Jan 20, 2014

Grants & Awards

Congratulations to Matthias Hoben and Elizabeth Dogherty.

Both are recipients of Alberta Innovates – Health Solutions (AIHS) Training and Early Career Development Programs competition for Postgraduate Fellowship and will be supervised by Dr. Carole Estabrooks. This award fosters the development of future health research and innovation leaders, and prepares them to be drivers of change in diverse settings and environments. Matthias’ will be looking at quality indicators for oral health and Elizabeth will be developing and testing a facilitation intervention to enhance evidence uptake in the management of depression in LTC. Way to go Elizabeth and Matthias!!!


New Report by Dr. Greta Cummings
Shining a Light on the Unregulated Healthcare Aide Workforce

The study’s goal was to identify what is known, what is not known, and what needs to be done in the future to guide research and policy related to the HCA workforce.

Article recommended by Dr. Carole Estabrooks
Nursing Home Characteristics Associated with Resident Transfers to Emergency Departments. Canada-flat-icon
Non UofA Access
McGregor MJ, Abu-Laban RB, Ronald LA, McGrail KM, Andrusiek D, Baumbusch J, et al.
Canadian journal on aging 2014 Jan 3:1-11

This study examined how nursing home facility ownership and organizational characteristics relate to emergency department (ED) transfer rates. The sample included a retrospective cohort of nursing home residents in the Vancouver Coastal Health region (n = 13,140). Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis. Crude ED transfer rates (transfers/100 resident years) were 69, 70, and 51, respectively, in for-profit, non-profit, and publicly owned facilities. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared to for-profit and non-profit ownership. Results showed that higher total direct-care nursing hours per resident day, and presence of allied health staff – disproportionately present in publicly owned facilities – were associated with lower transfer rates. A number of other facility organizational characteristics – unrelated to ownership – were also associated with transfer rates.

CALL FOR ABSTRACTS: Gerontological Society of America’s Annual Scientific Meeting
5-9 November 2014 Washington DC
DEADLINE 5 March 2014

GSA continually strives to provide the gerontological community with the most advanced research and education. Present at this year’s Annual Scientific Meeting to an engaged audience of professional peers, gain exposure of your work, and advance your career.

CALL FOR ABSTRACTS: 13th Annual Advances in Qualitative Methods Conference
23-25 June 2014 Edmonton AB
DEADLINE 13 February

Contemporary, societal, and organizational issues are complex and practitioners and policy-makers are seeking strong evidence upon which to base decisions. Qualitative research is increasingly used to understand or address specific issues or problems in relation to practice, policy, or outcomes. While qualitative studies are necessary and important in applied social research, many issues arise in their enactment. AQM 2014 will provide a forum for the discussion of experiences and challenges with applied qualitative research and for the sharing of ideas that can strengthen it.

19-20 June 2014 Nottingham UK
DEADLINE 14 February

The Health Services Research Network (HSRN) Symposium presents the leading edge of health services research. The multidisciplinary programme will include research presentations and posters, plenaries from research and service leaders, and commissioned themes.

CALL FOR PAPERS: IJQM: How Mixed Methods Informs and Enhances Qualitative Research
DEADLINES 1 March (abstracts), 31 August (papers)

There is a need for high quality examples of mixed methods research that guide and encourage innovation for qualitative researchers. This special issue include manuscripts covering a range of topics including examples of integrating mixed methods into qualitative research, innovations, challenges, and future directions.

CALL FOR ABSTRACTS: Translation and Communications Interest Group for the AcademyHealth 2014 Annual Research Meeting
7 June 2014 San Diego, California
DEADLINE 14 February 2014

The Translation and Communications Interest Group (IG) invites submission of abstracts by both early career (less than five years post-Ph.D.) and senior investigators for panel or Pecha Kucha presentations, and by early career investigators for poster presentations. Submitted abstracts will undergo blind peer review by a committee of volunteers. This Interest Group provides support and collaboration to all IGs in translating and communicating research. We invite abstracts that touch on issues of translation and communication, whether it is a communications-focused research project, an outreach program summary, a policy-related endeavor, or other innovative ideas related to translating and communicating health services research.

CALL FOR ABSTRACTS: Long-Term Care Supports and Services Interest Group for the AcademyHealth 2014 Annual Research Meeting
7 June 2014 San Diego, California
DEADLINE 14 February 2014

The call for abstracts offers researchers, policymakers, and practitioners the opportunity to present and discuss research on topics that may not be featured during the ARM and in a more in-depth manner than typical ARM presentations allow. The model for the meeting this year is one that focuses on attracting the best and most rigorous empirical research currently being conducted on long-term care issues and then providing ample time for presentation and discussion of each paper.

CALL FOR ABSTRACTS: Interdisciplinary Research Group on Nursing Issues (IRGNI) Interest Group for the AcademyHealth 2014 Annual Research Meeting
7 June 2014 San Diego, California
DEADLINE 14 February 2014

All topics related to IRGNI’s focus are welcome. Interdisciplinary research is of particular interest. Important themes include:
-Interdisciplinary policy and practice solutions for ensuring health care access and quality
-Developing the evidence base for work environment change
-Measurement and improvement of quality of patient care
-Integrating nursing into pay-for-performance initiatives
-Translating nursing research into policy change
-Technological and information systems to enhance communication, decision-making,and patient safety

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Grants & Awards

CIHR: Institute of Aging Summer Program in Aging
16-20 June 2014 York University Toronto ON
DEADLINE 8 March 2014.

The Summer Program in Aging (SPA) 2014 partners have identified “Work and Health: The Aging Perspective” as the key theme for this year’s SPA Training Program. Trainees conducting research on work and health that is relevant to the mandate areas of any of the partner Institutes and who are interested in expanding their research horizons to include “an aging perspective” are encouraged to apply to this program. Research areas of interest include but are not limited to:
-health, safety and productivity issues in the aging workforce;
-gender differences and needs of the aging workforce;
-motivating, managing, retaining and accommodating the aging workforce;
-innovations in accommodation for the aging workforce (e.g., flexible employment strategies, new -technologies, automation);
-understanding and enabling older workers’ musculoskeletal health;
-understanding and enabling older workers’ mental health;
-current and future demographics of the aging workforce;
-economic and social drivers of delayed retirement; and
-intergenerational communication and collaboration in the workplace, among other topics.

CFHI EXTRA Fellowship
DEADLINE Wed 5 February

As one of CFHI’s flagship programs, the EXTRA program for healthcare improvement develops capacity and leadership to optimize the use of research evidence in managing Canadian healthcare organizations.

Student Travel Awards for the Statistical Society of Canada (SSC) Annual Scientific Meeting in Toronto, May 2014
DEADLINE 14 February

Full-time students at the University of Alberta or Grant MacEwan University presenting a poster or giving a talk in a Contributed or Invited Paper Session, or participating in a Case Study Session are eligible to apply for a Student Travel Award to this meeting.

TVN Strategic Impact Grant Program
DEADLINE Intent to Apply 10:00 MT 26 February

This Program is non-traditional and unique in that we are seeking researchers with potential projects interested in achieving greater impact by collaborating with other like-minded researchers and projects, and partnering with industry partners, knowledge users and trainees on a wider basis. For this program, specific themes have been selected targeting patient-centered outcomes with the potential for significant impact:
-End-of-Life Care
-Trajectories of Care
-Appropriate Medication Prescription
-Technology as a Means to Improve Health Care Outcomes
-Quality of Care Indicators
-Improved Supports
A webinar will be held on Thursday 23 January 10:00-11:00 MT, and it is strongly suggested that researchers interested in submitting an EOI participate.

