December 3, 2012

New KUSP articles
Grants & Awards

Congratulations to Susan Slaughter

Susan was successful in receiving funding from AIHS for her CRIO project Sustaining Transfers through Affordable Research Translation (START): Knowledge Translation Interventions to Support the Uptake of Innovations in Continuing Care Settings. Her co-investigators are Dr. Allyson Jones, Dr. Carole A. Estabrooks, and Dr. Adrian Wagg. Way to go Susan!!!!

New KUSP Articles

Should we feed back research results in the midst of a study?
Non UofA Access
Estabrooks CA, Teare GF, Norton PG.
Implementation science : IS 2012 Sep 13;7:87-5908-7-87

This report is an introduction to a series of three research papers that describe the evolution of the approaches taken by the Translating Research in Elder Care (TREC) research team during its first four years to feed back the research findings to study participants. TREC is an observational multi-method health services research project underway in 36 nursing homes in the prairie provinces of Canada. TREC has actively involved decision makers from the sector in all stages from initial planning, through data collection to dissemination activities. However, it was not planned as a fully integrated knowledge translation project. These three papers describe our progress towards fully integrated knowledge translation-with respect to timely and requested feedback processes. The first paper reports on the process and outcomes of creating and evaluating the feedback of research findings to healthcare aides (unregulated health professionals). These aides provide over 80% of the direct care in our sample and actively requested the feedback as a condition of their continued cooperation in the data acquisition process. The second paper describes feedback from nursing home administrators on preliminary research findings (a facility annual report) and evaluation of the reports’ utility. The third paper discusses an approach to providing a more in-depth form of feedback (expanded feedback report) at one of the TREC nursing homes. FINDINGS: Survey and interview feedback from healthcare aides is presented in the first paper. Overall, healthcare aides’ opinions about presentation of the feedback report and the understand ability, usability, and usefulness of the content were positive. The second paper describes the use of telephone interviews with facility administrators and indicates that the majority of contextual areas (e.g., staff job satisfaction) addressed in facility annual report to be useful, meaningful, and understandable. More than one-half of the administrators would have liked to have received information on additional areas. The third paper explores how a case study that examined how involvement with the TREC study influenced management and staff at one of the TREC nursing homes. The importance of understanding organizational routines and the impact of corporate restructuring were key themes emerging from the case study. In addition, the Director of Care suggested changes to the structure and format of the feedback report that would have improved its usefulness. CONCLUSIONS: We believe that these findings will inform others undertaking integrated knowledge translation activities and will encourage others to become more engaged in feedback processes.

Nursing home administrators’ perspectives on a study feedback report: a cross sectional survey
Non UofA Access
Bostrom AM, Cranley LA, Hutchinson AM, Cummings GG, Norton PG, Estabrooks CA.
Implementation science : IS 2012 Sep 13;7:88-5908-7-88

This project is part of the Translating Research in Elder Care (TREC) program of research, a multi-level and longitudinal research program being conducted in 36 nursing homes in three Canadian Prairie Provinces. The overall goal of TREC is to improve the quality of care for older persons living in nursing homes and the quality of work life for care providers. The purpose of this paper is to report on development and evaluation of facility annual reports (FARs) from facility administrators’ perspectives on the usefulness, meaningfulness, and understandability of selected data from the TREC survey. METHODS: A cross sectional survey design was used in this study. The feedback reports were developed in collaboration with participating facility administrators. FARs presented results in four contextual areas: workplace culture, feedback processes, job satisfaction, and staff burnout. Six weeks after FARs were mailed to each administrator, we conducted structured telephone interviews with administrators to elicit their evaluation of the FARs. Administrators were also asked if they had taken any actions as a result of the FAR. Descriptive and inferential statistics, as well as content analysis for open-ended questions, were used to summarize findings. RESULTS: Thirty-one facility administrators (representing thirty-two facilities) participated in the interviews. Six administrators had taken action and 18 were planning on taking action as a result of FARs. The majority found the four contextual areas addressed in FAR to be useful, meaningful, and understandable. They liked the comparisons made between data from years one and two and between their facility and other TREC study sites in their province. Twenty-two indicated that they would like to receive information on additional areas such as aggressive behaviours of residents and information sharing. Twenty-four administrators indicated that FARs contained enough information, while eight found FARs ‘too short’. Administrators who reported that the FAR contained enough information were more likely to take action within their facilities than administrators who reported that they needed more information. CONCLUSIONS: Although the FAR was brief, the presentation of the four contextual areas was relevant to the majority of administrators and prompted them to plan or to take action within their facility.

Feedback reporting of survey data to healthcare aides.
Non UofA Access
Hutchinson AM, Batra-Garga N, Cranley L, Bostrom AM, Cummings G, Norton P, et al.
Implementation science : IS 2012 Sep 13;7:89-5908-7-89

This project occurred during the course of the Translating Research in Elder Care (TREC) program of research. TREC is a multilevel and longitudinal research program being conducted in the three Canadian Prairie Provinces of Alberta, Saskatchewan, and Manitoba. The main purpose of TREC is to increase understanding about the role of organizational context in influencing knowledge use in residential long-term care settings. The purpose of this study was to evaluate healthcare aides’ (HCAs) perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practice) from the TREC survey they had recently completed. METHODS: A convenience sample of 7 of the 15 nursing homes participating in the TREC research program in Alberta were invited to participate. Specific facility-level summary data were provided to each facility in the form of a one-page poster report. Two weeks following delivery of the report, a convenience sample of HCAs was surveyed using one-to-one structured interviews. RESULTS: One hundred twenty-three HCAs responded to the evaluation survey. Overall, HCAs’ opinions about presentation of the feedback report and the understandability, usability, and usefulness of the content were positive. For each report, analysis of data and production and inspection of the report took up to one hour. Information sessions to introduce and explain the reports averaged 18 minutes. Two feedback reports (minimum) were supplied to each facility at a cost of CAN$2.39 per report, for printing and laminating. CONCLUSIONS: This study highlights not only the feasibility of producing understandable, usable, and useful feedback reports of survey data but also the value and importance of providing feedback to survey respondents. More broadly, the findings suggest that modest strategies may have a positive and desirable effect in participating sites.

Insights into the impact and use of research results in a residential long-term care facility: a case study.
Non UofA Access
Cranley LA, Birdsell JM, Norton PG, Morgan DG, Estabrooks CA.
Implementation science : IS 2012 Sep 13;7:90-5908-7-90

Engaging end-users of research in the process of disseminating findings may increase the relevance of findings and their impact for users. We report findings from a case study that explored how involvement with the Translating Research in Elder Care (TREC) study influenced management and staff at one of 36 TREC facilities. We conducted the study at ‘Restwood’ (pseudonym) nursing home because the Director of Care engaged actively in the study and TREC data showed that this site differed on some areas from other nursing homes in the province. The aims of the case study were two-fold: to gain a better understanding of how frontline staff engage with the research process, and to gain a better understanding of how to share more detailed research results with management. METHODS: We developed an Expanded Feedback Report for use during this study. In it, we presented survey results that compared Restwood to the best performing site on all variables and participating sites in the province. Data were collected regarding the Expanded Feedback Report through interviews with management. Data from staff were collected through interviews and observation. We used content analysis to derive themes to describe key aspects related to the study aims. RESULTS: We observed the importance of understanding organizational routines and the impact of key events in the facility’s environment. We gleaned additional information that validated findings from prior feedback mechanisms within TREC. Another predominant theme was the sense that the opportunity to engage in a research process was reaffirming for staff (particularly healthcare aides)-what they did and said mattered, and TREC provided a means of having one’s voice heard. We gained valuable insight from the Director of Care about how to structure and format more detailed findings to assist with interpretation and use of results. CONCLUSIONS: Four themes emerged regarding staff engagement with the research process: sharing feedback reports from the TREC study; the meaning of TREC to staff; understanding organizational context; and using the study feedback for improvement at Restwood. This study has lessons for researchers on how to share research results with study participants, including management.

Identifying resident care areas for a quality improvement intervention in long-term care: a collaborative approach.
Non UofA Access
Cranley LA, Norton PG, Cummings GG, Barnard D, Batra-Garga N, Estabrooks CA.
BMC geriatrics 2012 Sep 25;12:59-2318-12-59

In Canada, healthcare aides (also referred to as nurse aides, personal support workers, nursing assistants) are unregulated personnel who provide 70-80% of direct care to residents living in nursing homes. Although they are an integral part of the care team their contributions to the resident care planning process are not always acknowledged in the organization. The purpose of the Safer Care for Older Persons [in residential] Environments (SCOPE) project was to evaluate the feasibility of engaging front line staff (primarily healthcare aides) to use quality improvement methods to integrate best practices into resident care. This paper describes the process used by teams participating in the SCOPE project to select clinical improvement areas. METHODS: The study employed a collaborative approach to identify clinical areas and through consensus, teams selected one of three areas. To select the clinical areas we recruited two nursing homes not involved in the SCOPE project and sampled healthcare providers and decision-makers within them. A vote counting method was used to determine the top five ranked clinical areas for improvement. RESULTS: Responses received from stakeholder groups included gerontology experts, decision-makers, registered nurses, managers, and healthcare aides. The top ranked areas from highest to lowest were pain/discomfort management, behaviour management, depression, skin integrity, and assistance with eating. CONCLUSIONS: Involving staff in selecting areas that they perceive as needing improvement may facilitate staff engagement in the quality improvement process.


CALL FOR PAPERS: Action Research in Healthcare
Action Research Journal
DEADLINE May 1, 2013

We call for papers that deal with the following questions, while at the same time remaining open to pleasant surprises in papers on topics we do not list.- Case studies of significant action research at first, second and third person levels

  • Case studies of improved care delivery that highlights learning and action from a multi-disciplinary perspective, integrating knowledge from different scientific fields
  • Tackling the issue of generating patient participation in AR projects
  • Addressing especially the behavioral aspects of chronic illness and palliative care
  • Transforming cultures that entrench the interests of powerful stakeholders
  • Addressing presuppositions about how conventional healthcare research looks
  • International networks of learning and collaboration to address healthcare disparities.

CALL FOR ABSTRACTS: Health Care Quality Summit
April 10-11, 2013, Regina, SK
DEADLINE December 15, 2012

Have you contributed to the recent design or redesign of a health care service or process in Saskatchewan? Do you have an improvement story you’d like to share at the 2013 Quality Summit? We’re looking for improvement champions, like you, to share their strategies, successes and challenges, to inspire and motivate others!
Submit an abstract outlining your improvement efforts in one of the following areas: better health, better care, better value, or better teams.

CALL FOR ABSTRACTS: 2013 Summer Institutes on Evidence-Based Quality Improvement
July 9-13, 2013 San Antonio, TX
DEADLINE Monday March 4, 2013

Clinicians, Educators and Researchers share your EBP successes. Nurses, physicians, pharmacists, managers, and health professionals are invited to submit for consideration, abstracts consistent with the theme of these national, interdisciplinary conferences. You will build scientific capacity and apply evidence to improve care and patient outcomes. Experience a full immersion in the latest advances in healthcare improvement. Take advantage of back-to-back institutes to improve care and patient outcomes, from research to implementation to outcomes.

