrition consultation and a thrice-weekly exercise-training program while PST group subjects received 6 sessions in 3 month. Subjects were followed at 3, 6, and 12 months. Primary outcome was improvement of the CHS_PCF by at least one category (from pre-frail to robust, or from frail to pre-frail or robust) from baseline assessments. One hundred and one completed final assessments. Intention-to-treat analysis with the generalized estimating equation model was applied with adjustment for time and treatment-by-time interactions. RESULTS: Mean age was 71.4 +/- 3.7 years, with 59% females. Baseline characteristic were generally comparable between groups. EN group subjects had a higher improvement rate on the primary outcome than non-EN group subjects (45% vs 27%, adjusted p = 0.008) at 3 months, but not 6 or 12 months. They also had more increase of serum 25(OH) vitamin D level (4.9 +/- 7.7 vs 1.2 +/- 5.4, p = 0.006) and lower percentage of osteopenia (74% vs 89% p = 0.042) at 12 months. PST group subjects had better improvement (2.7 +/- 6.1 vs 0.2 +/- 6.7, p = 0.035, 6-month) and less deterioration (-3.5 +/- 9.7 vs -7.1 +/- 8.7, p = 0.036, 12-month) of dominant leg extension power than non-PST subjects. Some secondary outcomes were also improved in control groups (non-EN or non-PST). No adverse effects were reported. CONCLUSIONS: The three-month EN intervention resulted in short-term (3-month) frailty status improvement and long-term effect on bone mineral density and serum vitamin D (12-month) among Taiwanese community-dwelling elders. The effect of PST was less pronounce.Trial registrationClinicalTrials.gov: EC0970301.

Older adults’ home- and community-based care service use and residential transitions: a longitudinal study.
Chen YM, Berkowitz B.
BMC geriatrics 2012 Aug 10;12:44

BACKGROUND: As Home-and Community-Based Services (HCBS), such as skilled nursing services or personal care services, have become increasingly available, it has become clear that older adults transit through different residential statuses over time. Older adults may transit through different residential statuses as the various services meet their needs. The purpose of this exploratory study was to better understand the interplay between community-dwelling older adults’ use of home- and community-based services and their residential transitions. METHODS: The study compared HCBS service-use patterns and residential transitions of 3,085 older adults from the Second Longitudinal Study of Aging. Based on older adults’ residential status at the three follow-up interviews, four residential transitions were tracked: (1) Community-Community-Community (CCC: Resided in community during the entire study period); (2) Community-Institution-Community (CIC: Resided in community at T1, had lived in an institution at some time between T1 and T2, then had returned to community by T3); (3) Community-Community-Institution (CCI: Resided in community between at T1, and betweenT1 and T2, including at T2, but had used institutional services between T2 and T3); (4) Community-Institution-Institution (CII: Resided in community at T1 but in an institution at some time between T1 and T2, and at some time between T2 and T3.). RESULTS: Older adults’ use of nondiscretionary and discretionary services differed significantly among the four groups, and the patterns of HCBS use among these groups were also different. Older adults’ use of nondiscretionary services, such as skilled nursing care, may help them to return to communities from institutions. Personal care services (PCS) and senior center services may be the key to either support elders to stay in communities longer or help elders to return to their communities from institutions. Different combinations of PCS with other services, such as senior center services or meal services, were associated with different directions in residential transition, such as CIC and CII respectively. CONCLUSIONS: Older adults’ differing HCBS use patterns may be the key to explaining older adults’ transitions. Attention to older adults’ HCBS use patterns is recommended for future practice. However, this was an exploratory study and the analyses cannot establish causal relationships.