CIHR: Betty Havens Prize for Knowledge Translation in Aging
DEADLINE 28 March 2014

Betty Havens Prize for Knowledge Translation in Aging Through the Betty Havens Prize for Knowledge Translation in Aging, IA will recognize individual(s), team(s) or organization(s) that have advanced the translation of research in aging at a local or regional level. The maximum amount awarded for a single one-year award is $20,000 to recognize impact at the local or regional level in research on aging.

TVN Knowledge Synthesis Grant Program
DEADLINE 12:00 19 February 2014 registration of intent & 12:00 3 March 2014 final application

The 2014 Knowledge Synthesis Grants will support teams of researchers and knowledge users in producing knowledge syntheses and scoping reviews that will contribute to the use of synthesized evidence in decision-making and practice, inform future research priorities of TVN, and guide the development of Network knowledge translation activities.
Qualified researchers are invited to submit proposals for knowledge synthesis in the following areas:
* Quality indicators for the care of seriously ill, frail elderly patients
* Strategies for patient/family and caregiver engagement in the health care system
* Advance Care Planning – methods of implementation, including approaches that consider the diversity of patients such as cultural issues and health literacy
* Advance Care Planning – impact of ACP on patient-centred outcomes, including patient/family satisfaction and consumption of health care resources

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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice & Methodology
Healthcare in Canada


Identifying and Applying a Targeted Evidence-Based Practice Change in the Maternal/Child Health Inpatient Setting
Non UofA Access
Wilson BL, Phelps C.
Nursing for Women’s Health 2013;17(6):490-497

As the literature on implementation research continues to expand, it’s important to address the unique aspects and challenges of research dissemination and implementation in maternal/child health settings. This article describes a nurse-initiated evidence-based practice (EBP) study on urinary catheterization at a labor and delivery unit in the southwestern United States. It describes successful strategies for implementing EBP, as well as barriers encountered, and provides recommendations for the facilitation of EBP in the maternal/child inpatient setting.

Institutionalising knowledge brokering as a sustainable knowledge translation solution in healthcare: how can it work in practice?
Non UofA Access
Chew S, Armstrong N, Martin G.
Evidence & Policy 2013-08-01T00:00:00;9(3):335-351

In healthcare, translating evidence into changed practice remains challenging. Novel interventions are being used to address these challenges, including the use of ‘knowledge brokers’. But how sustainable these roles might be, and the consequences for the individual of enacting such roles, are unknown. We explore these questions by drawing on qualitative data from case studies of full-time roles in research-practice collaboration. We suggest that structural issues around professional boundaries, organisational norms and career pathways may make such roles difficult to sustain in the long term, but highlight interventions that might improve their feasibility.

Bridging Research and Practice through the Nursing Research Facilitator Program in British Columbia Canada-flat-icon
Non UofA Access
Katrina Plamondon, Charlene Ronquillo, Linda Axen, Agnes Black, Lynn Cummings and,Bubli Chakraborty.
Nursing leadership 2013 12/18;26(4):32-43

As Canadian health systems transform to meet changing needs, grounding nursing practice in evidence remains an essential goal for providing safe, high-quality care. nursing research facilitators (NRFs) are strengthening the use of evidence in nursing practice across the province of British Columbia. NRFs are nurses with a research background, whose work is focused on supporting people within health systems to use and do research in their practice and decision-making. Since this role was established in 2009, NRFs have provided facilitative support to over 50 funded research projects, led numerous workshops and journal clubs, and conducted more than 600 research-related consultations. In this paper, we discuss the role and offer exemplars of creative ways in which NRFs are strengthening nurses’ engagement in doing and using research by developing capacity for research and evidence-informed practice, building meaningful partnerships and cultivating a culture of curiosity among nurses and other healthcare providers. We reflect on factors contributing to the success of this role and some of the challenges of integration. The paper concludes with a comment on the strategic value of the role.

Realities of replication: implementation of evidence-based interventions for HIV prevention in real-world settings
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Cunningham SD, Card JJ.
Implementation science 2014 Jan 6;9(1):5

The Center for Disease Control and Prevention’s Replicating Effective Programs and Diffusion of Effective Behavioral Interventions programs disseminate select Evidence Based Interventions (EBIs) by providing program materials and training health providers on their appropriate use and implementation. Sociometrics’ HIV/AIDS Prevention Program Archive (HAPPA) and Program Archive for Sexuality, Health, and Adolescents (PASHA) are likewise the largest EBI collections targeting sexual risk behaviors in the private sector. This study examined the extent to which organizations that obtain EBIs from HAPPA and PASHA implement, adapt and evaluate them and factors associated with program implementation. METHODS: Survey data were collected from 123 organizations that acquired, and had been in possession for a minimum of six months, at least one EBI from HAPPA or PASHA between January 2009 and June 2011. Data regarding program characteristics and date of acquisition were obtained from Sociometrics’ sales and marketing databases. Logistic regression was used to assess barriers to program implementation. RESULTS: Among organizations that obtained an EBI from Sociometrics intending to implement it, 53% had implemented the program at least once or were in the process of implementing the program for the first time; another 22% were preparing for implementation. Over the three-year time period assessed, over 11,381 individuals participated in these interventions. Almost two-thirds (65%) of implementers made changes to the original program. Common adaptations included: editing content to be more current and of local relevance (81%); adding, deleting or modifying incentives for participation (50%); changing the location in which the program takes place (44%); and/or changing the number, length and/or frequency of program sessions (42%). In total, 80% of implementers monitored program delivery. Participant outcomes were tracked by 78%; 28% of which used evaluation designs that included a control or comparison group. Lack of adequate resources was significantly associated with decreased likelihood of program implementation (odds ratio = 0.180, p <0.05). CONCLUSIONS: Findings provide greater understanding of implementation processes, barriers and facilitators that may be used to develop strategies to increase the appropriate use of EBIs.

Evaluating nurses’ use of HOBIC in home care. Canada-flat-icon
Non UofA Access
Nagle LM, White P.
The Canadian journal of nursing research 2013 Sep;45(3):92-114

Health Outcomes for Better Information and Care (HOBIC), a program funded by the Ontario Ministry of Health and Long-Term Care, introduces a collection of evidence-based clinical outcome measures reflective of nursing care. The authors report on an evaluation of the experiences of nurse early adopters of HOBIC in home care. The findings reveal challenges and nuances associated with the introduction of HOBIC and the use of supporting technologies in the delivery of home nursing care. Future implementation efforts should focus on optimizing the usability of technology and the usefulness of HOBIC in nursing practice. In addition, efforts need to be directed at supporting the full integration and use of HOBIC outcome data by nurses and management personnel to inform practice directions.

The nursing work of hospital-based clinical practice guideline implementation: An explanatory systematic review using Normalisation Process Theory.
Non UofA Access
May C, Sibley A, Hunt K.
International journal of nursing studies 2014 Feb;51(2):289-299

To investigate the dynamics of nurses’ work in implementing Clinical Practice Guidelines. Seven studies met the inclusion criteria of the review. These revealed that clinical practice guidelines are disposed to normalisation when: (a) They are associated with activities that practitioners can make workable in practice, and practitioners are able to integrate it into their collective workflow. (b) When they are differentiated from existing clinical practice by its proponents, and when claims of differentiation are regarded as legitimate by their potential users. (c) When they are associated with an emergent community of practice, and when members of that community of practice enrol each other into group processes that specify their engagement with it. (d) When they are associated with improvements in the collective knowledge of its users, and when users are able to integrate the application of that knowledge into their individual workflow. And, (e) when nurses can minimise disruption to behaviour norms and agreed professional roles, and mobilise structural and cognitive resources in ways that build shared commitments across professional boundaries. CONCLUSIONS: This review demonstrates the feasibility and benefits of theory-led review of studies of nursing practice, and proposes a dynamic model of implementation. Normalisation Process Theory supports the analysis of nursing work. It characterises mechanisms by which work is made coherent and meaningful, is formed around sets of relational commitments, is enacted and contextualised, and is appraised and reconfigured. It facilitates such analysis from within the frame of nursing knowledge and practice itself. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.

Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices
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Prasad V, Ioannidis JP.
Implementation science 2014 Jan 8;9(1):1-5908-9-1

Abandoning ineffective medical practices and mitigating the risks of untested practices are important for improving patient health and containing healthcare costs. Historically, this process has relied on the evidence base, societal values, cultural tensions, and political sway, but not necessarily in that order. We propose a conceptual framework to guide and prioritize this process, shifting emphasis toward the principles of evidence-based medicine, acknowledging that evidence may still be misinterpreted or distorted by recalcitrant proponents of entrenched practices and other biases.

A systematic review of barriers to and facilitators of the use of evidence by policymakers.
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Oliver K, Innvar S, Lorenc T, Woodman J, Thomas J.
BMC health services research 2014 Jan 3;14(1):2

The gap between research and practice or policy is often described as a problem. To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, we updated a systematic review. RESULTS: 145 new studies were identified, of which over half were published after 2010. Thirteen systematic reviews were included. Compared with the original review, a much wider range of policy topics was found. Although still primarily in the health field, studies were also drawn from criminal justice, traffic policy, drug policy, and partnership working. The most frequently reported barriers to evidence uptake were poor access to good quality relevant research, and lack of timely research output. The most frequently reported facilitators were collaboration between researchers and policymakers, and improved relationships and skills. There is an increasing amount of research into new models of knowledge transfer, and evaluations of interventions such as knowledge brokerage. CONCLUSIONS: Timely access to good quality and relevant research evidence, collaborations with policymakers and relationship- and skills-building with policymakers are reported to be the most important factors in influencing the use of evidence. Although investigations into the use of evidence have spread beyond the health field and into more countries, the main barriers and facilitators remained the same as in the earlier review. Few studies provide clear definitions of policy, evidence or policymaker. Nor are empirical data about policy processes or implementation of policy widely available. It is therefore difficult to describe the role of evidence and other factors influencing policy. Future research and policy priorities should aim to illuminate these concepts and processes, target the factors identified in this review, and consider new methods of overcoming the barriers described.

Interventions to modify health care provider adherence to asthma guidelines: a systematic review.
Non UofA Access
Okelo SO, Butz AM, Sharma R, Diette GB, Pitts SI, King TM, et al.
Pediatrics 2013 Sep;132(3):517-534

Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance. CONCLUSIONS: Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes.

Capturing lessons learned from evidence-to-policy initiatives through structured reflection
El-Jardali F, Lavis J, Moat K, Pantoja T, Ataya N.
Health Research Policy and Systems 2014;12(1):2

Knowledge translation platforms (KTPs), which are partnerships between policymakers, stakeholders, and researchers, are being established in low- and middle-income countries (LMICs) to enhance evidence-informed health policymaking (EIHP). This paper triangulated qualitative data from: i) 17 semi-structured interviews with 47 key informants including KTP leaders, policymakers, and stakeholders from 10 KTPs; ii) document reviews, and iii) observation of deliberations at the International Forum on EIHP in LMICs held in Addis Ababa in August 2012. Results Deliberative dialogues informed by evidence briefs were identified as the most commendable tools by interviewees for enhancing EIHP. KTPs reported that they have contributed to increased awareness of the importance of EIHP and strengthened relationships among policymakers, stakeholders, and researchers. Support from policymakers and international funders facilitated KTP activities, while the lack of skilled human resources to conduct EIHP activities impeded KTPs. Ensuring the sustainability of EIHP initiatives after the end of funding was a major challenge for KTPs. KTPs reported that institutionalization within the government has helped to retain human resources and secure funding, whereas KTPs hosted by universities highlighted the advantage of autonomy from political interests.

No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention Canada-flat-icon
Ivers N, Sales A, Colquhoun H, Michie S, Foy R, Francis J, et al.
Implementation Science 2014;9(1):14

Background Audit and feedback interventions in healthcare have been found to be effective, but there has been little progress with respect to understanding their mechanisms of action or identifying their key ‘active ingredients.’ Discussion Given the increasing use of audit and feedback to improve quality of care, it is imperative to focus further research on understanding how and when it works best. In this paper, we argue that continuing the ‘business as usual’ approach to evaluating two-arm trials of audit and feedback interventions against usual care for common problems and settings is unlikely to contribute new generalizable findings. Future audit and feedback trials should incorporate evidence- and theory-based best practices, and address known gaps in the literature. Summary We offer an agenda for high-priority research topics for implementation researchers that focuses on reviewing best practices for designing audit and feedback interventions to optimize effectiveness.

World Bank: Evidence gap maps – a tool for promoting evidence-informed policy and prioritizing future research

Evidence-gap maps present a new addition to the tools available to support evidence-informed policy making. Evidence-gap maps are thematic evidence collections covering a range of issues such as maternal health, HIV/AIDS, and agriculture. They present a visual overview of existing systematic reviews or impact evaluations in a sector or subsector, schematically representing the types of interventions evaluated and outcomes reported. Gap maps enable policy makers and practitioners to explore the findings and quality of the existing evidence and facilitate informed judgment and evidence-based decision making in international development policy and practice. The gap map also identifies key “gaps” where little or no evidence from impact evaluations and systematic reviews is available and where future research should be focused. Thus, gap maps can be a useful tool for developing a strategic approach to building the evidence base in a particular sector. This paper provides an introduction to evidence-gap maps, outlines the gap-map methodology, and presents some examples.

WHO: Evidence briefs and deliberative dialogues: perceptions and intentions to act on what was learnt
Moat KA, Lavis JN, Clancy SJ, El-Jardali F, Pantoja T

The main aim of this study, published in the Bulletin of the WHO, was to determine whether health system policy-makers, stakeholders and researchers in low- and middle-income countries viewed evidence briefs and deliberative dialogues as helpful knowledge translation strategies.

Alliance for Useful Evidence: Learning from Research: Systematic Reviews for Informing Policy Decisions (UK)
December 2013

This guide is a short introduction for decision-makers and researchers or anyone else considering whether a systematic review may be appropriate to fill a gap in knowledge or to use as a resource. It will help anybody planning on commissioning a review of what research is already out there. You may be an analyst, evaluator, policymaker or commissioner. The guide is aimed at anybody from central government, local authorities, public service providers, regulatory and advisory bodies, charities or the consultancy sector.

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Health Care Administration and Organization

How hospital leaders contribute to patient safety through the development of trust.
Non UofA Access
Auer C, Schwendimann R, Koch R, De Geest S, Ausserhofer D.
The Journal of nursing administration 2014 Jan;44(1):23-29

The aim of this study was to explore the associations between hospital management support for patient safety, registered nurses’ trust in hospital management, and their overall perception of patient safety, considering aspects of safety communication as possible mediating variables. BACKGROUND: Limited research exists regarding how key elements of a patient safety culture, that is, leadership, safety communication, and trust, are interrelated. METHODS: This study used cross-sectional nurse survey data from 1,633 registered nurses working in 35 acute care hospitals participating in the Swiss arm of the RN4CAST (Nurse Forecasting in Europe) study. RESULTS: A path analysis revealed that the indirect associations between “management support for patient safety” and “overall perception of patient safety” were more prominent than the direct association. CONCLUSION: Our findings confirm that safety communication plays a partially mediating role between “management support for patient safety” and nursing professionals’ assessments of patient safety. This suggests that hospital leader-unit exchanges might improve patient safety.