CALL FOR PAPERS: Nursing Science Quarterly Special Issue on Leadership

Nursing Science Quarterly (NSQ) is a peer-reviewed, quarterly publication for nurse researchers, educators, practitioners, and graduate students in nursing science, philosophy, or research. The journal publishes original manuscripts focusing on nursing theory development, nursing theory-guided practice, quantitative and qualitative research, and practice.

Grants & Awards
CIHR: Knowledge Translation Fellowship Winter 2013
DEADLINE Feb 1, 2013

The Knowledge Translation (KT) Branch of CIHR will provide funding for applications that are determined to be relevant to the following research priority areas described below:
KT Science (the determinants of knowledge use and effective methods of promoting the uptake of knowledge):
Increase understanding of the theory and practice of KT
Develop tools/measures to evaluate the effectiveness/impact of KT practices/interventions
KT Practice (Moving research into action)
Increase the uptake/application of knowledge to bridge knowledge to action gap.
Increase the understanding of knowledge application.
The purpose of this funding opportunity is to advance KT (synthesis, dissemination, exchange and ethically sound application of knowledge). It is expected that this targeted investment will lead to a better understanding of concepts, theories and practices that underlie effective KT in order to improve the health of Canadian, provide more effective health services and products and strengthen the health care system.

CIHR: Prize of Excellence in Research on Aging (RPF)
DEADLINE February 1, 2013

The CIHR Institute of Aging (CIHR-IA) aims to advance knowledge in the field of aging to improve the quality of life and the health of older Canadians. With this goal in mind, CIHR-IA has been investing in the future of research on aging by developing and supporting capacity-building research initiatives and programs to train and support new and emerging researchers in the field of aging.
The CIHR-IA Fellowship Prize of Excellence in Research on Aging encourages and honours our brightest rising stars. It consists of a supplement, valued at $5,000, to the research allowance in year one of the Fellowship award. No additional application is needed.
More information on the research priorities of CIHR-Institute of Aging can be found on their website.

Alberta Innovates Health: Conference Grants
DEADLINE January 11, 2013

Funding under the Conference Grant program is provided to help bring distinguished researchers to Alberta to present lectures and to participate in panel discussions. The process facilitates the dissemination of knowledge to the province’s researchers, health professionals and other stakeholders. The conference must demonstrate the intent to promote collaboration and exchange between individuals, research groups, institutions, and organizations within Alberta and beyond.

CALL FOR NOMINATIONS: BioMed Central’s 7th Annual Research Awards
DEADLINE 31 January 2013

It’s that time of year again! Nominations are open for you to put forward your favorite BioMed Central open access research article for our seventh annual Research Awards. Articles must be published in one of our 240 plus BioMed Central journals and that includes Implementation Science, BMC Geriatrics, and Health Services Research , during 2012 to qualify. BioMed Central’s Research Awards have been successfully highlighting the very best research that has been made available through open access publishing for the last six years, chosen by you and selected by internationally renowned judges.

AIHS: Summer Studentships
DEADLINE February 1, 2013

The Summer Studentship program offers motivated students with exceptional academic records the opportunity to participate directly in medical or health research in Alberta in the summer months (May to August). The intent of the program is to encourage such students to consider formal training and a career in medical/health research.
Candidates will usually be registered in an Alberta undergraduate degree program relevant to the objectives of AIHS. Students registered in an undergraduate degree program outside Alberta may also apply; however, the research must be undertaken at an Alberta institution. A student registered in a M.D. program who may already hold an undergraduate or graduate degree may also apply to the Summer Studentship program. Exceptional senior year high school students with records of participation in the health care system and clear interest in a medical/health research career will also be considered.
Faculty supervisors sponsoring candidates to this program must have a record of productive research and sufficient funding to ensure the satisfactory conduct of the research. A separate research project must be submitted for each student. The supervisor must be prepared to provide direct and continuous supervision during the term of the award.
Students must be willing to participate full-time in the project for the duration of the award and agree not to change the supervisor or project during the term of the award. The minimum term of support for this award is two months. The award will provide funds to the sponsoring institution to be used as a stipend for the period of the award.

CIHR: MD/PhD Studentships
DEADLINE December 14, 2012

CIHR, through its Patient-Oriented Research Strategy, has the goal of further strengthening the Canadian clinical research endeavour by increasing the number of clinician-investigators. The CIHR MD/PhD Grants Program is a modified version of the CIHR MD/PhD Studentships Program, created in 1995, that provides MD/PhD Program Directors greater flexibility in maximizing the number of students that can be supported with CIHR funds. MD/PhD Grant program is offered to MD/PhD Program Directors for support of students pursuing a combined MD/PhD degree at a Canadian institution. As part of the implementation of Canada’s Strategy for Patient-Oriented Research, CIHR is reviewing the suite of funding opportunities offered under the CIHR Patient-Oriented Research envelope. Included in this suite of opportunities is the MD/PhD Grant program.


Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Methodology
Health Care in Canada


Managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols.
Non UofA Access
Stacey D, Bakker D, Ballantyne B, Chapman K, Cumminger J, Green E, et al.
Implementation science : IS 2012 Nov 19;7(1):110

BACKGROUND: Management of cancer treatment-related symptoms is an important safety issue given that symptoms can become life-threatening and often occur when patients are at home. With funding from the Canadian Partnership Against Cancer, a pan-Canadian steering committee was established with representation from eight provinces to develop symptom protocols using a rigorous methodology (CAN-IMPLEMENT(c)). Each protocol is based on a systematic review of the literature to identify relevant clinical practice guidelines. Protocols were validated by cancer nurses from across Canada. The aim of this study is to build an effective and sustainable approach for implementing evidence-informed protocols for nurses to use when providing remote symptom assessment, triage, and guidance in self-management for patients experiencing symptoms while undergoing cancer treatments. METHODS: A prospective mixed-methods study design will be used. Guided by the Knowledge to Action Framework, the study will involve (a) establishing an advisory knowledge user team in each of three targeted settings; (b) assessing factors influencing nurses’ use of protocols using interviews/focus groups and a standardized survey instrument; (c) adapting protocols for local use, ensuring fidelity of the content; (d) selecting intervention strategies to overcome known barriers and implementing the protocols; (e) conducting think-aloud usability testing; (f) evaluating protocol use and outcomes by conducting an audit of 100 randomly selected charts at each of the three settings; and (g) assessing satisfaction with remote support using symptom protocols and change in nurses’ barriers to use using survey instruments. The primary outcome is sustained use of the protocols, defined as use in 75% of the calls. Descriptive analysis will be conducted for the barriers, use of protocols, and chart audit outcomes. Content analysis will be conducted on interviews/focus groups and usability testing with comparisons across settings. DISCUSSION: Given the importance of patient safety, patient-centered care, and delivery of quality services, learning how to effectively implement evidence-informed symptom protocols in oncology healthcare services is essential for ensuring safe, consistent, and effective care for individuals with cancer. This study is likely to have a significant contribution to the delivery of remote oncology services, as well as influence symptom management by patients at home.

Applying a Health Network approach to translate evidence-informed policy into practice: A review and case study on musculoskeletal health.
Non UofA Access
Briggs AM, Bragge P, Slater H, Chan M, Towler SC.
BMC health services research 2012 Nov 14;12(1):394

BACKGROUND: While translation of evidence into health policy and practice is recognised as critical to optimising health system performance and health-related outcomes for consumers, mechanisms to effectively achieve these goals are neither well understood, nor widely communicated. Health Networks represent a framework which offers a possible solution to this dilemma, particularly in light of emerging evidence regarding the importance of establishing relationships between stakeholders and identifying clinical leaders to drive evidence integration and translation into policy. This is particularly important for service delivery related to chronic diseases. In Western Australia (WA), disease and population-specific Health Networks are comprised of cross-discipline stakeholders who work collaboratively to develop evidence-informed policies and drive their implementation. Since establishment of the Health Networks in WA, over 50 evidence-informed Models of Care (MOCs) have been produced across 18 condition or population-focused Networks. The aim of this paper is to provide an overview of the Health Network framework in facilitating the translation of evidence into policy and practice with a particular focus on musculoskeletal health. Case Presentation A review of activities of the WA Musculoskeletal Health Network was undertaken, focussing on outcomes and the processes used to achieve them in the context of: development of policy, procurement of funding, stakeholder engagement, publications, and projects undertaken by the Network which aligned to implementation of MoCs. The Musculoskeletal Health Network has developed four MoCs which reflect Australian National Health Priority Areas. Establishment of community-based services for consumers with musculoskeletal health conditions is a key recommendation from these MoCs. Through mapping barriers and enablers to policy implementation, working groups, led by local clinical leaders and supported by the broader Network and government officers, have undertaken a range of integrated projects, such as the establishment of a community-based, multidisciplinary rheumatology service. The success of these projects has been contingent on developing relationships between key stakeholders across the health system. CONCLUSIONS: In WA, Networks have provided a sustainable mechanism to meaningfully engage consumers, carers, clinicians and other stakeholders; provided a forum to exchange ideas, information and evidence; and collaboratively plan and deliver evidence-based and contextually-appropriate health system improvements for consumers.

“More bang for the buck”: exploring optimal approaches for guideline implementation through interviews with international developers.
Non UofA Access
Gagliardi AR.
BMC health services research 2012 Nov 15;12(1):404

BACKGROUND: Population based studies show that guidelines are underused. Surveys of international guideline developers found that many do not implement their guidelines. The purpose of this research was to interview guideline developers about implementation approaches and resources. METHODS: Semi-structured telephone interviews were conducted with representatives of guideline development agencies identified in the National Guideline Clearinghouse and sampled by country, type of developer, and guideline clinical indication. Participants were asked to comment on the benefits and resource implications of three approaches for guideline implementation that varied by responsibility: developers, intermediaries, or users. RESULTS: Thirty individuals from seven countries were interviewed, representing government (n = 12) and professional (n = 18) organizations that produced guidelines for a variety of clinical indications. Organizations with an implementation mandate featured widely inconsistent funding and staffing models, variable approaches for choosing promotional strategies, and an array of dissemination activities. When asked to choose a preferred approach, most participants selected the option of including information within guidelines that would help users to implement them. Given variable mandate and resources for implementation, it was considered the most feasible approach, and therefore most likely to have impact due to potentially broad use. CONCLUSIONS: While implementation approaches and strategies need not be standardized across organizations, the findings may be used by health care policy makers and managers, and guideline developers to generate strategic and operational plans that optimize implementation capacity. Further research is needed to examine how to optimize implementation capacity by guideline developers, intermediaries and users.