The relationship between quality of life, health and care transition: an empirical comparison in an older post-acute population.
Couzner L, Ratcliffe J, Crotty M.
Health and quality of life outcomes 2012 Jun 15;10:69

BACKGROUND: The aim of this study was to explore, via empirical comparison, the relationship between quality of life, as measured by the ICECAP-O capability index (a new instrument designed to measure and value quality of life in older people), with both self-reported health status and the quality of care transition in adults aged 65 and over participating in two post acute rehabilitation programs (outpatient day rehabilitation and the Australian National Transition Care residential program). METHODS: The ICECAP-O was administered to patients receiving either outpatient day rehabilitation (n = 53) or residential transition care (n = 29) during a face to face interview. The relationships between the ICECAP-O and other instruments, including the EQ-5D (a self-reported measure of health status) and CTM-3 (a self-reported measure of the quality of care transitions), the type of post-acute care being received and socio-demographic characteristics were examined. RESULTS: The mean ICECAP-O score for the total sample was 0.81 (SD: 0.15). Patients receiving outpatient day rehabilitation generally reported higher levels of capability, than patients receiving residential transition care (mean 0.82 [SD: 0.15] and 0.79 [SD: 0.164] respectively), however these differences were not statistically significant. The mean EQ-5D score for the total sample was somewhat lower than the ICECAP-O (mean 0.55; SD: 0.27) indicating significant levels of health impairment with the outpatient day rehabilitation group demonstrating slightly higher levels of health status than the transition care group (mean 0.54 [SD: 0.254] and mean 0.49 [SD: 0.30]). The ICECAP-O was found to be positively correlated with both the CTM-3 (Spearman’s r =0.234; p </= 0.05) and the EQ-5D (Spearman's r = 0.437; p </= 0.001). The relationships between the total EQ-5D and CTM-3 scores and the individual attributes of the ICECAP-O indicate health status and quality of care transition in this patient population to be influential in some, but not all aspects of capability. CONCLUSIONS: The correlations between the ICECAP-O, EQ-5D and CTM-3 instruments illustrate that capability is strongly and positively associated with health-related quality of life and the quality of care transitions. However further research is required to further examine the construct validity of the ICECAP-O and to examine its potential for incorporation into economic evaluation.

Profiling the multidimensional needs of new nursing home residents: evidence to support planning.
Doupe M, St John P, Chateau D, Strang D, Smele S, Bozat-Emre S, et al.
Journal of the American Medical Directors Association 2012 Jun;13(5):487.e9-487.17

INTRODUCTION: Nursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas. METHODS: Research was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents’ needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges. RESULTS: Of our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges. CONCLUSIONS: Overall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents’ needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Environmental determinants of quality of life in nursing home residents with severe dementia.
Garre-Olmo J, Lopez-Pousa S, Turon-Estrada A, Juvinya D, Ballester D, Vilalta-Franch J.
Journal of the American Geriatrics Society 2012 Jul;60(7):1230-1236

OBJECTIVES: To determine the relationship between quality of life (QOL) and environmental factors of temperature, noise, and lighting in nursing home residents with severe dementia. DESIGN: Cross-sectional, observational, analytical. SETTING: Eight public, long-term care nursing homes in the province of Girona, Spain. PARTICIPANTS: Random sample of 160 nursing home residents with severe dementia. MEASUREMENTS: Functional and cognitive impairment, pain, neuropsychiatric disturbances, and QOL were determined using standardized instruments. Temperature, noise, and lighting in bedrooms, dining rooms, and living rooms were measured in the morning and afternoon using a multifunction environment meter in a standardized manner. RESULTS: Adjusted multivariate linear regression models demonstrated that environmental measures were independently associated with QOL and related factors. High temperature in the bedroom was associated with lower QOL (standardized beta = 0.184), high noise levels in the living room were associated with low behavioral signs of social interactions (beta = 0.196), and low lighting levels in the bedroom were associated with number of signs of negative affective mood (beta = -0.135). CONCLUSION: The QOL of nursing home residents with severe dementia was related to environmental factors such as temperature, noise, and lighting. The monitoring of these environmental factors may improve these individuals’ QOL. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Testing an integral conceptual model of frailty.
Gobbens RJ, van Assen MA, Luijkx KG, Schols JM.
Journal of advanced nursing 2012 Sep;68(9):2047-2060