Attachment and coping of dementia care staff: The role of staff attachment style, geriatric nursing self-efficacy, and approaches to dementia in burnout.
Non UofA Access
Kokkonen TM, Cheston RI, Dallos R, Smart CA.
Dementia (London, England) 2013 Mar 14

Past research suggests that dementia care staff are vulnerable to the development of burnout, which has implications for staff well-being and hence the quality of care for people with dementia. Studying personal vulnerability factors in burnout is important as it can guide staff training and support. Attachment theory suggests that adult attachment styles affect caregiving relationships and individuals’ responses to stress, providing a framework for understanding caregivers’ styles of coping. This cross-sectional survey study examined relationships between staff attachment styles, geriatric nursing self-efficacy, and approaches to dementia in burnout. Seventy-seven members of dementia care staff working on inpatient wards for older people completed self-report questionnaires. Insecure attachment, lower levels of self-efficacy, and more optimistic attitudes in staff were related to higher levels of burnout. Staff training on the role of attachment in dementia care is recommended. Further research is required to explore mediating factors between adult attachment styles and burnout.

The effect of skill mix in non-nursing assistants on work engagements among home visiting nurses in Japan.
Non UofA Access
Naruse T, Taguchi A, Kuwahara Y, Nagata S, Sakai M, Watai I, et al.
Journal of nursing management 2014 Jan 2

This study evaluated the effect of a skill-mix programme intervention on work engagement in home visiting nurses. METHOD: Pre- and post-intervention evaluations of work engagement were conducted using self-administered questionnaires. A skill-mix programme was introduced in the intervention group of home visiting nurses. After 6 months, their pre- and post-intervention work engagement ratings were compared with those of a control group. RESULT: Baseline questionnaires were returned by 174 home visiting nurses (44 in the intervention group, 130 in the control group). Post-intervention questionnaires were returned by 38 and 97 home visiting nurses from each group. The intervention group’s average work engagement scores were 2.2 at baseline and 2.3 at post-intervention; the control group’s were 3.3 and 2.6. Generalised linear regression showed significant between-group differences in score changes. CONCLUSION: The skill-mix programme might foster home visiting nurses’ work engagement by improving the quality of care for each client. Future research is needed to explain the exact mechanisms that underlie its effectiveness. IMPLICATIONS FOR NURSING MANAGEMENT: In order to improve the efficiency of services provided by home visiting nurses and foster their work engagement, skill-mix programmes might be beneficial. © 2014 John Wiley & Sons Ltd.

Why Some Employees Adopt or Resist Reorganization of Work Practices in Health Care: Associations between Perceived Loss of Resources, Burnout, and Attitudes to Change. Canada-flat-icon
Non UofA Access
Dubois CA, Bentein K, Mansour JB, Gilbert F, Bedard JL.
International journal of environmental research and public health 2013 Dec 20;11(1):187-201

In recent years, successive work reorganization initiatives have been implemented in many healthcare settings. The failure of many of these change efforts has often been attributed in the prominent management discourse to change resistance. Few studies have paid attention to the temporal process of workers’ resource depletion/accumulation over time and its links with workers’ psychological states and reactions to change. Drawing upon the conservation of resources theory, this study examines associations between workers’ perceptions of loss of resources, burnout, and attitudes to change. The study was conducted in five health and social service centres in Quebec, in units where a work reorganization project was initiated. A prospective longitudinal design was used to assess workers’ perceptions at two time points 12 months apart. Our findings are consistent with the conservation of resources theory. The analysis of latent differences scores between times 1 and 2 showed that the perceived loss of resources was associated with emotional exhaustion, which, in turn, was negatively correlated with commitment to change and positively correlated with cynicism. In confirming the temporal relationship between perceived loss of resources, occupational burnout, and attitude to change, this research offers a new perspective to explain negative and positive reactions to change implementation.

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Health Care Innovation and Quality Assurance

Making improvement interventions happen–the work before the work: four leaders speak.
Non UofA Access
Batalden P.
BMJ quality & safety 2014 Jan;23(1):4-7

Masterful work requires preparation. This anticipatory thinking, rehearsal, attention, reflection, real-world grounding can be done in many different ways, but it must be done well. Paul Batalden asked four expert leaders how they prepare for making improvement interventions happen. What they reveal provides inspiration, guidance and practical knowledge.

Evaluation of AHRQ’s On-Time Pressure Ulcer Prevention Program: A Facilitator-assisted Clinical Decision Support Intervention for Nursing Homes.
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Olsho LE, Spector WD, Williams CS, Rhodes W, Fink RV, Limcangco R, et al.
Medical care 2013 Dec 26

Pressure ulcers present serious health and economic consequences for nursing home residents. The Agency for Healthcare Research & Quality, in partnership with the New York State Department of Health, implemented the pressure ulcer module of On-Time Quality Improvement for Long Term Care (On-Time), a clinical decision support intervention to reduce pressure ulcer incidence rates. OBJECTIVE:: To evaluate the effectiveness of the On-Time program in reducing the rate of in-house-acquired pressure ulcers among nursing home residents. RESEARCH DESIGN AND SUBJECTS:: We employed an interrupted time-series design to identify impacts of 4 core On-Time program components on resident pressure ulcer incidence in 12 New York State nursing homes implementing the intervention (n=3463 residents). The sample was purposively selected to include nursing homes with high baseline prevalence and incidence of pressure ulcers and high motivation to reduce pressure ulcers. Differential timing and sequencing of 4 core On-Time components across intervention nursing homes and units enabled estimation of separate impacts for each component. Inclusion of a nonequivalent comparison group of 13 nursing homes not implementing On-Time (n=2698 residents) accounts for potential mean-reversion bias. Impacts were estimated via a random-effects Poisson model including resident-level and facility-level covariates. RESULTS:: We find a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of 4 core On-Time components (incidence rate ratio=0.409; P=0.035). Impacts vary with implementation of specific component combinations. CONCLUSIONS:: On-Time implementation is associated with sizable reductions in pressure ulcer incidence.

Evaluation of an education intervention to implement a capability model of dementia care.
Non UofA Access
Cooke M, Moyle W, Venturato L, Walters C, Kinnane J.
Dementia (London, England) 2013 Mar 19

This paper outlines an intervention protocol used to educate carers in a project that implemented and evaluated a capability model of dementia care (CMDC) in three long-term aged care facilities. It outlines an evaluation of the content of the education and processes used to deliver the intervention through an analysis of surveys and reflective field notes. The education protocol was designed for adult learners and grounded in the six assumptions of Knowles’ learning theory. Results suggest the education protocol positively impacted on the knowledge, skills and attitudes of participants towards providing quality dementia care to residents in long-term care. The paper also acknowledges the challenges involved in sustaining a practice change through an educational intervention.

The implementation of integrated emotion-oriented care: Did it actually change the attitude, skills and time spent of trained caregivers?
Non UofA Access
van der Kooij C, Droes R, de Lange J, Ettema T, Cools H, van Tilburg W.
Dementia (London, England) 2013 Sep 1;12(5):536-550

Successful implementation is a vital precondition for investigating the outcome of care innovation. This study concerned the evaluation of the implementation of integrated emotion-oriented care (IEOC) in psychogeriatric nursing home wards. The main question was whether the trained caregivers actually applied the knowledge and techniques of IEOC during their daily work. Methods: The study was conducted within the framework of a randomized clinical trial into the effectiveness of IEOC in 16 wards. Preceding the experimental period, staff from 16 wards were educated and trained to work with a standardized care plan, resulting in a similar level of quality of care at the start of the trial. On the experimental wards IEOC was then implemented by training on the job in addition to training courses for personnel. To examine the implementation effectiveness, a self-report questionnaire, ‘Emotion-oriented Skills in the Interaction with Elderly People with Dementia’, was administered at baseline and after 7 months to a sample of caregivers from the experimental and the control wards. In addition, participant observation was conducted on four experimental and four control wards, and time spent by care personnel on different type of care tasks was registered. Results: The implementation of IEOC resulted in increased emotion-oriented skills and more knowledge of the residents among the caregivers. Providing IEOC was not more time consuming for the caregivers than providing usual care. Conclusion: This study shows that the implementation of IEOC was effective. It is recommended that in intervention studies the correct application of a new intervention or care approach is examined before jumping to conclusions about the effectiveness of the intervention or care approach itself.