Institutionalization of evidence-informed practices in healthcare settings.
Non UofA Access
Novotna G, Dobbins M, Henderson J.
Implementation science : IS 2012 Nov 21;7(1):112

BACKGROUND: The effective and timely integration of the best available research evidence into healthcare practice has considerable potential to improve the quality of provided care. Knowledge translation (KT) approaches aim to develop, implement, and evaluate strategies to address the research-practice gap. However, most KT research has been directed toward implementation strategies that apply cognitive, behavioral, and, to a lesser extent, organizational theories. In this paper, we discuss the potential of institutional theory to inform KT-related research. DISCUSSION: Despite significant research, there is still much to learn about how to achieve KT within healthcare systems and practices. Institutional theory, focusing on the processes by which new ideas and concepts become accepted within their institutional environments, holds promise for advancing KT efforts and research. To propose new directions for future KT research, we present some of the main concepts of institutional theory and discuss their application to KT research by outlining how institutionalization of new practices can lead to their ongoing use in organizations. In addition, we discuss the circumstances under which institutionalized practices dissipate and give way to new insights and ideas that can lead to new, more effective practices. SUMMARY: KT research informed by institutional theory can provide important insights into how knowledge becomes implemented, routinized, and accepted as institutionalized practices. Future KT research should employ both quantitative and qualitative research designs to examine the specifics of sustainability, institutionalization, and deinstitutionalization of practices to enhance our understanding of these complex constructs.

REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol.
Non UofA Access
Macfarlane A, O’Donnell C, Mair F, O’Reilly-de Brun M, de Brun T, Spiegel W, et al.
Implementation science : IS 2012 Nov 20;7(1):111

BACKGROUND: The implementation of guidelines and training initiatives to support communication in crosscultural primary care consultations is ad hoc across a range of international settings with a range of negative consequences particularly for migrants. This situation reflects a welldocumented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology–Participatory Learning and Action–to investigate and support implementation of such guidelines and training initiatives in routine practice. METHODS: This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders–migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory’s four constructs–coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings. DISCUSSION: This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

Building theories of knowledge translation interventions: Use the entire menu of constructs.
Non UofA Access
Brehaut JC, Eva KW.
Implementation science : IS 2012 Nov 22;7(1):114

BACKGROUND: In the ongoing effort to develop and advance the science of knowledge translation (KT), an important question has emerged around how theory should inform the development of KT interventions. DISCUSSION: Efforts to employ theory to better understand and improve KT interventions have until recently mostly involved examining whether existing theories can be usefully applied to the KT context in question. In contrast to this general theory application approach, we propose a ‘menu of constructs’ approach, where individual constructs from any number of theories may be used to construct a new theory. By considering the entire menu of available constructs, rather than limiting choice to the broader level of theories, we can leverage knowledge from theories that would never on their own provide a complete picture of a KT intervention, but that nevertheless describe components or mechanisms relevant to it. We can also avoid being forced to adopt every construct from a particular theory in a one-size-fits-all manner, and instead tailor theory application efforts to the specifics of the situation. Using audit and feedback as an example KT intervention strategy, we describe a variety of constructs (two modes of reasoning, cognitive dissonance, feed forward, desirable difficulties and cognitive load, communities of practice, and adaptive expertise) from cognitive and educational psychology that make concrete suggestions about ways to improve this class of intervention. SUMMARY: The ‘menu of constructs’ notion suggests an approach whereby a wider range of theoretical constructs, including constructs from cognitive theories with scope that makes the immediate application to the new context challenging, may be employed to facilitate development of more effective KT interventions.

Peri-operative nurses’ knowledge and reported practice of pressure injury risk assessment and prevention: A before-after intervention study.
Non UofA Access
Sutherland-Fraser S, McInnes E, Maher E, Middleton S, Middleton S.
BMC nursing 2012 Nov 24;11(1):25

BACKGROUND: Patients are at risk of developing pressure injuries in the peri-operative setting. Studies evaluating the impact of educational interventions on peri-operative nurses’ knowledge and reported practice are scarce. The purpose of this study was to evaluate the effect of a multifaceted intervention on peri-operative nurses’ (a) knowledge of pressure injury risks, risk assessment and prevention strategies for patients in the operating suite; and (b) reported practice relating to risk assessment practices and implementation of prevention strategies for patients in the operating suite. METHODS: A before-after research design was used. A convenience sample of all registered and enrolled nurses employed in two hospitals’ operating suites was recruited. A multifaceted intervention was delivered which comprised of a short presentation, educational materials and reminder posters. A 48-item survey tool was completed pre-and post-intervention to measure self-reported knowledge and practice. RESULTS: 70 peri-operative eligible nurses completed both surveys. Post-intervention, statistically significant improvements were seen in knowledge of correct descriptions of pressure injury stages (p=0.001); appropriate reassessment for patients with a new pressure injury (p=0.05); appropriate actions for patients with an existing stage 1 (p=0.02) and stage 2 pressure injury (p=0.04). Statistical improvements were also seen in reported practice relating to an increase in the use of a risk assessment tool in conjunction with clinical judgement (p=0.0008); verbal handover of patients’ pressure injury risk status from the operating room nurse to the recovery room (p=0.023) and from the recovery room nurse to the postoperative ward nurse (p=0.045). The number of participants reporting use of non-recommended and recommended pressure-relieving strategies was unchanged. CONCLUSION: A multi-faceted educational intervention can improve some aspects of perioperative nurses’ knowledge and reported practice such as risk assessment practices but not others such as use of recommended pressure-relieving devices. Further research is required to ascertain effective interventions which improve all areas of practice and knowledge, particularly in the use of appropriate pressure-relieving devices in order to prevent pressure injuries in surgical patients.

“Push” versus “Pull” for mobilizing pain evidence into practice across different health professions: A protocol for a randomized trial
Non UofA Access
Macdermid JC, Law M, Buckley N, Haynes RB.
Implementation science : IS 2012 Nov 24;7(1):115

BACKGROUND: Optimizing pain care requires ready access and use of best evidence within and across different disciplines and settings. The purpose of this randomized trial is to determine whether a technology-based “push” of new, high-quality pain research to physicians, nurses, and rehabilitation and psychology professionals results in better knowledge and clinical decision making around pain, when offered in addition to traditional “pull” evidence technology. A secondary objective is to identify disciplinary variations in response to evidence and differences in the patterns of accessing research evidence. METHODS: Physicians, nurses, occupational/physical therapists, and psychologists (n = 670) will be randomly allocated in a crossover design to receive a pain evidence resource in one of two different ways. Evidence is extracted from medical, nursing, psychology, and rehabilitation journals; appraised for quality/relevance; and sent out (PUSHed) to clinicians by email alerts or available for searches of the accumulated database (PULL). Participants are allocated to either PULL or PUSH + PULL in a randomized crossover design. The PULL intervention has a similar interface but does not send alerts; clinicians can only go to the site and enter search terms to retrieve evidence from the cumulative and continuously updated online database. Upon entry to the trial, there is three months of access to PULL, then random allocation. After six months, crossover takes place. The study ends with a final three months of access to PUSH + PULL. The primary outcomes are uptake and application of evidence. Uptake will be determined by embedded tracking of what research is accessed during use of the intervention. A random subset of 30 participants/ discipline will undergo chart-stimulated recall to assess the nature and depth of evidence utilization in actual case management at baseline and 9 months. A different random subset of 30 participants/ discipline will be tested for their skills in accessing evidence using a standardized simulation test (final 3 months). Secondary outcomes include usage and self-reported evidence-based practice attitudes and behaviors measured at baseline, 3, 9, 15 and 18 months. DISCUSSION: The trial will inform our understanding of information preferences and behaviors across disciplines/practice settings. If this intervention is effective, sustained support will be sought from professional/health system initiatives with an interest in optimizing pain management.Trial registrationRegistered as NCT01348802 on

Applying a Health Network approach to translate evidence-informed policy into practice: A review and case study on musculoskeletal health.
Non UofA Access
Briggs AM, Bragge P, Slater H, Chan M, Towler SC.
BMC health services research 2012 Nov 14;12(1):394

BACKGROUND: While translation of evidence into health policy and practice is recognised as critical to optimising health system performance and health-related outcomes for consumers, mechanisms to effectively achieve these goals are neither well understood, nor widely communicated. Health Networks represent a framework which offers a possible solution to this dilemma, particularly in light of emerging evidence regarding the importance of establishing relationships between stakeholders and identifying clinical leaders to drive evidence integration and translation into policy. This is particularly important for service delivery related to chronic diseases. In Western Australia (WA), disease and population-specific Health Networks are comprised of cross-discipline stakeholders who work collaboratively to develop evidence-informed policies and drive their implementation. Since establishment of the Health Networks in WA, over 50 evidence-informed Models of Care (MOCs) have been produced across 18 condition or population-focused Networks. The aim of this paper is to provide an overview of the Health Network framework in facilitating the translation of evidence into policy and practice with a particular focus on musculoskeletal health. Case Presentation A review of activities of the WA Musculoskeletal Health Network was undertaken, focussing on outcomes and the processes used to achieve them in the context of: development of policy, procurement of funding, stakeholder engagement, publications, and projects undertaken by the Network which aligned to implementation of MoCs. The Musculoskeletal Health Network has developed four MoCs which reflect Australian National Health Priority Areas. Establishment of community-based services for consumers with musculoskeletal health conditions is a key recommendation from these MoCs. Through mapping barriers and enablers to policy implementation, working groups, led by local clinical leaders and supported by the broader Network and government officers, have undertaken a range of integrated projects, such as the establishment of a community-based, multidisciplinary rheumatology service. The success of these projects has been contingent on developing relationships between key stakeholders across the health system. CONCLUSIONS: In WA, Networks have provided a sustainable mechanism to meaningfully engage consumers, carers, clinicians and other stakeholders; provided a forum to exchange ideas, information and evidence; and collaboratively plan and deliver evidence-based and contextually-appropriate health system improvements for consumers.

Failure of Clinical Practice Guidelines to Meet Institute of Medicine Standards: Two More Decades of Little, If Any, Progress.
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Kung J, Miller RR, Mackowiak PA.
Archives of Internal Medicine 2012 Oct 22:1-6

BACKGROUND In March 2011, the Institute of Medicine (IOM) issued a new set of standards for clinical practice guidelines intended to enhance the quality of guidelines being produced. To our knowledge, no systematic review of adherence to such standards has been undertaken since one published over a decade ago. METHODS Two reviewers independently screened 130 guidelines selected at random from the National Guideline Clearinghouse (NGC) website for compliance with 18 of 25 IOM standards. RESULTS The overall median number (percentage) of IOM standards satisfied (out of 18) was 8 (44.4%), with an interquartile range of 6.5 (36.1%) to 9.5 (52.8%). Fewer than half of the guidelines surveyed met more than 50% of the IOM standards. Barely a third of the guidelines produced by subspecialty societies satisfied more than 50% of the IOM standards surveyed. Information on conflicts of interest (COIs) was given in fewer than half of the guidelines surveyed. Of those guidelines including such information, COIs were present in over two-thirds of committee chairpersons (71.4%) and 90.5% of co-chairpersons. Except for US government agency-produced guidelines, criteria used to select committee members and the selection process were rarely described. Committees developing guidelines rarely included an information scientist or a patient or patient representative. Non-English literature, unpublished data, and/or abstracts were rarely considered in developing guidelines; differences of opinion among committee members generally were not aired in guidelines; and benefits of recommendations were enumerated more often than potential harms. Guidelines published from 2006 through 2011 varied little with regard to average number of IOM standards satisfied. CONCLUSION Analysis of a random sample of clinical practice guidelines archived on the NGC website as of June 2011 demonstrated poor compliance with IOM standards, with little if any improvement over the past 2 decades.