AIM: This paper is a report of a study conducted to test three hypotheses derived from an integral conceptual model of frailty. BACKGROUND: The integral model of frailty describes the pathway from life-course determinants to frailty to adverse outcomes. The model assumes that life-course determinants and the three domains of frailty (physical, psychological, social) affect adverse outcomes, the effect of disease(s) on adverse outcomes is mediated by frailty, and the effect of frailty on adverse outcomes depends on the life-course determinants. METHODS: In June 2008 a questionnaire was sent to a sample of community-dwelling people, aged 75 years and older (n = 213). Life-course determinants and frailty were assessed using the Tilburg frailty indicator. Adverse outcomes were measured using the Groningen activity restriction scale, the WHOQOL-BREF and questions regarding healthcare utilization. The effect of seven self-reported chronic diseases was examined. RESULTS: Life-course determinants, chronic disease(s), and frailty together explain a moderate to large part of the variance of the seven continuous adverse outcomes (26-57%). All these predictors together explained a significant part of each of the five dichotomous adverse outcomes. The effect of chronic disease(s) on all 12 adverse outcomes was mediated at least partly by frailty. The effect of frailty domains on adverse outcomes did not depend on life-course determinants. CONCLUSION: Our finding that the adverse outcomes are differently and uniquely affected by the three domains of frailty (physical, psychological, social), and life-course determinants and disease(s), emphasizes the importance of an integral conceptual model of frailty.

Creating a quality of life assessment measure for residents in long term care.
Iris M, DeBacker NA, Benner R, Hammerman J, Ridings J.

Journal of the American Medical Directors Association 2012 Jun;13(5):438-447

OBJECTIVES: The objectives of this study were to (1) gain an empirical understanding of how stakeholder (residents, family members, staff) groups view quality of life (QoL) for residents in long term care; (2) create a visual map of the domain of QoL and describe differences in importance of key elements; and (3) identify key elements of QoL that could be used to develop a standardized assessment instrument for use in person-centered care planning. DESIGN: This is a descriptive study, using a mixed-method, qualitative/quantitative approach called “concept mapping.” SETTING: The study was conducted at a 240-bed skilled nursing facility located in a major metropolitan area. It is part of a not-for-profit religiously affiliated social service organization. PARTICIPANTS: A convenience sample included 3 groups of participants: staff members, family members of residents, and residents. Fifty-three people participated in the brain-storming sessions, and 45 people completed sorting and rating tasks. Sample sizes varied by group and by task. MEASUREMENTS: Statements about the elements of QoL for residents in long term care were elicited during 14 brain-storming sessions. Sorting and rating activities were completed using a final list of 88 items. RESULTS: A visual map was generated, with 5 clusters of elements representing 5 conceptual areas within QoL. Importance ratings of elements were similar for family members and staff members, and a set of elements rated as high in importance but requiring attention to implementation was produced. CONCLUSIONS: Family members and staff produced similar conceptual models of QoL, and their views on the importance of the various elements were consistent. There was a high degree of consensus regarding elements considered least important and those considered most important. Elements considered most important addressed quality of care, autonomy and respect, and aspects of daily life, including food and sleep. There was less concern with the physical appearance of the facility, the amenities offered, and issues related to independence; however, all items scored above the mean of 2.5 on the 5-point rating scale. This project has shown that it is possible to use concept mapping methodology to obtain facility-specific information about stakeholders’ QoL perceptions in the long term care setting, and that residents’ views can be assessed and incorporated. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

The Role of Community-Based Care Capacity in Shaping Risk of Long-Term Care Facility Placement.
Kerry Kuluski, A Paul Williams, Audrey Laporte and,Whitney Berta.
Healthcare Policy 2012 08/21;8(1):92-105

Objectives: Across the developed world, wait lists for facility-based long-term care (LTC) beds continue to grow. Wait lists are primarily driven by the needs of aging populations (demand-side factors). Less attention has been given to system capacity to provide community alternatives to LTC (supply-side factors). We examine the role of both demand- and supply-side factors by comparing the characteristics of individuals who have been assessed and deemed eligible for LTC in urban and rural/underserviced parts of northwestern Ontario, Canada.
Methods: Home care assessment data were analyzed for all individuals waiting for LTC in northwestern Ontario as of March 2008 (n=858). For the analysis, the sample was separated into urban and rural groups to account for geographical differences in wait list location. Characteristics between these two groups were compared. Results: Individuals on LTC wait lists in the rural areas were significantly less impaired in activities of daily living and cognition than their counterparts in the urban area. However, in both areas, impairments in lighter-care activities appeared to be a key wait list driver, and few people had an informal caregiver living in the home. Conclusions: Our data suggest that LTC wait lists reflect, at least to some extent, insufficient community capacity, not just need for LTC.