Experience of a care pathway for psychological and behavioral symptoms of dementia.
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Delphin-Combe F, Martin-Gaujard G, Roubaud C, Fortin ME, Husson F, Rouch I, et al.
Geriatrie et psychologie neuropsychiatrie du vieillissement 2013 Dec 1;11(4):416-422

Behavioral and psychological symptoms of dementia (BPSD) are present in more than eighty percent of patients, resulting in a significant decrease of quality of life of patients and caregivers. To provide the most appropriate and early response to behavioral disorders, a specific care pathway, unique in France, has been created within the Memory Center at the Hospices Civils of Lyon. It includes a consultation “Behavior” aimed to intervention and guidance, a Cognitive-Behavioral Unit for pharmacological and non-pharmacological interventions in a comprehensive care of the patient during 3 to 4 weeks, and an Alzheimer’s disease mobile team, which can assess the BPSD in the patient’s living environment at home or in nursing homes, appraise drug treatments and environment, and give training for caregivers. This care pathway is aimed to provide individualized and early care for behavioral crises secondary prevention, taking into account the psychological, neuropsychological and somatic context of the behavioral disorders occurrence.

Quality improvement training: experiences of frontline staff.
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Daugherty JD, Blake SC, Kohler SS, Culler SD, Hawley JN, Rask KJ.
International journal of health care quality assurance 2013;26(7):627-641

Healthcare organizations have employed numerous strategies to promote quality improvement (QI) initiatives, yet little is known about their effectiveness. In 2008, staff in one organization developed an in-house QI training program designed for frontline managers and staff and this article aims to report employee perspectives. DESIGN/METHODOLOGY/APPROACH: Qualitative interviews were conducted with 22 course participants to examine satisfaction, self-assessed change in proficiency and ability to successfully engage with QI initiatives. Sampling bias may have occurred as the participants volunteered for the study and they may not represent all course participants. Recall bias is also possible since most interviews took place one year after the course was completed to assess long-term impact. Respondents were asked to self-rate their pre- and post-course knowledge and skill, which may not represent what was actually learned. FINDINGS: Informants reported that the course expanded their QI knowledge and skills, and that supervisor support for the course was essential for success. Additionally, the course QI project provided participants with an opportunity to translate theory into practice, which has the potential to influence patient outcomes. PRACTICAL IMPLICATIONS: Several lessons for future QI training can be gleaned from this evaluation, including respondent opinions that it is challenging to offer one program when participants have different QI knowledge levels before the course begins, that “booster sessions” or refresher classes after the course ends would be helpful and that supervisor support was critical to successful QI-initiative implementation. ORIGINALITY/VALUE: This study conducts in-depth interviews with QI course participants to elicit staff feedback on program structure and effectiveness. These findings can be used by QI educators to disseminate more effective training programs.

Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes.
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Wagner LM, Roup BJ, Castle NG.
American Journal of Infection Control 2014 Jan;42(1):2-6

Health care-associated infections are the leading cause of morbidity and mortality in US nursing homes (NHs). The objective of the research is to assess the impact of Maryland NH infection preventionists (IPs) on NH quality measures. METHODS: Two hundred thirty-four NHs were queried through mailed survey. These survey data were then linked with 2008 quality data from Nursing Home Compare and the On-line Survey Certification of Automated Records. RESULTS: Three of the 8 quality measures examined-influenza vaccination for both short- and long-stay residents and pressure ulcer prevention in high-risk residents-were significantly associated with the number of IPs. None of the quality measures were shown to be significant with IPs who received specialized training on infection prevention and management compared with those who did not receive specialized training. CONCLUSION: IPs play a critical role in preventing and managing health care-associated infections in nursing homes, especially in the areas of influenza vaccination and pressure ulcer prevention among high-risk nursing home residents. Quality measures that reflect the effects of IP training may not have been elucidated yet. Further research is needed to support the IP role in order for policy to advocate for increased IP funding. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Nurses’ experiences with the implementation of the Kinaesthetics movement competence training into elderly nursing care: a qualitative focus group study.
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Fringer A, Huth M, Hantikainen V.
Scandinavian journal of caring sciences 2014 Jan 6

This study aimed to examine nurses’ experiences with regard to the implementation of Kinaesthetics movement competence training into a nursing home. DESIGN: Qualitative descriptive design with focus groups’ interviews. METHOD: Thirty-two (three men) geriatric nurses from a Swiss nursing home who participated first time in Kinaesthetics training were interviewed in three focus groups (average 79 minutes). Interviews were analysed using inductive coding, categorisation and abstraction. The ethics committees of the cantons Basel-Stadt and Basel-Land (Switzerland) approved the study on 16 September 2010 (reference no. 224/10). FINDINGS: Nurses’ experiences with the implementation of Kinaesthetics were divided into two categories: nurses’ attitudes with regard to the implementation of Kinaesthetics and nurses experience of Kinaesthetics with regard to integration into daily practice. Even though the participants showed a positive attitude towards the design and structure of the Kinaesthetics training, its implementation into daily practice initially posed a noticeable challenge for the participating nurses. The results indicate that various factors exist that may either promote or impede the implementation of Kinaesthetics in nursing. CONCLUSION: The successful implementation of Kinaesthetics can be promoted by the structural integration of the concept at various levels of nursing home as well as complementary supporting measures. Regular professional support and education after Kinaesthetics training appears to be a necessary approach to sustainably implement the concepts into daily nursing practice. © 2014 Nordic College of Caring Science.

Engaging Pediatric Intensive Care Unit (PICU) clinical staff to lead practice improvement: the PICU Participatory Action Research Project (PICU-PAR). Canada-flat-icon
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Collet JP, Skippen PW, Mosavianpour MK, Pitfield A, Chakraborty B, Hunte G, et al.
Implementation science 2014 Jan 8;9(1):6

Despite considerable efforts, engaging staff to lead quality improvement activities in practice settings is a persistent challenge. At British Columbia Children’s Hospital (BCCH), the pediatric intensive care unit (PICU) undertook a new phase of quality improvement actions based on the Community of Practice (CoP) model with Participatory Action Research (PAR). This approach aims to mobilize the PICU ‘community’ as a whole with a focus on practice; namely, to create a ‘community of practice’ to support reflection, learning, and innovation in everyday work.Methodology: An iterative two-stage PAR process using mixed methods has been developed among the PICU CoP to describe the environment (stage 1) and implement specific interventions (stage 2). Stage 1 is ethnographic description of the unit’s care practice. Surveys, interviews, focus groups, and direct observations describe the clinical staff’s experiences and perspectives around bedside care and quality endeavors in the PICU. Contrasts and comparisons across participants, time and activities help understanding the PICU culture and experience. Stage 2 is a succession of PAR spirals, using results from phase 1 to set up specific interventions aimed at building the staff’s capability to conduct QI projects while acquiring appropriate technical skills and leadership capacity (primary outcome). Team communication, information, and interaction will be enhanced through a knowledge exchange (KE) and a wireless network of iPADs.Relevance: Lack of leadership at the staff level in order to improve daily practice is a recognized challenge that faces many hospitals. We believe that the PAR approach within a highly motivated CoP is a sound method to create the social dynamic and cultural context within which clinical teams can grow, reflect, innovate and feel proud to better serve patients.

Quality Improvement in Neurology: Dementia Management Quality Measures.
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Odenheimer G, Borson S, Sanders AE, Swain-Eng RJ, Kyomen HH, Tierney S, et al.
Journal of the American Geriatrics Society 2014 Jan 7

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer’s Project Act in 2011, an Advisory Council for Alzheimer’s Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer’s disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at http://www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.