Challenges in identifying barriers to adoption in a theory-based implementation study: lessons for future implementation studies.
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Hanbury A, Farley K, Thompson C, Wilson P, Chambers D.
BMC health services research 2012 Nov 23;12(1):422

BACKGROUND: Exploring barriers to the uptake of research based recommendations into practice is an important part of the development of implementation programmes. Techniques to identify barriers can include use of theory-informed questionnaires and qualitative interviews. Conceptualising and measuring theory-informed factors, and engaging health professionals’ to uncover all potential barriers, can be a difficult task. This paper presents a case study of the process of trying to identify, systematically, the key factors influencing health professionals’ referrals for women diagnosed with mild to moderate postnatal depression for psychological treatment. The paper illustrates how the factors were conceptualised and measured and explores the real world challenges experienced, with implications for future implementation studies. METHODS: Theory-informed factors were conceptualised and measured using a questionnaire and interviews. The questionnaire was piloted, before being administered to general practitioners, practice nurses and health visitors working in general practices in one area of the UK NHS. The interviews were conducted with a small sample of general practitioners who had not completed the questionnaire, further exploring factors influencing their referral decisions in the local context. RESULTS: The response rate to the questionnaire was low (19%), despite selecting the recommendation to target through engagement with local stakeholders and surveying local health professionals, and despite using two reminders, an incentive prize, and phone calls to practice managers to bolster response rates. CONCLUSIONS: Two significant challenges to achieving higher response rates and successfully exploring local context were identified: the difficulties of developing a robust- but feasible- questionnaire to explore theory-informed factors, and targeting recommendations that are important to policy makers, but which health professionals view as unimportant. This case study highlights the “trade-off” between scientifically rigorous collection of data against the pragmatism and flexibility requirements of “real world” implementation. Future implementation studies should explore different ways of identifying factors influencing the adoption of recommendations to bridge this gulf.

CHIN: Public Engagement and Knowledge Translation Environmental Scan
Nov 2012

Alberta’s Collaborative Health Innovation Network (CHIN) strives to develop effective knowledge translation (KT) and improve links between evidence and decision-making. This new CHIN environmental scan determines best practices related to public engagement and examines Alberta’s current KT landscape for health innovation.

Center on Health Care Effectiveness: Paying Wisely: Reforming Incentives to Promote Evidence-Based Decisions at the Point of Care
October 2012

This paper from the U.S. Center on Health Care Effectiveness explores how moving from a fee-for-service payment model to other options can reward clinical evidence-based decision-making. The authors report that a combination of payment models may be the best way to enhance evidence-based decision making at the point of care.

Health Care Administration & Organization
Workplace aggression, including bullying in nursing and midwifery: A descriptive survey (the SWAB study).
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Farrell GA, Shafiei T.
International journal of nursing studies 2012 Nov;49(11):1423-1431

Workplace aggression remains an important source of distress among nurses and midwives and has negative effects on staff health, patient care and organisations’ reputation and fiscal health. OBJECTIVES: To report on the nature and extent of workplace aggression, including bullying experienced by nurses and midwives in Victoria, Australia. DESIGN: A descriptive study design was chosen. SETTINGS AND METHODS: The Nurses Board of Victoria posted 5000 surveys to the randomly selected registered nurses and midwives in Victoria, Australia, in 2010. The participants were asked about their experiences of violence (from clients) and bullying (from colleagues) within their most recent four working weeks. In addition, the study investigated staff actions following incidents, staff training and safety at work, and what staff believe contribute to incidents. Data analysis involved descriptive statistics, including frequencies and percentages. Chi square tests and P value were used to assess differences in categorical data. FINDINGS: 1495 returned questionnaires were included in the study (30% response rate). Over half of the participants (52%) experienced some form of workplace aggression. Thirty-six percent experienced violence mostly from patients or their visitors/relatives and 32% experienced bullying mostly from colleagues or from their managers/supervisors. Significant differences were found between those who experienced aggression from patients and those who were bullied in respect to handling of incidents; factors thought to contribute to incidents; and organisations’ handling of incidents. CONCLUSION: The study suggests that staff are less worried by patient initiated aggression compared to bullying from colleagues. For all types of aggression, respondents clearly wanted better/more realistic training, as well as enforcement of policies and support when incidents arise. Copyright © 2012 Elsevier Ltd. All rights reserved.

Job satisfaction of neonatal intensive care nurses.
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McDonald K, Rubarth LB, Miers LJ.
Advances in neonatal care 2012 Aug;12(4):E1-8

The purpose of this study was to describe the job satisfaction of neonatal intensive care unit (NICU) nurses in the Midwestern United States. The factors explored in job satisfaction were monetary compensation (pay), job stress, caring for patients in stressful situations, level of autonomy, organizational support, level of knowledge of the specialty, work environment, staffing levels, communication with physicians, communication with neonatal nurse practitioners, interdisciplinary communication, team spirit, and the amount of required “floating” to other nursing units. SUBJECTS: Participants were 109 NICU nurses working as either staff nurses (n = 72) or advanced practice nurses (n = 37). Of the participants, 96% worked in a level 3 NICU. DESIGN: A descriptive, correlational design was used to study job satisfaction among NICU nurses. METHODS: Nurses were recruited at 2 regional NICU conferences in 2009 and 2010. The questionnaire was a researcher-developed survey consisting of 14 questions in a Likert-type response rating 1 to 5, with an area for comments. Descriptive statistics and correlations were used to analyze the resulting data. MAIN OUTCOME MEASURES: The majority of participants were moderately satisfied overall in their current position and workplace (mean ranking = 4.07 out of 5.0). Kendall’s Tau b (TB) revealed that the strongest positive correlations were between organizational support and team spirit with overall job satisfaction (TB = 0.53). RESULTS: The individual factors with the highest mean scores were caring for patients in a stressful situation, level of autonomy, and communication between nurses and neonatal nurse practitioners. This indicates that our population of NICU nurses feels most satisfied caring for patients in stressful situations (m = 4.48), are satisfied with their level of autonomy (M = 4.17), and are satisfied with the interdisciplinary communication in their units (m = 4.13). CONCLUSIONS: Nurses in the NICU are relatively satisfied with their jobs. The small sample size (n = 109) of Midwest NICU nurses proves to be a limitation for generalization. Additional research is needed to further evaluate nursing role, educational level, and job satisfaction in the NICU.

Integrated working between residential care homes and primary care: a survey of care homes in England.
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Gage H, Dickinson A, Victor C, Williams P, Cheynel J, Davies SL, et al.
BMC geriatrics 2012 Nov 14;12(1):71

BACKGROUND: Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor “fit” between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services. METHODS: A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621) in England in 2009. Responses were analysed using quantitative and qualitative methods. RESULTS: The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean (SD) professionals/services per bed of .39 (.163). The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for the experience and knowledge of care home staff. CONCLUSIONS: Care homes are a hub for a wide range of NHS activity, but this is ad hoc with no recognised way to support working together. Integration between care homes and local health services is only really evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. More integrated working between care homes and primary health services has the potential to improve quality of care in a cost- effective manner, but strategic decisions to create more formal arrangements are required to bring this about. Commissioners of services for older people need to capitalise on good working relationships and address idiosyncratic patterns of provision to care homes.The low response rate is indicative of the difficulty of undertaking research in care homes.

Psychological consequences of bullying for hospital and aged care nurses.
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Rodwell J, Demir D.
International nursing review 2012 Dec;59(4):539-546

Aim:  This study examines the psychological consequences of workplace bullying by negative affectivity (NA) and demographics for hospital and aged care nurses. Introduction/Background:  Nurses are particularly vulnerable to workplace bullying, with suggestions that oppressed group behaviours may play a role. Bullying is a potent stressor that can negatively impact psychological well-being, which, with NA and demographics, may be important in understanding the consequences of nurse bullying. Such factors are yet to be examined together across different nursing contexts. Methods:  A cross-sectional survey was conducted across hospital and aged care nurses working within a medium to large Australian healthcare organization in October 2009. The sample comprised 233 (29.1%) hospital and 208 (43.8%) aged care nurses. Analyses of covariance were used to evaluate the data. Results:  For hospital nurses, psychological distress was noted as an impact of bullying, while depression was the impact for aged care nurses. Full-time aged care nurses reporting bullying had higher psychological distress scores, compared with part-time workers in the same area. NA was a significant covariate across both outcomes in both contexts. Discussion/Conclusion:  This study demonstrates that bullying has detrimental consequences for the mental health of nurses in both hospital and aged care contexts. The results support the suggestion that nurses are an oppressed group at high risk of bullying, confirm the intrinsic nature of NA to the bullying process, and highlight the importance of employment type for aged care nurses. Given the shortage of nurses, managers need to give higher priority to addressing workplace bullying and implementing zero tolerance policies.
© 2012 The Authors. International Nursing Review © 2012 International Council of Nurses.

Cultivating nursing leadership for our envisioned future.
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Galuska LA.
ANS.Advances in nursing science 2012 Oct;35(4):333-345

Nurses have been called upon to lead and partner in the transformation of health care. Leadership is a component of the scope of nursing practice; however, the optimal approach to development of leadership competency has not been established. A metasynthesis of qualitative studies on leadership development was conducted to enhance an understanding of conditions that nurses reported to support or hinder their development as leaders. Noblit and Hare’s approach was used for the metasynthesis process. Three overarching themes emerged. Opportunity structure, the relationship factor, and organizational culture are essential factors contributing to the successful cultivation of leadership competencies in nurses.

Health Care Innovation and Quality Assurance
Sit-Stand Powered Mechanical Lifts in Long-Term Care and Resident Quality Indicators.
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Gucer PW, Gaitens J, Oliver M, McDiarmid MA.
Journal of occupational and environmental medicine 2012 Nov 7

OBJECTIVE: To determine associations between long-term care powered mechanical lift (PML) availability and mobility-related resident outcomes. METHODS:: Long-term care directors of nursing (N = 271) nationwide gave facility information on the PML availability and the lifting policy to which we linked data on mobility-related resident outcomes from the Centers for Medicare & Medicaid Services Minimum Data Set Quality Indicators. RESULTS: Four of six Centers for Medicare & Medicaid Services-derived resident indicators improved with the PML number but were maximal for the sit-stand lift use. In facilities with the fewest lifts, 16% of residents had pressure ulcers and 4% were bedfast. In facilities with the maximum number of lifts, only 10% had pressure ulcers (P = 0.000) and 2% were bedfast (P = 0.002). Although falls were more frequent with more lift use, this risk was blunted by a comprehensive safe lift program. CONCLUSION:: The PML availability is associated with benefits to resident outcomes, and accompanying risks are mitigated by safe lift policies.