Deciding when to put grandma in the nursing home: measuring inclinations to place persons with dementia.
Klug MG, Volkov B, Muus K, Halaas GW.

American Journal of Alzheimer’s Disease and Other Dementias 2012 Jun;27(4):223-227

For caregivers of persons with dementia, estimating when that person should be placed in long-term care is difficult. Health care providers also find it hard to give an exact time as to when the person should be placed. Using data from 197 caregivers working with the Dementia Care Services Project in North Dakota, we show that asking the caregiver about their inclination to place can be equated to asking them for a specific time to place (kappa = .616). Using the probability density function of time to place we were able to translate it into inclination. This inclination is easier information for the caregiver to provide and places fewer burdens on the caregiver and patient. It also provides the health care provider with a measure of time to help advise caregivers and recommend interventions and provide service organizations with measures of cost savings to support the impact of outreach and intervention.

Home care or long-term care? Setting the balance of care in urban and rural Northwestern Ontario, Canada.
Kuluski K, Williams AP, Berta W, Laporte A.

Health & social care in the community 2012 Jul;20(4):438-448

The objective of the study was to determine the extent to which community care packages could be provided at a lower cost than facility-based long-term care (LTC) for 864 individuals on the LTC waiting list in urban and rural parts of Northwestern Ontario, Canada. A sequential mixed methods design was used entailing a retrospective chart review, the formation of case vignettes, the creation of community care packages with an ‘expert panel’ of care managers, the costing of care packages and the calculation of potential diversion rates from LTC. Data collection took place in Northwestern Ontario between the months of March and June 2008. Eight per cent of individuals in the urban area and 50% of individuals from the rural areas could potentially be safely diverted to the community and provided with a community care package at a cost lower than facility-based LTC. There is potential for home and community care to substitute for more costly long-term care, but doing so requires building capacity in this sector, particularly in rural areas, which are currently underserviced. Reconfiguring the ‘balance of care’ may lead to long-term cost efficiencies for an ageing population. © 2012 Blackwell Publishing Ltd.

Gender differences in care home admission risk: partner’s age explains the higher risk for women.

McCann M, Donnelly M, O’Reilly D. 

Age and Ageing 2012 May;41(3):416-419

BACKGROUND: older women have a higher risk of care home admission than men, this difference remains even after accounting for variations in health. A likely reason for this is the difference in social support provided by spouses. Older men may provide less care for their wives than women do for their husbands. OBJECTIVES: this study assessed two competing explanations for this. First, older men are less willing to undertake traditionally feminine caring roles; secondly, older men are less physically able to provide care. DESIGN: the Northern Ireland Longitudinal Study (NILS), a representative (c28%) sample of the Northern Ireland population. Findings: a total of 20,830 couples were followed over 6 years, with 415 care home admissions among NILS cohort members. Women had a higher admission risk after controlling for cohort members’ age and health; however, there was no gender difference after adjusting for partner’s age. CONCLUSION: these results suggest that advanced age and physical frailty explain why men provide less care for their partners than women do; rather than being unwilling to undertake a caring role. The narrowing gap in life expectancy between men and women may have an effect on the future demand for formal care.

The elder-friendly emergency department assessment tool: development of a quality assessment tool for emergency department-based geriatric care.