Evaluation of the Performance Improvement CME Paradigm for Pain Management in the Long-Term Care Setting.
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Fine PG, Bradshaw DH, Cohen MJ, Connor SR, Donaldson G, Gharibo C, et al.
Pain medicine (Malden, Mass.) 2014 Jan 14

A performance improvement continuing medical education (PI CME) activity was designed to assist clinicians with accurately identifying and appropriately managing persistent pain in long-term care facility (LTCF) residents. DESIGN: Volunteer LTCFs participated in a three-stage PI CME model consisting of: 1) baseline assessment, 2) implementation of practice improvement interventions, and 3) reassessment. Expert faculty chose performance measures and interventions for the activity. A champion was designated ateach LTCF to collect resident charts and enter data into an online database. SETTING: Eight LTCFs located across the United States participated in the activity. PATIENTS: Fifty resident charts were randomly selected by each LTCF champion (25 for stage 1 and 25 for stage 3); a total of 350 charts were reviewed. INTERVENTIONS: In addition to a toolkit containing numerous performance improvement resources, an in-service meeting led by an expert faculty member was conducted at each LTCF. OUTCOME MEASURES: Stage 3 data were collected 6 weeks after implementation of interventions and compared with stage 1 baseline data to measure change in performance. RESULTS: Aggregate data collected from seven LTCFs completing the PI CME activity through stage 3 revealed improvements from baseline in four of five performance measures. CONCLUSIONS: This CME activity allowed for collection of data demonstrating performance improvement in persistent pain management. The tools used as part of the intervention (available at http://www.achlpicme.org/LTC/toolkit) may help other clinicians enhance their management of LTCF residents with persistent pain.

Validity of the RAI-MDS for ascertaining diabetes and comorbid conditions in long-term care facility residents. Canada-flat-icon
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Lix LM, Yan L, Blackburn D, Hu N, Schneider-Lindner V, Teare GF.
BMC health services research 2014 Jan 15;14(1):17

This study assessed the validity of the Resident Assessment Instrument Minimum Data Set (RAI-MDS) Version 2.0 for diagnoses of diabetes and comorbid conditions in residents of long-term care facilities (LTCFs). METHODS: Hospital inpatient, outpatient physician billing, RAI-MDS, and population registry data for 1997 to 2011 from Saskatchewan, Canada were used to ascertain cases of diabetes and 12 comorbid conditions. Prevalence estimates were calculated for both RAI-MDS and administrative health data. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated using population-based administrative health data as the validation data source. Cohen’s kappa was used to estimate agreement between the two data sources. RESULTS: 23,217 LTCF residents were in the diabetes case ascertainment cohort. Diabetes prevalence was 25.3% in administrative health data and 21.9% in RAI-MDS data. Overall sensitivity of a RAI-MDS diabetes diagnoses was 0.79 (95% CI: 0.79, 0.80) and the PPV was 0.92 (95% CI: 0.91, 0.92), when compared to administrative health data. Sensitivity of the RAI-MDS for ascertaining comorbid conditions ranged from 0.21 for osteoporosis to 0.92 for multiple sclerosis; specificity was high for most conditions. CONCLUSIONS: RAI-MDS clinical assessment data are sensitive to ascertain diabetes cases in LTCF populations when compared to administrative health data. For many comorbid conditions, RAI-MDS data have low validity when compared to administrative data. Risk-adjustment measures based on these comorbidities might not produce consistent results for RAI-MDS and administrative health data, which could affect the conclusions of studies about health outcomes and quality of care across facilities.

Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes.
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Trinkoff AM, Han K, Storr CL, Lerner N, Johantgen M, Gartrell K.
The Journal of nursing administration 2013 Dec;43(12):630-636

BACKGROUND: Staff turnover is a serious concern in nursing homes as it has been found to adversely affect care. When employee turnover is minimized, better care quality is more likely in nursing homes. METHODS: Data from the National Nursing Home Survey, a nationally representative sample of US nursing homes, were linked to Nursing Home Compare quality outcomes and analyzed using logistic regression. RESULTS: Nursing homes with high certified nursing assistant turnover had significantly higher odds of pressure ulcers, pain, and urinary tract infections even after controlling for staffing, skill mix, bed size, and ownership. Nurse turnover was associated with twice the odds of pressure ulcers, although this was attenuated when staffing was controlled. CONCLUSIONS: This study suggests turnover may be more important in explaining nursing home (NH) outcomes than staffing and skill mix and should therefore be given greater emphasis.

Quality of care and long-term care administrators’ education: Does it make a difference?
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Castle NG, Furnier J, Ferguson-Rome JC, Olson D, Johs-Artisensi J.
Health care management review 2013 Dec 30

Long-term care administrators (administrators) can influence the care nursing home residents receive. However, little research has examined what factors of administrators are associated with how they influence care. PURPOSES: In this research, the association between administrators’ education and quality of nursing home care is examined. In addition, the association between state educational and training requirements and quality of nursing home care is examined. METHODOLOGY:: Information collected from 3,941 administrators was matched with secondary data, including Nursing Home Compare; the Online Survey, Certification and Reporting data; and the Area Resource File. The quality indicators restraint use, catheter use, inadequate pain management, low-risk residents with pressure ulcers, and high-risk residents with pressure ulcers were examined. FINDINGS: Positive, statistically significant associations were found between the education level of administrators and all five quality indicators. Likewise, positive statistically significant associations were found between state educational requirements and state training requirements and the five quality indicators. PRACTICE IMPLICATIONS: If these associations hold true, then promoting further educational attainment of individual administrators may influence quality of care. The state educational requirements and training requirements for administrators’ licensure may represent an additional means of influencing the quality of care in nursing homes.

An Implementation Science Framework for Conceptualizing and Operationalizing Fidelity in Early Childhood Intervention Studies
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Dunst CJ, Trivette CM, Raab M.
Journal of Early Intervention 2013;35(2):85-101

An implementation science framework is used to differentiate between two types of practices (implementation and intervention) and to describe how the fidelity of the two practices are related and would be expected to influence outcomes of interest. The two practices are the methods and procedures used by implementation agents (e.g., a coach) to promote adoption of early childhood intervention practices and the methods and procedures used by intervention agents (e.g., early childhood practitioners) to influence changes or improvements in individual or group outcomes. Data from a study using an evidence-based adult learning practice to promote Head Start staff use of an evidence-based naturalistic instructional practice are used to illustrate the applicability of the fidelity framework. © 2013 Sage Publications.

Milbank Memorial Fund: The Patient-Centered Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012–2013 (US)
January 2014

This annual report by the Patient-Centered Primary Care Collaborative with support from the Milbank Memorial Fund highlights recently published clinical, quality, and financial outcomes of patient-centered medical home (PCMH) initiatives from across the United States. Profiling a showcase of PCMH initiatives, the report focuses on studies released between August 2012 and December 2013 and identifies where they are happening, who is leading them, and highlights the outcomes they are achieving. Although the evidence is early from an academic perspective, and this report does not represent a formal peer-reviewed meta-analysis of the literature, the expanding body of research provided here suggests that when fully transformed primary care practices have embraced the PCMH model of care, we find a number of consistent, positive outcomes.

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Organizational Change

Organizational readiness for implementing change: a psychometric assessment of a new measure
Shea C, Jacobs S, Esserman D, Bruce K, Weiner B.
Implementation Science 2014;9(1):7

We conducted four studies to assess the psychometric properties of ORIC. Content adequacy assessment indicated that the items developed to measure change commitment and change efficacy reflected the theoretical content of these two facets of organizational readiness and distinguished the facets from hypothesized determinants of readiness. Exploratory and confirmatory factor analysis in the lab and field studies revealed two correlated factors, as expected, with good model fit and high item loadings. Reliability analysis in the lab and field studies showed high inter-item consistency for the resulting individual-level scales for change commitment and change efficacy. Inter-rater reliability and inter-rater agreement statistics supported the aggregation of individual level readiness perceptions to the organizational level of analysis.