Collaboration between local health and local government agencies for health improvement.
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Hayes SL, Mann MK, Morgan FM, Kelly MJ, Weightman AL.
Cochrane database of systematic reviews (Online) 2012 Oct 17;10:CD007825

In many countries, national, regional and local inter- and intra-agency collaborations have been introduced to improve health outcomes. Evidence is needed on the effectiveness of locally developed partnerships which target changes in health outcomes and behaviours. OBJECTIVES: To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes in any population or age group. SEARCH METHODS: We searched the Cochrane Public Health Group Specialised Register, AMED, ASSIA, CENTRAL, CINAHL, DoPHER, EMBASE, ERIC, HMIC, IBSS, MEDLINE, MEDLINE In-Process, OpenGrey, PsycINFO, Rehabdata, Social Care Online, Social Services Abstracts, Sociological Abstracts, TRoPHI and Web of Science from 1966 through to January 2012. ‘Snowballing’ methods were used, including expert contact, citation tracking, website searching and reference list follow-up. SELECTION CRITERIA: Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported individual health outcomes arising from interagency collaboration between health and local government agencies compared to standard care. Studies were selected independently in duplicate, with no restriction on population subgroup or disease. DATA COLLECTION AND ANALYSIS: Two authors independently conducted data extraction and assessed risk of bias for each study. MAIN RESULTS: Sixteen studies were identified (28,212 participants). Only two were considered to be at low risk of bias. Eleven studies contributed data to the meta-analyses but a narrative synthesis was undertaken for all 16 studies. Six studies examined mental health initiatives, of which one showed health benefit, four showed modest improvement in one or more of the outcomes measured but no clear overall health gain, and one showed no evidence of health gain. Four studies considered lifestyle improvements, of which one showed some limited short-term improvements, two failed to show health gains for the intervention population, and one showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies considered chronic disease management and all failed to demonstrate health gains. Three studies considered environmental improvements and adjustments, of which two showed some health improvements and one did not.Meta-analysis of three studies exploring the effect of collaboration on mortality showed no effect (pooled relative risk of 1.04 in favour of control, 95% CI 0.92 to 1.17). Analysis of five studies (with high heterogeneity) looking at the effect of collaboration on mental health resulted in a standardised mean difference of -0.28, a small effect favouring the intervention (95% CI -0.51 to -0.06). From two studies, there was a statistically significant but clinically modest improvement in the global assessment of function symptoms score scale, with a pooled mean difference (on a scale of 1 to 100) of -2.63 favouring the intervention (95% CI -5.16 to -0.10).For physical health (6 studies) and quality of life (4 studies) the results were not statistically significant, the standardised mean differences were -0.01 (95% CI -0.10 to 0.07) and -0.08 (95% CI -0.44 to 0.27), respectively. AUTHORS’ CONCLUSIONS: Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that interagency collaboration, compared to standard services, necessarily leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, difficulties in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these weaknesses are addressed in future studies (for example by providing greater detail on the implementation of programmes; using more robust designs, integrated process evaluations to show how well the partners of the collaboration worked together, and measurement of health outcomes) it could provide a better understanding of what might work and why. It is possible that local collaborative partnerships delivering environmental Interventions may result in health gain but the evidence base for this is very limited.Evaluations of interagency collaborative arrangements face many challenges. The results demonstrate that collaborative community partnerships can be established to deliver interventions but it is important to agree goals, methods of working, monitoring and evaluation before implementation to protect programme fidelity and increase the potential for effectiveness.

Patient participation in quality improvement: managers’ opinions of patients as resources.
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Andersson AC, Olheden A.
Journal of clinical nursing 2012 Dec;21(23-24):3590-3593

The aim of this study was to investigate managers’ opinions of how to take advantage of patients as resources in quality improvement work in the Swedish healthcare sector. METHODS: This study is a pilot, part of an ongoing evaluation of the county council improvement programme. Every year, all managers at all levels and representing all professions, from the county council director, heads of administrations and division managers, to unit and first-line managers, are invited to a managers meeting. All participating managers at this meeting in January 2011 were divided into 31 groups, including 300 of the total 330 managers in the county council. The groups were asked to write a short answer to the question, ‘How can I as a manager involve the patient to increase safety in health care by 2014?’ The 31 answers were analysed using a descriptive content analysis by both authors until consensus was reached (Graneheim & Lundman 2004). The result is presented in categories and subcategories. RESULTS: The result shows the different aspects of how managers in a healthcare organisation (i.e. a county council) consider the options to incorporate patients in the improvement process. Four categories and 10 subcategories were identified (Table 1). The first, overall category was Culture, consisting of the subcategories Attitude and Actions. Attitude involves openness and permission to be involved, moving the perspective from the organisational view to the patient process view. Actions are about demands, requests and making use of patients’ ideas. All personnel are part of the culture in an organisation, and a positive, inviting culture is considered to have greater potential for success. The managers think that the organisation must become more open-minded and the managers themselves must create space for improvement work for both patients and personnel.

Quality improvement in nursing: administrative mandate or professional responsibility?
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Izumi S.
Nursing forum 2012 Oct;47(4):260-267

For professionals, providing quality service and striving for excellence are ethical responsibilities. In many hospitals in the United States, however, there is evidence indicating that current quality improvement (QI) involving nurses is not always driven by their professional accountability and professional values. QI has become more an administrative mandate than an ethical standard for nurses. In this paper, the tension between QI as nurses’ professional ethics and an administrative mandate will be described, and the implicit ideal-reality gap of QI will be examined. The threat to professional nursing posed by the current approach to QI will be examined, and ways to incorporate nursing professional values in a practical QI effort will be explored. © 2012 Wiley Periodicals, Inc.

The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool.
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Okoniewska BM, Santana MJ, Holroyd-Leduc J, Flemons W, O Beirne M, White D, et al.
BMC health services research 2012 Nov 21;12(1):414

BACKGROUND: The transition between acute care and community care represents a vulnerable period in health care delivery. The vulnerability of this period has been attributed to changes to patients’ medication regimens during hospitalization, failure to reconcile discrepancies between admission and discharge and the burdening of patients/families to take over care responsibilities at discharge and to relay important information to the primary care physician. Electronic communication platforms can provide an immediate link between acute care and community care physicians (and other community providers), designed to ensure consistent information transfer. This study examines whether a transfer-of-care (TOC) communication tool is efficacious and cost-effective for reducing hospital readmission, adverse events and adverse drug events as well as reducing death. METHODS: A randomized controlled trial conducted on the Medical Teaching Unit of a Canadian tertiary care centre will evaluate the efficacy and cost-effectiveness of a TOC communication tool. Medical in-patients admitted to the unit will be considered for this study. Data will be collected upon admission, and a total of 1400 patients will be randomized. The control group’s acute care stay will be summarized using a traditional dictated summary, while the intervention group will have a summary generated using the TOC communication tool. The primary outcome will be a composite, at 3 months, of death or readmission to any Alberta acute-care hospital. Secondary outcomes will be the occurrence of post-discharge adverse events and adverse drug events at 1 month post discharge. Patients with adverse outcomes will have their cases reviewed by two Royal College certified internists or College-certified family physicians, blinded to patients’ group assignments, to determine the type, severity, preventability and ameliorability of all detected adverse outcomes. An accompanying economic evaluation will assess the cost per life saved, cost per readmission avoided and cost per QALY gained with the TOC communication tool compared to traditional dictation summaries. DISCUSSION: This paper outlines the study protocol for a randomized controlled trial evaluating an electronic transfer-of-care communication tool, with sufficient statistical power to assess the impact of the tool on the significant outcomes of post-discharge death or readmission. The study findings will inform health systems around the world on the potential benefits of such tools, and the value for money associated with their widespread implementation.Trial NCT01402609.

Appraising Hospital Performance by Using the JCHAO/CMS Quality Measures in Southern Italy.
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Flotta D, Rizza P, Coscarelli P, Pileggi C, Nobile CG, Pavia M.
PloS one 2012;7(11):e48923

The main objective of the present study was to estimate the uptake to quality indicators that reflect the current evidence-based recommendations and guidelines.
METHODS: A retrospective review of medical records of patients admitted to two hospitals in the South of Italy was conducted. For the purposes of the analysis, a sets of quality indicators has been used from the Joint Commission on Accreditation of Hospital Organizations and Centers for Medicare & Medicaid Services. Four areas of care were selected: acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and surgical care improvement project (SCIP). Frequency or median was calculated, as appropriate, for each indicator. A composite score was calculated to estimate the overall performance for each area of care. RESULTS: A total of 1772 medical records were reviewed. The adherence rates showed a wide-ranging variability among the selected indicators. The use of aspirin and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for AMI, the use of ACEI or ARB for HF, the use of appropriate thromboembolism prophylaxis and appropriate hair removal for surgical patients almost approached optimal adherence. At the other extreme, rates regarding adherence to smoking-cessation counseling in AMI and HF patients, discharge instructions in HF patients, and influenza and pneumococcal vaccination in pneumonia patients were noticeably intangible. Overall, the recommended processes of care among eligible patients were provided in 70% for AMI, in 32.4% for HF, in 46.4% for PN, and in 46% for SCIP. CONCLUSIONS: The results show that there is still substantial work that lies ahead on the way to improve the uptake to evidence-based processes of care. Improvement initiatives should be focused more on domains of healthcare than on specific conditions, especially on the area of preventive care.

Hospital implementation of health information technology and quality of care: are they related?
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Restuccia JD, Cohen AB, Horwitt JN, Shwartz M.
BMC medical informatics and decision making 2012 Sep 27;12(1):109

BACKGROUND: Recently, there has been considerable effort to promote the use of health information technology (HIT) in order to improve health care quality. However, relatively little is known about the extent to which HIT implementation is associated with hospital patient care quality. We undertook this study to determine the association of various HITs with: hospital quality improvement (QI) practices and strategies; adherence to process of care measures; riskadjusted inpatient mortality; patient satisfaction; and assessment of patient care quality by hospital quality managers and front-line clinicians. METHODS: We conducted surveys of quality managers and front-line clinicians (physicians and nurses) in 470 short-term, general hospitals to obtain data on hospitals’ extent of HIT implementation, QI practices and strategies, assessments of quality performance, commitment to quality, and sufficiency of resources for QI. Of the 470 hospitals, 401 submitted complete data necessary for analysis. We also developed measures of hospital performance from several publicly data available sources: Hospital Compare adherence to process of care measures; Medicare Provider Analysis and Review (MEDPAR) file; and Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS(R) survey. We used Poisson regression analysis to examine the association between HIT implementation and QI practices and strategies, and general linear models to examine the relationship between HIT implementation and hospital performance measures. RESULTS: Controlling for potential confounders, we found that hospitals with high levels of HIT implementation engaged in a statistically significant greater number of QI practices and strategies, and had significantly better performance on mortality rates, patient satisfaction measures, and assessments of patient care quality by hospital quality managers; there was weaker evidence of higher assessments of patient care quality by front-line clinicians. CONCLUSIONS: Hospital implementation of HIT was positively associated with activities intended to improve patient care quality and with higher performance on four of six performance measures.