McCusker J, Verdon J, Vadeboncoeur A, Levesque JF, Sinha SK, Kim KY, et al. 
Journal of the American Geriatrics Society 2012 Aug;60(8):1534-1539

OBJECTIVES: To develop and conduct a preliminary validation of selected subscales of an elder-friendly emergency department (ED) assessment tool. DESIGN: Content validation of tool by an international panel. Construct validation using care ratings of ED lead physicians and nurses. SETTING: Quebec, Canada. PARTICIPANTS: The international panel comprised 34 clinicians, administrators, and researchers. The construct validation was based on a 2006 survey of ED lead physicians and nurses at all 103 EDs in the province, of whom 68 (66%) supplied complete data. MEASUREMENTS: The initial tool included five subscales: ED staffing, screening and assessment, discharge planning, community services, and care philosophy. Differences in subscale scores were examined according to ED size, and of these scores were correlated with care ratings made by lead physicians and nurses. RESULTS: The average scores for three subscales (ED staffing, discharge planning, and community services) varied according to ED size. After adjustment for ED size, three subscales (screening and assessment, discharge planning, and community services) were correlated with ED nurse or physician care ratings. A preliminary tool, taking into account all factors, is proposed. CONCLUSION: This study provides preliminary evidence of the validity of three subscales of the proposed elder-friendly ED assessment tool. Results suggest that ED size should be considered in interpreting these subscales. Further evaluation and validation of the proposed tool will be needed to further its utility in helping to focus the quality improvement efforts of clinicians, managers, and administrators related to the care they provide older adults. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Nurse-patient encounters in the hospital ward, from the perspectives of older persons: an analysis using the Authentic Consciousness Framework.
Mitchell EA, McCance T.
International journal of older people nursing 2012 Jun;7(2):95-104

BACKGROUND: Despite a growing theoretical base to support the development of person-centred practice, the evidence would suggest that this way of working is somewhat elusive in the care of older people. AIMS: The study aims to explore nurse-older person encounters and relationships within the context of person-centredness. DESIGN AND METHODS: This study involved secondary analysis of interview data originally collected from a commissioned study investigating whole-systems approaches in services for older people. The process of analysis used the Authentic Consciousness Framework. RESULTS: Nurses are often invisible to the patient, unless they are providing care to address a physical need. A sense of rolelessness pervaded the data, when patients were deprived from actively participating in important decisions about their future care. CONCLUSIONS: Patients would like nurses to work with them in more transparent ways. Patients are very conscious that nurses are busy and attempt to share the coping with the busy workload by limiting their expectations of the nurse. RELEVANCE TO CLINICAL PRACTICE: Person-centred strategies must enhance the capacity of not only older patients and their ability to assert self, but also the capacity of their nurses. Nurses must work to actively recruit the patient in all decision making. © 2010 Blackwell Publishing Ltd.

Acute hospital use, nursing home placement, and mortality in a frail community-dwelling cohort managed with Primary Integrated Interdisciplinary Elder Care at Home.
Rosenberg T.
Journal of the American Geriatrics Society 2012 Jul;60(7):1340-1346

OBJECTIVES: To evaluate the effect of medical Primary Integrated Interdisciplinary Elder Care at Home (PIECH) on acute hospital use and mortality in a frail elderly population. DESIGN: Comparison of acute hospital care use for the year before entering the practice (pre-entry) with the most-recent 12-month period (May 1, 2010-April 30, 2011, postentry) for active and discharged patients. SETTING: Community. PARTICIPANTS: All 248 frail elderly adults enrolled in the practice for at least 12 months who were living in the community and not in nursing homes in Victoria, British Columbia. INTERVENTION: Primary geriatric care provided by a physician, nurse, and physiotherapist in participants’ homes. MEASUREMENTS: Acute hospital admissions, emergency department (ED) contacts that did not lead to admission, reason for leaving practice, and site of death. RESULTS: There was a 39.7% (116 vs 70; P = .004) reduction in hospital admissions, 37.6% (1,700 vs 1,061; P = .04) reduction in hospital days, and 20% (120 vs 95; P = .20) reduction in ED contacts after entering the practice. Fifty participants were discharged from the practice, 64% (n = 32) of whom died, 20% (n = 10) moved, and 16% (n = 8) were admitted to nursing homes. Fifteen (46.9%) deaths occurred at home. CONCLUSION: Primary Integrated Interdisciplinary Elder Care at Home may reduce acute hospital admissions and facilitate home deaths. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Mental healthcare need and service utilization in older adults living in public housing.
Simning A, van Wijngaarden E, Fisher SG, Richardson TM, Conwell Y.
The American Journal of Geriatric Psychiatry : Official Journal of the American Association for Geriatric Psychiatry 2012 May;20(5):441-451