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Research Practice & Methodology

Lancet publishes landmark series on ‘waste’ in biomedical research

Misguided research questions, poorly designed experiments and consistent failure to report negative findings are all to blame for causing “avoidable waste” in research, according to a series of papers published in medical journal The Lancet. The series, published on 8 January, identifies five categories of what it calls inefficiencies, ranging from the selection of research questions to how results are reported. The package of content, which consists of five peer-reviewed papers and two comment articles, also makes recommendations for funders, publishers, educators and professional bodies encouraging them to recognise and tackle the problems described.
How should medical science change?
Sabine Kleinert, Richard Horton
Biomedical research: increasing value, reducing waste
Malcolm R Macleod, Susan Michie, Ian Roberts, Ulrich Dirnagl, Iain Chalmers, John P A Ioannidis, Rustam Al-Shahi Salman, An-Wen Chan, Paul Glasziou
How to increase value and reduce waste when research priorities are set
Iain Chalmers, Michael B Bracken, Ben Djulbegovic, Silvio Garattini, Jonathan Grant, A Metin Gülmezoglu, David W Howells, John P A Ioannidis, Sandy Oliver
Increasing value and reducing waste in research design, conduct, and analysis
John P A Ioannidis, Sander Greenland, Mark A Hlatky, Muin J Khoury, Malcolm R Macleod, David Moher, Kenneth F Schulz, Robert Tibshirani
Increasing value and reducing waste in biomedical research regulation and management
Rustam Al-Shahi Salman, Elaine Beller, Jonathan Kagan, Elina Hemminki, Robert S Phillips, Julian Savulescu, Malcolm Macleod, Janet Wisely, Iain Chalmers
Increasing value and reducing waste: addressing inaccessible research
An-Wen Chan, Fujian Song, Andrew Vickers, Tom Jeff erson, Kay Dickersin, Peter C Gøtzsche, Harlan M Krumholz, Davina Ghersi,H Bart van der Worp
Reducing waste from incomplete or unusable reports of biomedical research
Paul Glasziou, Douglas G Altman, Patrick Bossuyt, Isabelle Boutron, Mike Clarke, Steven Julious, Susan Michie, David Moher, Elizabeth Wager

Articulating the strategies for maximising the inclusion of people with dementia in qualitative research studies
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Murphy K, Jordan F, Hunter A, Cooney A, Casey D.
Dementia 2014

It is essential to understand the experience of living with dementia from the perspective of the person with dementia so that services can be appropriately constructed. This review paper, drawing on prior work, identifies key strategies for the meaningful inclusion of persons with dementia within qualitative research studies, it examines the articulation of these strategies and shares how these strategies were operationalised within one national research study in Ireland. Strategies within the literature were categorised and then synthesized into a guide consisting of four main areas; gaining COnsent, maximizing Responses, Telling the story, and Ending on a high (CORTE). The CORTE guideline was used to as a tool for analysing relevant research reports. CORTE is a synthesized account of grouped strategies that could be used to maximize the meaningful involvement of persons with dementia and can also provide a guide for reporting the strategies used so that researchers can learn from each other.

Importance of mixed methods in pragmatic trials and dissemination and implementation research.
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Albright K, Gechter K, Kempe A.
Academic pediatrics 2013 Sep-Oct;13(5):400-407

With increased attention to the importance of translating research to clinical practice and policy, recent years have seen a proliferation of particular types of research, including pragmatic trials and dissemination and implementation research. Such research seeks to understand how and why interventions function in real-world settings, as opposed to highly controlled settings involving conditions not likely to be repeated outside the research study. Because understanding the context in which interventions are implemented is imperative for effective pragmatic trials and dissemination and implementation research, the use of mixed methods is critical to understanding trial results and the success or failure of implementation efforts. This article discusses a number of dimensions of mixed methods research, utilizing at least one qualitative method and at least one quantitative method, that may be helpful when designing projects or preparing grant proposals. Although the strengths and emphases of qualitative and quantitative approaches differ substantially, methods may be combined in a variety of ways to achieve a deeper level of understanding than can be achieved by one method alone. However, researchers must understand when and how to integrate the data as well as the appropriate order, priority, and purpose of each method. The ability to demonstrate an understanding of the rationale for and benefits of mixed methods research is increasingly important in today’s competitive funding environment, and many funding agencies now expect applicants to include mixed methods in proposals. The increasing demand for mixed methods research necessitates broader methodological training and deepened collaboration between medical, clinical, and social scientists. Although a number of challenges to conducting and disseminating mixed methods research remain, the potential for insight generated by such work is substantial. Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

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Scientific publishing. Google Scholar wins raves–but can it be trusted?
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Bohannon J.
Science (New York, N.Y.) 2014 Jan 3;343(6166):14.

Researchers aren’t just using Google Scholar as a search engine. Its algorithm provides citation metrics that quantify the impact of their own published work, and these numbers are becoming part of a standard scientific CV. This byproduct of Google Scholar has sparked a new concern: Because it includes sources from across the Internet—not only vetted journals—and has no human curators, Google Scholar’s citation metric can be easily gamed.

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Healthcare in Canada

Latest articles from ICES Canada-flat-icon

Association between Birth Order and Emergency Room Visits and Acute Hospital Admissions following Pediatric Vaccination: A Self-Controlled Study.
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Atlas on the Primary Care of Adults with Developmental Disabilities in Ontario
Patients with rheumatoid arthritis are at increased risk for complications following total joint arthroplasty.
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Admission to hospital for pneumonia and influenza attributable to 2009 pandemic A/H1N1 influenza in First Nations communities in three provinces of Canada
Risk of kidney stones with surgical intervention in living kidney donors.
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CD Howe Institute: Capturing Value from Health Technologies in Lean Times Canada-flat-icon

In budget-constrained times, adopting new drugs or medical technology is a high-stakes challenge that requires a comprehensive, balanced approach, according to a report released today by the C.D. Howe Institute. In “Capturing Value from Health Technologies in Lean Times,” authors Ake Blomqvist, Colin Busby and Don Husereau argue healthcare policymakers should make greater use of Health Technology Assessment (HTA), a policy tool that can help them balance demand and supply pressures for new technologies within a health-system budget.

Realizing the Promise of Healthcare Innovation in Ontario Canada-flat-icon
Ontario Bioscience Innovation Organization, CLEAR, St. Michael’s Hospital, Innovation Cell Massey College 2013

Currently, innovation adoption in Ontario faces certain systemic barriers and we lag behind some other technologically advanced jurisdictions in deriving the health and value benefits of some innovative health products and services. Our research reveals that a significant barrier to adoption appears to be the inability of government and industry to overcome mutual distrust which has become institutionalized and systemic. This can be ameliorated if government and industry work to collaborate on standardized metrics that can be used to objectively measure enhanced value for patients, and the system as a whole. Other obstacles to rapid innovation adoption include: misalignment of priorities (among providers, patients, industry and government), a differing view on assessing value, aversion to risk, and upfront cost as a primary factor in decision making.