Sustainability of healthcare innovations (SUSHI): long term effects of two implemented surgical care programmes (protocol).
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Ament SM, Gillissen F, Maessen JM, Dirksen CD, van der Weijden T, von Meyenfeldt MF.
BMC health services research 2012 Nov 23;12(1):423

BACKGROUND: Two healthcare innovations were successfully implemented using different implementation strategies. First, a Short Stay Programme for breast cancer surgery (MaDO) was implemented in four early adopter hospitals, using a hospital-tailored implementation strategy. Second, the Enhanced Recovery After Surgery (ERAS) programme for colonic surgery was implemented in 33 Dutch hospitals, using a generic breakthrough implementation strategy. Both strategies resulted in a shorter hospital length of stay without a decrease in quality of care. Currently, it is unclear to what extent these innovative programmes and their results have been sustained three to five years following implementation. The aim of the sustainability of healthcare innovations (SUSHI) study is to analyse sustainability and its determinants using two implementation cases. METHODS: This observational study uses a mixed methods approach. The study will be performed in 14 hospitals in the Netherlands, from November 2010. For both implementation cases, the programme aspects and the effects will be evaluated by means of a follow-up measurement in 160 patients who underwent breast cancer surgery and 300 patients who underwent colonic surgery. A policy cost-effectiveness analysis from a societal perspective will be performed prospectively for the Short Stay Programme for breast cancer surgery in 160 patients. To study determinants of sustainability key professionals in the multidisciplinary care processes and implementation change agents will be interviewed using semi-structured interviews. DISCUSSION: The concept of sustainability is not commonly studied in implementation science. The SUSHI study will provide insight in to what extent the short-term implementation benefits have been maintained and in the determinants of long-term continuation of programme activities.

Quality assurance and performance improvement in nursing homes: using evidence-based protocols to observe nursing care processes in real time.
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Dellefield ME, Kelly A, Schnelle JF.
Journal of nursing care quality 2013 Jan;28(1):43-51

The Quality Assurance and Performance Improvement Initiative, a component of the Affordable Care Act (2010), is a new approach to quality improvement for US nursing homes. The article describes components of the Quality Assurance and Performance Improvement Initiative, the unique contributions of registered nurses to its implementation, and data collection strategies using direct observation and evidence-based measures and protocols in a Quality Assurance and Performance Improvement program.

Research Methodology
A model for the electronic support of practice-based research networks.
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Peterson KA, Delaney BC, Arvanitis TN, Taweel A, Sandberg EA, Speedie S, et al.
Annals of family medicine 2012 Nov;10(6):560-567

PURPOSE The principal goal of the electronic Primary Care Research Network (ePCRN) is to enable the development of an electronic infrastructure to support clinical research activities in primary care practice-based research networks (PBRNs). We describe the model that the ePCRN developed to enhance the growth and to expand the reach of PBRN research. METHODS Use cases and activity diagrams were developed from interviews with key informants from 11 PBRNs from the United States and United Kingdom. Discrete functions were identified and aggregated into logical components. Interaction diagrams were created, and an overall composite diagram was constructed describing the proposed software behavior. Software for each component was written and aggregated, and the resulting prototype application was pilot tested for feasibility. A practical model was then created by separating application activities into distinct software packages based on existing PBRN business rules, hardware requirements, network requirements, and security concerns. RESULTS We present an information architecture that provides for essential interactions, activities, data flows, and structural elements necessary for providing support for PBRN translational research activities. The model describes research information exchange between investigators and clusters of independent data sites supported by a contracted research director. The model was designed to support recruitment for clinical trials, collection of aggregated anonymous data, and retrieval of identifiable data from previously consented patients across hundreds of practices. CONCLUSIONS The proposed model advances our understanding of the fundamental roles and activities of PBRNs and defines the information exchange commonly used by PBRNs to successfully engage community health care clinicians in translational research activities. By describing the network architecture in a language familiar to that used by software developers, the model provides an important foundation for the development of electronic support for essential PBRN research activities.

Quality of descriptions of treatments: a review of published randomised controlled trials.
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Schroter S, Glasziou P, Heneghan C.
BMJ open 2012 Nov 22;2(6):10.1136/bmjopen-2012-001978. Print 2012

To be useable in clinical practise, treatments studied in trials must provide sufficient information to enable clinicians and researchers to replicate. We sought to assess the completeness of treatment descriptions in published randomised controlled trials (RCTs) using a checklist and to determine the extent to which peer reviewers and editors comment on the quality of reporting of treatments. DESIGN: A cross-sectional study. SETTING: Trials published in the BMJ, a general medical journal. PARTICIPANTS: Fifty-one trials published in the BMJ were independently evaluated by two raters using a checklist. Reviewers’ and editors’ comments were also assessed for statements on treatment descriptions. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of trials rated as replicable (primary outcome). RESULTS: For 57% (29/51) of the papers, published treatment descriptions were not considered sufficient to allow replication. Most poorly described aspects were the actual procedures involved including the sequencing of the technique (what happened and when) and the physical or informational materials used (eg, training materials): 53% and 43% not clear, respectively. For a third of treatments, the dose/duration of individual sessions was not clear and for a quarter the schedule (interval, frequency, duration or timing) was not clear. Although the majority of problems were not picked up by reviewers and editors, when they were detected only about two-thirds were fixed before publication. CONCLUSIONS: Journals wanting to publish the research of use to practising healthcare professionals need to pay more attention to descriptions of treatments. Our checklist, may be useful for reviewers, and editors and could help ensure that important details of treatments are provided before papers are in the public domain.

Should researchers use single indicators, best indicators, or multiple indicators in structural equation models?
Non UofA Access
Hayduk LA, Littvay L.
BMC medical research methodology 2012 Oct 22;12:159-2288-12-159

Structural equation modeling developed as a statistical melding of path analysis and factor analysis that obscured a fundamental tension between a factor preference for multiple indicators and path modeling’s openness to fewer indicators. DISCUSSION: Multiple indicators hamper theory by unnecessarily restricting the number of modeled latents. Using the few best indicators – possibly even the single best indicator of each latent – encourages development of theoretically sophisticated models. Additional latent variables permit stronger statistical control of potential confounders, and encourage detailed investigation of mediating causal mechanisms. SUMMARY: We recommend the use of the few best indicators. One or two indicators are often sufficient, but three indicators may occasionally be helpful. More than three indicators are rarely warranted because additional redundant indicators provide less research benefit than single indicators of additional latent variables. Scales created from multiple indicators can introduce additional problems, and are prone to being less desirable than either single or multiple indicators.

Health Care in Canada

Commonwealth Fund: International Profiles of Health Care Systems: Australia, Canada, Denmark, England, France, Germany, Japan, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States
November 2012

This publication presents overviews of the health care systems of Australia, Canada, Denmark, England, France, Germany, Japan, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Each overview covers health insurance, public and private financing, health system organization, quality of care, health disparities, efficiency and integration, care coordination, use of health information technology, use of evidence-based practice, cost containment, and recent reforms and innovations. In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views.

CIHI: Health Care in Canada 2012: A Focus on Wait Times
Nov 29, 2012

To improve the overall performance of the health care system, an understanding of wait times beyond the 5 priority areas and across the health care continuum is required. Health Care in Canada 2012 highlights what is known about the patient’s experience in waiting for care in different settings, and where gaps exist. It also provides examples of initiatives that have been successful in improving wait times in different areas.

CIHI: Seniors and Alternate Level of Care: Building on our Knowledge
Nov 29, 2012

Using data from three CIHI databases, this study looks at seniors waiting in acute care for discharge to the community. It examines the factors related to having alternate level of care (ALC) days and to the level of care to which the person is discharged (residential care or home with home care services).

Canada’s Clinical Trial Infrastructure
November 2012, Senate: The Standing Senate Committee on Social Affairs, Science and Technology

On 22 November 2011, the Senate adopted an Order of Reference authorizing the Senate Standing Committee on Social Affairs, Science and Technology to examine and report on prescription pharmaceuticals in Canada. The study includes four components, each to be studied separately, which are: the process to approve prescription pharmaceuticals with a particular focus on clinical trials; the post-approval monitoring of prescription pharmaceuticals; the off-label use of prescription pharmaceuticals; and the nature of unintended consequences in the use of prescription pharmaceuticals. This report is on this first phase of the study, for which the committee heard from witnesses between 28 March and 30 May 2012. Over the course of 11 meetings, the committee heard testimony from Health Canada and Office of the Auditor General of Canada officials, representatives from the pharmaceutical and clinical trial industries, patient advocacy groups, medical, ethical and legal academics and finally, representatives of research ethics boards.

CHSRF: Strengthening primary health care through primary care and public health collaboration
October 2012

The objectives of this four and a half year program of research were to: explore structures and processes required to build successful collaborations between PC and PH; understand the nature of existing collaborations in Canada; and, examine roles that nurses and other providers played in collaborations. h e research team represents academic researchers and decisionmakers from British Columbia (BC), Ontario (ON) and Nova Scotia (NS), as well as national leaders in PC and PH. By gaining a stronger understanding of the nature of existing collaborations and the structures and processes that support and hinder their success, this program of research has begun to answer how to create and enhance future PC and PH collaborations.

Effect of an occupation-based cultural heritage intervention in long-term geriatric care: a two-group control study.
Non UofA Access
Hersch G, Hutchinson S, Davidson H, Wilson C, Maharaj T, Watson KB.
American Journal of Occupational Therapy 2012 Mar-Apr;66(2):224-232

OBJECTIVE. We investigated the effectiveness of an occupation-based cultural heritage intervention to facilitate adaptation to relocation into long-term care (LTC) facilities as measured by quality of life, activity engagement, and social participation. METHOD. We used a quasi-experimental nonequivalent control group design with pre- and posttests. Residents receiving the cultural intervention were compared with residents in a typical activity group. Eight sessions, two per week for 4 wk, were facilitated by certified occupational therapy assistants. RESULTS. Twenty-nine participants completed the group sessions. Quality-of-life scores improved significantly over time for both groups. Statistically, a greater percentage of time was spent in discretionary than obligatory time, pretest and posttest, with no significant difference between groups. CONCLUSION. The study demonstrated effectiveness of a structured, occupation-based social group intervention that improved quality of life, an indicator of adaptation. It also provided a description of activity patterns and social participation of LTC residents. Copyright © 2012 by the American Occupational Therapy Association, Inc.