OBJECTIVES: Anxiety and depression in socioeconomically disadvantaged older adults frequently go unrecognized and untreated. This study aims to characterize mental illness and its treatment in older adult public housing residents who have many risk factors for anxiety and depression. DESIGN: Cross-sectional study. SETTING: Public housing high-rises in Rochester, New York. PARTICIPANTS: One hundred ninety residents aged 60 years and older. MEASUREMENTS: Anxiety and depression were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, GAD-7, and Patient Health Questionnaire. We obtained information on mental healthcare from medication review and self-report. RESULTS: Participants had a median age of 66 years, 58% were women, 80% were black, and 92% lived alone. Many participants (31%) were in need of mental healthcare: 21% had syndromal and 11% had subsyndromal anxiety or depression. Mental healthcare need was associated with younger age; intact cognitive functioning; impairments in instrumental activities of daily living (IADL); more medical illness; decreased mobility; smaller social network size; more severe life events; and increased utilization of medical, human, and informal services. Of those with mental healthcare need, most were not receiving it. Compared with residents receiving mental healthcare, residents with untreated need were more likely to be men and have less IADL impairment, medical illness, severe life events, onsite social worker use, and human services utilization. CONCLUSIONS: Mental illness was common and largely untreated in public housing residents. Increasing collaboration between medical, mental, and human services is needed to improve identification, treatment, and ultimately prevention of late-life mental illness in this community setting.

I want to move, but cannot: characteristics of involuntary stayers and associations with health among Canadian seniors.
Strohschein L. 

Journal of aging and health 2012 Aug;24(5):735-751

OBJECTIVES: The purpose of this study was to investigate characteristics of seniors in the Canadian population who are involuntary stayers and to assess associations with health. METHOD: Data come from the 1994 Canadian National Population Health Survey, with the sample restricted to those 65 and older (N = 2,551). RESULTS: Nearly 1 in 10 seniors identified as an involuntary stayer. Seniors with few socioeconomic resources, poor health, greater need for assistance, and low social involvement were more likely to identify as an involuntary stayer. Furthermore, seniors who were involuntary stayers report significantly more distress and greater odds of low self-rated health than other seniors. DISCUSSION: This study brings into visibility an understudied segment of the elderly population: seniors who are unable to move from their present location despite their desire to do so. Further research and policy responses assisting seniors to age in a setting of their own choosing are needed.

Newfoundland and Labrador: 80/20 staffing model pilot in a long-term care facility.
Stuckless T, Power M.

Nursing leadership (Toronto, Ont.) 2012 Mar;25 Spec No 2012:45-50

This project, based in Newfoundland and Labrador’s Central Regional Health Authority, is the first application of an 80/20 staffing model to a long-term care facility in Canada. The model allows nurse participants to spend 20% of their paid time pursuing a professional development activity instead of providing direct patient care. Newfoundland and Labrador has the highest aging demographic in Canada owing, in part, to the out-migration of younger adults. Recruiting and retaining nurses to work in long-term care in the province is difficult; at the same time, the increasing acuity of long-term care residents and their complex care needs mean that nurses must assume greater leadership roles in these facilities. This project set out to increase capacity for registered nurse (RN) leadership, training and support and to enhance the profile of long-term care as a place to work. Six RNs and one licensed practical nurse (LPN) participated and engaged in a range of professional development activities. Several of the participants are now pursuing further nursing educational activities. Central Health plans to continue a 90/10 model for one RN and one LPN per semester, with the timeframe to be determined. The model will be evaluated and, if it is deemed successful, the feasibility of implementing it in other sites throughout the region will be explored.