Medication adherence in older adults with cognitive impairment: a systematic evidence-based review.
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Campbell NL, Boustani MA, Skopelja EN, Gao S, Unverzagt FW, Murray MD.
The American journal of geriatric pharmacotherapy 2012 Jun;10(3):165-177

Cognitive impairment challenges the ability to adhere to the complex medication regimens needed to treat multiple medical problems in older adults. OBJECTIVE: Our aim was to conduct a systematic evidence-based review to identify barriers to medication adherence in cognitively impaired older adults and interventions aimed at improving medication adherence. METHODS: A search of MEDLINE, EMBASE, PsycINFO, GoogleDocs, and CINAHL for articles published between 1966 and February 29, 2012 was performed. Studies included older adults with a diagnosis of cognitive impairment of any degree (mild cognitive impairment or mild, moderate, or severe dementia). To identify barriers to adherence, we reviewed observational studies. To identify relevant interventions, we reviewed clinical trials targeting medication adherence in cognitively impaired older adults. We excluded studies lacking a measure of medication adherence or lacking an assessment of cognitive function, case reports or series, reviews, and those focusing on psychiatric disorders or infectious diseases. Population demographics, baseline cognitive function, medication adherence methods, barriers to adherence, and prospective intervention methodologies were extracted. RESULTS: The initial search identified 594 articles. Ten studies met inclusion criteria for barriers to adherence and three met inclusion criteria for interventional studies. Unique barriers to adherence included understanding new directions, living alone, scheduling medication administration into the daily routine, using potentially inappropriate medications, and uncooperative patients. Two studies evaluated reminder systems and showed no benefit in a small group of participants. One study improved adherence through telephone and televideo reminders at each dosing interval. The results of the review are limited by reviewing only published articles, missing barriers or interventions due to lack of subgroup analysis, study selection and extraction completed by 1 reviewer, and articles with at least an abstract published in English. CONCLUSIONS: The few studies identified limit the assessment of barriers to medication adherence in the cognitively impaired population. Successful interventions suggest that frequent human communication as reminder systems are more likely to improve adherence than nonhuman reminders.Copyright © 2012 Elsevier HS Journals, Inc. All rights reserved.

‘Are decisions about discharge of elderly hospital patients mainly about freeing blocked beds?’ A qualitative observational study.
Non UofA Access
Ekdahl AW, Linderholm M, Hellstrom I, Andersson L, Friedrichsen M.
BMJ open 2012 Nov 19;2(6):10.1136/bmjopen-2012-002027. Print 2012

To explore the interactions concerning the frail and elderly patients having to do with discharge from acute hospital wards and their participation in medical decision-making. The views of the patients and the medical staff were both investigated. DESIGN: A qualitative observational and interview study using the grounded theory. SETTING AND PARTICIPANTS: The setting was three hospitals in rural and urban areas of two counties in Sweden of which one was a teaching hospital. The data comprised observations, healthcare staff interviews and patient interviews. The selected patients were all about to be informed that they were going to be discharged. RESULTS: The patients were seldom invited to participate in the decision-making regarding discharge. Generally, most communications regarding discharge were between the doctor and the nurse, after which the patient was simply informed about the decision. It was observed that the discharge information was often given in an indirect way as if other, albeit absent, people were responsible for the decision. Interviews with the healthcare staff revealed their preoccupation with the need to free up beds: ‘thinking about discharge planning all the time’ was the core category. This focus not only failed to fulfil the complex needs of elderly patients, it also generated feelings of frustration and guilt in the staff, and made the patients feel unwelcome. CONCLUSIONS: Frail elderly patients often did not participate in the medical decision-making regarding their discharge from hospital. The staff was highly focused on patients getting rapidly discharged, which made it difficult to fulfil the complex needs of these patients.

What is the frailty in elderly? Value and significance of the multidimensional assessments.
Non UofA Access
Malaguarnera M, Vacante M, Frazzetto PM, Motta M.
Archives of Gerontology and Geriatrics 2013 Jan-Feb;56(1):23-26

Authors perform a critical revision of the concept of frailty in elderly going back to its first indication (1978). It is a particular phenotypic condition, characterized by advanced age, clinically unstable polypathologies in evolution, with cognitive disturbances, often very severe, loss of auto sufficiency and the critical socio-economic conditions. The diagnostic validity, both in the definition of the deficits and in the evaluation of the declines in the fundamental functions should be underlined. The first ones are needed particularly for the epidemiological and population studies, and the second one, at the individual level. Today, first of all in the geriatric field, the method of multidimensional evaluation (MDE) is the first choice for the early diagnosis of “elderly frailty” (EF), in order to determine the biological, functional, cognitive and clinical aspects of the elderly subjects, and also for the application of adequate programs of intervention at the sanitary-assistential-social levels. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Factors favoring a degradation or an improvement in activities of daily living (ADL) performance among nursing home (NH) residents: A survival analysis.
Non UofA Access
Burge E, von Gunten A, Berchtold A.
Archives of Gerontology and Geriatrics 2013 Jan-Feb;56(1):250-257

Different factors influence ADL performance among nursing home (NH) residents in long term care. The aim was to investigate which factors were associated with a significant change of ADL performance in NH residents, and whether or not these factors were gender-specific. The design was a survival analysis. The 10,199 participants resided in ninety Swiss NHs. Their ADL performance had been assessed by the Resident Assessment Instrument Minimum Data Set (RAI-MDS) in the period from 1997 to 2007. Relevant change in ADL performance was defined as 2 levels of change on the ADL scale between two successive assessments. The occurrence of either an improvement or a degradation of the ADL status) was analyzed using the Cox proportional hazard model. The analysis included a total of 10,199 NH residents. Each resident received between 2 and 23 assessments. Poor balance, incontinence, impaired cognition, a low BMI, impaired vision, no daily contact with proxies, impaired hearing and the presence of depression were, by hierarchical order, significant risk factors for NH residents to experience a degradation of ADL performance. Residents, who were incontinent, cognitively impaired or had a high BMI were significantly less likely to improve their ADL abilities. Male residents with cancer were prone to see their ADL improve. The year of NH entry was significantly associated with either degradation or improvement of ADL performance. Measures aiming at improving balance and continence, promoting physical activity, providing appropriate nourishment and cognitive enhancement are important for ADL performance in NH residents. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Supporting and promoting personhood in long term care settings: contextual factors.
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O Siegel E, A Anderson R, Calkin J, H Chu C, N Corazzini K, Dellefield ME, et al.
International journal of older people nursing 2012 Dec;7(4):295-302

The need for personhood-focused long-term care (LTC) is well-documented. A myriad of sociocultural, political, nursing/professional and organisational contexts facilitate or hinder registered nurses (RNs)’ capacity to ensure personhood-focused LTC. Complexities derive from the countless interrelated aspects of these contexts, blurring clear distinctions of causality, responsibility and accountability. Context-related complexities were highlighted at a recent international conference attended by invited experts in LTC leadership from six countries (Canada, USA, England, Northern Ireland, New Zealand and Sweden). The group was convened to explore the value and contributions of RNs in LTC (McGilton, , International Journal of Older People Nursing 7, 282). The purpose of this paper is to expand the discussion of personhood-focused care beyond RNs, to contexts that influence the RN’s capacity to ensure personhood-focused practices are embedded in LTC settings. Consistent with key topics covered at the international conference, we selected four major contexts for discussion in this paper: (i) sociocultural, (ii) public policy/financing/regulation, (iii) nursing/professional and (iv) organisational. For each context, we provide a brief description, literature and examples from a few countries attending the conference, potential impact on personhood-focused practices and RN strategies to facilitate personhood-focused care. The knowledge gained from attending to the influence of contextual factors on the RN’s role in facilitating personhood-focused practices provides critical insights and directions for interventions aimed to maximise RN role effectiveness in LTC. In practice, understanding linkages between the various contexts offers indispensable insight for LTC nurse leaders charged with managing day-to-day operations and leading quality improvement initiatives that promote personhood-focused practices. © 2012 Blackwell Publishing Ltd.

Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies
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You EC, Dunt D, Doyle C, Hsueh A.
BMC health services research 2012 Nov 14;12:395-6963-12-395

Case management has been applied in community aged care to meet frail older people’s holistic needs and promote cost-effectiveness. This systematic review aims to evaluate the effects of case management in community aged care on client and carer outcomes. METHODS: We searched Web of Science, Scopus, Medline, CINAHL (EBSCO) and PsycINFO (CSA) from inception to 2011 July. Inclusion criteria were: no restriction on date, English language, community-dwelling older people and/or carers, case management in community aged care, published in refereed journals, randomized control trials (RCTs) or comparative observational studies, examining client or carer outcomes. Quality of studies was assessed by using such indicators as quality control, randomization, comparability, follow-up rate, dropout, blinding assessors, and intention-to-treat analysis. Two reviewers independently screened potentially relevant studies, extracted information and assessed study quality. A narrative summary of findings were presented. RESULTS: Ten RCTs and five comparative observational studies were identified. One RCT was rated high quality. Client outcomes included mortality (7 studies), physical or cognitive functioning (6 studies), medical conditions (2 studies), behavioral problems (2 studies) , unmet service needs (3 studies), psychological health or well-being (7 studies) , and satisfaction with care (4 studies), while carer outcomes included stress or burden (6 studies), satisfaction with care (2 studies), psychological health or well-being (5 studies), and social consequences (such as social support and relationships with clients) (2 studies). Five of the seven studies reported that case management in community aged care interventions significantly improved psychological health or well-being in the intervention group, while all the three studies consistently reported fewer unmet service needs among the intervention participants. In contrast, available studies reported mixed results regarding client physical or cognitive functioning and carer stress or burden. There was also limited evidence indicating significant effects of the interventions on the other client and carer outcomes as described above. CONCLUSIONS: Available evidence showed that case management in community aged care can improve client psychological health or well-being and unmet service needs. Future studies should investigate what specific components of case management are crucial in improving clients and their carers’ outcomes.

Outbreaks of influenza-like illness in long-term care facilities in Winnipeg, Canada.
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Mahmud SM, Thompson LH, Nowicki DL, Plourde PJ.
Influenza and other respiratory viruses 2012 Nov 12

Background  Outbreaks of influenza-like illness (ILI) are common in long-term care facilities (LTCFs) and result in significant morbidity and mortality among residents. Objectives  We describe patterns of reported ILI outbreaks in LTCFs in Winnipeg, Canada, and examine LTCF and outbreak characteristics that influence the clinical outcomes of these outbreaks. Methods  We analyzed the electronic records of all ILI outbreaks reported by LTCFs in Winnipeg from 2003 to 2011. Outbreak duration, ILI attack rates among staff and residents, and residents’ death rates were calculated by presumed viral etiology, staff vaccination rates, type of influenza chemoprophylaxis used, and time to notification to public health. Results  Of a total of 154 reported outbreaks, most (N = 80) were attributed to influenza, and these outbreaks tended to have higher attack and death rates among LTCF residents compared with outbreaks caused by other respiratory viruses (12) or those of unknown etiology (62). About 92% of residents and 38% of staff of the average LTCFs were vaccinated. Chemoprophylaxis was used in 57·5% of influenza outbreaks. Regardless of presumed viral etiology, outbreaks reported within 3 days of onset ended sooner and had lower attack and mortality rates among residents. Conclusions  Influenza-like illness outbreaks still occur among highly immunized LTCF residents, so in addition to vaccination of staff and residents, it is important to maintain competent infection control practices. Early identification and notification to public health authorities and possibly early initiation of control measures could improve clinical outcomes of ILI outbreaks.
© 2012 Blackwell Publishing Ltd.