Honoring Identity Through Mealtimes in Chinese Canadian Immigrants.
T Y Lam I, Keller HH.
American Journal of Alzheimer’s Disease and Other Dementias 2012 Jun 12

Mealtimes are opportunities for social interactions and expressions of individual and family identity, and serve as a microcosm of the broader lives of families living with dementia. The Eating Together study and its resulting Life Nourishment Theory (LNT) explicated the importance of mealtimes for honouring individual and family identities in the context of dementia. This sub-study examined a specific ethnocultural group with cultural food-ways and caring expectations, to determine if the concept of honouring identity needed to be modified or extended. Using active interview techniques, two Cantonese speaking researchers completed dyad/triad family and individual interviews with six Chinese Canadian immigrant families, recruited from two service providers in a large, urban, multicultural city. This sub-study provided insight into the challenges and rewards of mealtimes for Chinese immigrant families with dementia in the community and specifically provided further insights into the honouring identity concept. Although LNT and specifically the honouring identity concept was generally confirmed in this group, some culturally-specific themes were also identified. This work serves as a basis for future studies examining the meaning and experience of mealtimes in specific cultural groups living with dementia. Such work would confirm if the LNT can be applied to specific ethnocultural groups as well as the general population living with dementia.

Dementia: a global health priority – highlights from an ADI and World Health Organization report.
Wortmann M.
Alzheimer’s research & therapy 2012 Sep 21;4(5):40

ABSTRACT: Alzheimer’s Disease International is the worldwide federation of Alzheimer associations that represent people with dementia and their families. Alzheimer’s Disease International has commissioned a number of World Alzheimer Reports since 2009 and was involved in the recently launched report Dementia: A Public Health Priority by the World Health Organization. From these reports, we can learn about the growing impact of Alzheimer’s disease and other dementias on our societies and the need to take action. Developing national Alzheimer plans is a key tool for this action.

Residential Long-Term Care Capacity Planning: The Shortcomings of Ratio-Based Forecasts.

Yue Zhang, Martin L Puterman and,Derek Atkins. 

Healthcare Policy 2012 11/05;7(4):68-81

This paper uses observations from two British Columbia studies to illustrate the shortcomings of widely used ratio-based approaches for residential long-term care capacity planning. It shows that capacity plans based on a fixed ratio of beds per population over age 75 may result in either excess capacity or long wait times for admission. It then investigates the use of linear regression models to obtain a “best” ratio by relating optimal plans derived by rigorous analytical methods to population characteristics and shows that no single ratio applies broadly. While the use of regression is promising, finding these “best” ratios is too analytically complex for general practice. The paper concludes by providing and evaluating an easy-to-use planning method, which we call the average flow model (AFM). The AFM combines demand forecasts with length-of-stay estimates to produce enhanced capacity plans. The AFM is transparent, easily implemented in a spreadsheet and well suited for “what if?” analyses.

Arts-Based Research Dissemination Possibilities and Challenges
Wednesday October 24, 2012 4-104 Education North, $30

Keynote speakers include: Dr Carl Leggo (UBC), Dr Patti Pente (U of A), Dr Katherine Boydell (U of T), Dr Joe Norris (Brock University) and Ron Wigglesworth (U of A).

Health Services Strategic Clinical Networks: a real opportunity for KT
David Johnson, Alberta Children’s Hospital, Thurs October 11, 2012 10:00-11:00 MT 12:00-13:00 ET

CPSI: Canada’s Virtual Forum on Patient Safety and Quality Improvement
Oct. 29-Nov. 2, 2012.

CIHR: Canadian Longitudinal Study on Aging

The CLSA is a national, long-term study of health and aging. Over the next 20 years, 50,000 men and women aged 45 to 85 will be followed as part of the study. McMaster University is at the forefront of this ambitious project, which includes 11 data collection sites, four telephone interview centres and three data analysis facilities across Canada. The CLSA National Coordinating Centre is located in Hamilton.

Implementation Sciences has new editors

Anne Sales and Michel Wensing will be co-editing the journal with Martin Eccles until the new year when Prof. Eccles will step down.

CIHR: A Guide to Evaluation in Health Research

Prepared by Dr. Sarah Bowen, School of Public Health UofA

AHRQ: CUSP Toolkit

The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety.

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