Effectiveness of Acute Geriatric Unit Care Using Acute Care for Elders Components: A Systematic Review and Meta-Analysis.
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Fox MT, Persaud M, Maimets I, O’Brien K, Brooks D, Tregunno D, et al.
Journal of the American Geriatrics Society 2012 Nov 23

To compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care. DESIGN: Systematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources. SETTING: Acute care geriatric and nongeriatric hospital units. PARTICIPANTS: Acutely ill or injured adults (N = 6,839) with an average age of 81. INTERVENTIONS: Acute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment. MEASUREMENTS: Falls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions. RESULTS: Acute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29-0.88), less delirium (RR = 0.73, 95% CI = 0.61-0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78-0.97), shorter length of hospital stay (weighted mean difference (WMD) = -0.61, 95% CI = -1.16 to -0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68-0.99), lower costs (WMD = -$245.80, 95% CI = -$446.23 to -$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01-1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions. CONCLUSION: Acute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults’ illness or injury, improves patient- and system-level outcomes. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Health economics research into supporting carers of people with dementia: A systematic review of outcome measures.
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Jones C, Tudor Edwards R, Hounsome B.
Health and quality of life outcomes 2012 Nov 26;10(1):142

ABSTRACT: Advisory bodies, such as the National Institute for Health and Clinical Excellence (NICE) in the UK, advocate using preference based instruments to measure the quality of life (QoL) component of the quality-adjusted life year (QALY). Cost per QALY is used to determine cost-effectiveness, and hence funding, of interventions. QALYs allow policy makers to compare the effects of different interventions across different patient groups. Generic measures may not be sensitive enough to fully capture the QoL effects for certain populations, such as carers, so there is a need to consider additional outcome measures, which are preference based where possible to enable cost-effectiveness analysis to be undertaken. This paper reviews outcome measures commonly used in health services research and health economics research involving carers of people with dementia. An electronic database search was conducted in PubMed, Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the National Health Service Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment database. Studies were eligible for inclusion if they included an outcome measure for carers of people with dementia. 2262 articles were identified. 455 articles describing 361 studies remained after exclusion criteria were applied. 228 outcome measures were extracted from the studies. Measures were categorised into 44 burden measures, 43 mastery measures, 61 mood measures, 32 QoL measures, 27 social support and relationships measures and 21 staff competency and morale measures. The choice of instrument has implications on funding decisions; therefore, researchers need to choose appropriate instruments for the population being measured and the type of intervention undertaken. If an instrument is not sensitive enough to detect changes in certain populations, the effect of an intervention may be underestimated, and hence interventions which may appear to be beneficial to participants are not deemed cost-effective and are not funded. If this is the case, it is essential that additional outcome measures which detect changes in broader QoL are included, whilst still retaining preference based utility measures such as EQ-5D to allow QALY calculation for comparability with other interventions.

Nonpharmacologic management of behavioral symptoms in dementia.
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Gitlin LN, Kales HC, Lyketsos CG.
JAMA 2012 Nov 21;308(19):2020-2029

This article is the topic of IHI and JAMA’a Author in the Room session see below for more details.

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behaviors can accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, and result in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case, we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction.

Care Quality Commission: State of Care Report 2011/12
November 2012

This report looks at the shape of care services in England and the quality of care that they provide to people. Due to England’s growing population and the increase in the number of people who are being treated for complex conditions, our inspectors are seeing a growth in services that are struggling to cope with the pressures on them. Most of all, this affects those who are unable to speak up for themselves. Therefore, we have focused this report on whether health and social care services are treating people with respect and dignity and involving them in decisions about their care. The findings in this report have been drawn from the information we gather about care services during registration, our inspections and themed reviews, the experiences of people who use services and national statistics.

AHRQ: Long-Term Care for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care
Nov 2012

Objectives. To compare long-term care (LTC) for older adults delivered through Home and Community-Based Services (HCBS) with care provided in nursing homes (NHs) by evaluating (1) the characteristics of older adults served through HCBS and in NHs; (2) the impact of HCBS and NH care on outcome trajectories of older adults; and (3) the per person costs of HCBS and NH care, costs for other services such as acute care, and family burden. Data sources. Bibliographic databases MEDLINE and AGELINE; grey literature in the form of program evaluation reports and reports and analyses from Web sites of relevant State and Federal agencies and research organizations; citation searches of articles; and hand searches. Review methods. We included randomized controlled trials (RCTs) and observational studies that directly compared LTC for older adults (age ≥60) served through HCBS and in NHs. Studies were limited by date (1995–March 2012), language (English), and geographical location (United States and other economically developed countries with well-established health and LTC systems). Because assisted living (AL) encompasses elements of institutions, we treated it as a separate category within HCBS. We compared the characteristics of LTC recipients and the impact of the setting on outcome trajectories for physical function, cognition, mental health, mortality, use of acute care services, harms, and costs. We qualitatively synthesized results. We assessed the risk of bias and applicability of individual studies and graded the overall strength of evidence for each examined outcome. Results. We identified 42 relevant studies (37 peer reviewed, 5 grey literature). We identified no RCTs. Of the 37 peer-reviewed articles, 22 evaluated recipient characteristics at a specific time, and 15 analyzed outcome trajectories over time (of which 14 were used in the longitudinal analytic set). On average, NH residents had more limitations in physical and cognitive function than both HCBS recipients and AL residents, but mental health and clinical status were mixed. The 14 studies that compared the outcome trajectories of HCBS recipients or AL residents with NH residents over time had a high risk of bias, resulting in low or insufficient evidence for all outcomes examined. In comparing AL with NH, low-strength evidence suggested no differences in outcomes for physical function, cognition, mental health, and mortality. In comparing HCBS with NHs, low-strength evidence suggested that HCBS recipients experienced higher rates of some harms while NH residents experienced higher rates of other harms. Evidence was insufficient for other outcome domains and comparisons. Evidence was also insufficient for cost comparisons. Conclusions. Determining whether and how the delivery of LTC through HCBS versus NHs affects outcome trajectories of older adults is difficult due to scant evidence and the methodological limitations of studies reviewed. More and better research is needed to draw robust conclusions about how the setting of care delivery influences the outcomes and costs of LTC for older adults.


Non UofA
Remodelling Healthcare to Increase Innovation and Sustainability
Tuesday Dec 11, 2012 Toronto, ON

This conference explores new models of innovative service delivery. It includes speakers from government, healthcare organizations, and industry.

KT Canada Seminar Series: Enhancing Coaching and Leadership Competencies to Promote Knowledge Translation in Long-term Care
Presenter Dr. Greta Cummings, 10:00-12:00 MT

Learning Objectives

  1. To discuss long-term care managers’ willingness and intentions to implement coaching practices with their staff.
  2. To discuss experiences of implementing coaching skills in the workplace.
  3. To discuss impact of real-world changes on study design.

December Author in the Room® Teleconference: Evidence-Based Management of Behavioral Symptoms in Dementia Using Nonpharmacologic Approaches
Wednesday, December 19 from 12:00-13:00 MT

Behavioral symptoms such as repetitive statements and questions, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, they can accelerate disease progression, worsen functional decline and quality of life, and may result in earlier nursing home placement. These behaviors also result in significant caregiver distress. Systematic screening for behavioral symptoms in dementia is an important prevention strategy and facilitates early treatment by identifying underlying causes and tailoring the treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, are associated with notable risks, and do not effectively treat some of the behaviors that family members find the most distressing. Nonpharmacologic treatments include caregiver education, training in problem solving, communication and task simplification skills, patient exercise, and/or activity programs. Targeted nonpharmacologic interventions involve therapy directed at the underlying causes for specific behaviors, for example, implementing nighttime routines to address sleep disturbances.


RWJF Connect eTraining Series: Leveraging the Media to Gain Policymaker Support
Friday Dec 14, 2012 12:00-13:30 MT

The media can play an important role in distributing your message, but navigating the press can be just as tricky as figuring out how to work with policymakers. This session will focus on how to engage local and national media in ways that help you get the attention of policymakers, and eventually, help grantees shape good policy.

NCCHPP: Introduction to Health Impact Assessment of Public Policies
English course available from May 1-June 12, 2013 Registration deadline March 20, 2013

An online course on health impact assessment (HIA) of public policies has been developed by the NCCHPP and the Institut national de santé publique du Québec (Québec’s public health institute – INSPQ) in collaboration with Dr. Richard Massé, associate professor at the Department of social and preventive medicine at the University of Montreal, and other partners. This course aims to help participants to develop and improve their competencies for leading an HIA process relating to public policies, and to do this with partners from different sectors. The course is intended for participants who wish to pursue the HIA of public policies. In particular, it is meant for practitioners in public health and in other related sectors, as well as for decision makers.

Alberta’s LTC facilties bathing standards to be reviewed

Associate Health Minister, George Vanderburg, announced that the Ministry will be looking into recent allegations of infrequent opportunities to bathe and shower for LTC residents.

10 Yrs Since the Romanow Report – Sholom Glouberman on Patient Participation

At the Canadian Association for Health Services and Policy Research (CAHSPR) conference ’10 Years Since the Romanow Report: Retrospect … and Prospect’ Patients’ Association President Sholom Glouberman speaks to the notion that people are no longer suffering from acute infectious diseases but long-term chronic conditions. For this reason patient engagement must be included in modern healthcare systems.

Tenure track positions for professor/researcher
DEADLINE: 25 January 2012

The department of family medicine and emergency medicine at Université Laval is recruiting to fill up two tenure-track positions (professor-researcher). The successful candidates will work closely with the Education and Professional Development’s Office (VDPDPC) which focuses on educating and supporting faculty members. Detailed information can be found at:
Interprofessional collaboration in health care—Professor-Researcher
In health Sciences Education—Professor-Researcher

CIHR: Creation of Task Force on Ethics Reform

At their August 2012 retreat, Governing Council directed CIHR to undertake a review of the approaches the organization currently uses to meet its mandate in the area of ethics. The objectives of the review are to ensure effective alignment of internal efforts and to achieve optimal impact vis-à-vis CIHR’s direction and processes and those of the newly created tri-council structure. To this end, I am pleased today to announce the creation of the Task Force on Ethics Reform at CIHR, which will conduct the review.

PDQ-Evidence for Informed Health Policy Making

PDQ (“pretty darn quick”)-Evidence facilitates rapid access to the best available evidence for decisions about health systems. It includes systematic reviews, overviews of reviews (including evidence-based policy briefs), primary studies included in systematic reviews and structured summaries of that evidence. The aim of PDQ-Evidence is to provide rapid access to systematic reviews of health systems evidence. A unique feature of PDQ-Evidence is that it links together systematic reviews, overviews of reviews and primary studies, thus providing a highly efficient method for searching. In addition, it includes translations of the titles and abstracts of included records to facilitate searching in different languages and it is continually updated by searching multiple sources of systematic reviews and overviews of reviews.
PDQ-Evidence is not a comprehensive database of health systems research. It only includes primary studies that have been included in a systematic review.

New and Free Qualitative Analysis Software: QDA Miner Lite

It can be used for the analysis of textual data such as interview and news transcripts, open-ended responses, etc. as well as for the analysis of still images.

Want to Know More: DEMENTIA Nursing Standard of Practice Protocol: Recognition and Management of Dementia

From the Hartford School of Geriatric Nursing, this information is organized to provide care for dementia patients.

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