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Efficiency at the Resident’s Level of the NABUCCOD Nutrition and Oral Health Care Training Program in Nursing Homes
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Poisson P, Barberger-Gateau P, Tulon A, Campos S, Dupuis V, Bourdel-Marchasson I.
Journal of the American Medical Directors Association

Participants One hundred thirty-eight NHs participated in the initial training. Training sessions for staff, director, and medical practitioners for nutritional and oral care in NH. Measurements Two waves of self-assessments over a 6- to 8-month interval described NH policies (Institution questionnaire), quality of care in newly admitted residents (Admission questionnaire), and in those present for more than 6 months (Stay questionnaire). Results Questionnaires were completed at both waves in 24 NHs (17.8%) for Institution, in 42 NHs including 646 residents for Admission, and in 34 NHs including 287 residents for Stay. There was no significant difference in bed capacity and resident dependency between NHs, which performed both assessments, and nonresponders. No change was observed for Institution. Malnutrition screening was carried out in almost all residents. Two risk factors were better screened after training: pressure ulcers (39.4% to 49.1%, P = .014) and dysphagia (33.5% to 41.0%, P = .049). Oral examination improved quantitatively (38.5% of residents to 48.5%) and qualitatively: risk factors for malnutrition and dysphagia were better sought (loss of posterior teeth (P < .0001), asialia (P < .0001), and candidosis (P = .002)). Similar improvements were seen in Stay assessments. Actions to counteract weight loss or low dietary intake records were not found in one third of resident records. Conclusions Training program improved staff knowledge with positive results at the level of residents but no significant changes were seen within NH policies.

Hospitalization of Elderly Medicaid Long-Term Care Users Who Transition from Nursing Homes.
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Wysocki A, Kane RL, Dowd B, Golberstein E, Lum T, Shippee T.
Journal of the American Geriatrics Society 2014 Jan 2

To compare hospitalizations of dually eligible older adults who had an extended Medicaid nursing home (NH) stay and transitioned out to receive Medicaid home- and community-based services (HCBS) with hospitalizations of those who remained in the NH. DESIGN: Retrospective matched cohort study using Medicaid and Medicare claims and NH assessment data. SETTING: Community (receiving Medicaid HCBS) or NH. PARTICIPANTS: Dually eligible fee-for-service beneficiaries aged 65 and older in Arkansas, Florida, Minnesota, New Mexico, Texas, Vermont, and Washington from 2003 to 2005. Individuals who had a Medicaid NH stay of at least 90 days and transitioned to Medicaid HCBS (N = 1,169) were matched to individuals who had a Medicaid NH stay of at least 90 days and remained in the NH (N = 1,169). MEASUREMENTS: Potentially preventable hospitalizations (defined according to ambulatory-care-sensitive conditions) and all hospitalizations were examined. RESULTS: Cox proportional hazards models were used to compare the risk of hospitalization between the groups, accounting for the differing time at risk and censoring. Being a NH transitioner increased the hazard of experiencing a potentially preventable hospitalization by 40% (95% confidence interval (CI) = 1.01-1.93) over remaining in the NH. NH transitioners had a 58% (95% CI = 1.32-1.91) greater risk of experiencing any type of hospitalization than NH stayers. CONCLUSION: Individuals who transitioned from the NH to HCBS had a greater risk of hospitalization. Most of the attention in long-term care transition programs has been focused on NH readmission, but programs encouraging NH transition should recognize that individuals may be at greater risk for hospitalization after returning to the community. Planning for the medical needs of individuals who transition from an extended NH stay may improve their posttransition outcomes. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge
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Toles M, Anderson RA, Massing M, Naylor MD, Jackson E, Peacock-Hinton S, et al.
Journal of the American Geriatrics Society 2014 Jan 2

To describe the time to first acute care use (e.g., emergency department (ED) use without hospitalization or rehospitalization) for older adults discharged to home after receiving postacute care in skilled nursing facilities (SNFs); to identify predictors of first acute care use. DESIGN: Retrospective cohort study using administrative claims data. SETTING: SNFs providing postacute care for patients in North and South Carolina (N = 1,474). PARTICIPANTS: A cohort of Medicare beneficiaries aged 65 and older (N = 55,980) who were hospitalized and then transferred to a SNF for postacute care and subsequently discharged home (January 1, 2010, to August 31, 2011). MEASUREMENTS: Medicare institutional claims data (Parts A and B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute care use was explored. Cox proportional hazards regression models were used to describe individual-, home care-, and nursing facility-level predictors. RESULTS: After discharge from SNF to home, 22.1% of older adults had an episode of acute care use within 30 days, including 7.2% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5% of older adults had their first acute care use within 90 days. Male sex, dual eligibility status, higher Charlson comorbidity score, certain primary diagnoses at index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient-day were associated with greater likelihood of acute care use. CONCLUSION: Medicare beneficiaries have a high use of acute care services after discharge from SNFs, and several factors associated with acute care use are potentially modifiable. Findings suggest the need for interventions to support beneficiaries as they transition from SNFs to home. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Prevalence of frailty and its ability to predict in hospital delirium, falls, and 6-month mortality in hospitalized older patients
Joosten E, Demuynck M, Detroyer E, Milisen K.
BMC Geriatrics 2014;14(1):1

The prevalence and significance of frailty are seldom studied in hospitalized patients. Aim of this study is to evaluate the prevalence of frailty and to determine the extent that frailty predicts delirium, falls and mortality in hospitalized older patients. Methods In a prospective study of 220 older patients, frailty was determined using the Cardiovascular Health Study (CHS) and the Study of Osteoporotic Fracture (SOF) frailty index. Patients were classified as nonfrail, prefrail, and frail, according to the specific criteria. Covariates included clinical and laboratory parameters. Outcome variables included in hospital delirium and falls, and 6-month mortality. Results The CHS frailty index was available in all 220 patients, of which 1.5% were classified as being nonfrail, 58.5% as prefrail, and 40% as frail. The SOF frailty index was available in 204 patients, of which 16% were classified as being nonfrail, 51.5% as prefrail, and 32.5% as frail. Frailty, as identified by the CHS and SOF indexes, was a significant risk factor for 6-month mortality. However, after adjustment for multiple risk factors, frailty remained a strong independent risk factor only for the model with the CHS index (OR 4.7, 95% CI 1.7-12.8). Frailty (identified by CHS and SOF indexes) was not found to be a risk factor for delirium or falls.

Resident and Facility-Level Predictors of Quality of Life in Long-Term Care.
Non UofA Access
Shippee TP, Henning-Smith C, L Kane R, Lewis T.
The Gerontologist 2013 Dec 17

Although there is substantial research on quality of care in nursing homes (NH), less is known about what contributes to quality of life (QOL) for NH residents. This study assesses multiple domains of QOL and examines facility- and resident-level correlates for different domains. DESIGN AND METHODS: Data come from (a) self-reported resident interviews using a multidimensional measure of QOL; (b) resident clinical data from the Minimum Data Set; and (c) facility-level characteristics from Minnesota Department of Human Services. We used factor analysis to confirm domains of QOL, and then employed cross-sectional hierarchical linear modeling to identify significant resident- and facility-level predictors of each domain. RESULTS: We examined six unique domains of QOL: environment, personal attention, food, engagement, negative mood, and positive mood. In multilevel models, resident-level characteristics were more reliable correlates of QOL than facility characteristics. Among resident characteristics, gender, age, marital status, activities of daily living, mood disorders, cognitive limitations, and length of stay consistently predicted QOL domains. Among facility characteristics, size, staff hours, quality of care, and percent of residents on Medicaid predicted multiple QOL domains. IMPLICATIONS: Examining separate domains rather than a single summary score makes associations with predictors more accurate. Resident characteristics account for the majority of variability in resident QOL. Helping residents maintain functional abilities, and providing an engaging social environment may be particularly important in improving QOL.

Predictors of institutionalization of dementia patients in mild and moderate stages: a 4-year prospective analysis.
Non UofA Access
Eska K, Graessel E, Donath C, Schwarzkopf L, Lauterberg J, Holle R.
Dementia and geriatric cognitive disorders extra 2013 Nov 1;3(1):426-445

At the start of this study, 357 patients with mild to moderate dementia were examined by their general practitioners, and a telephone interview was conducted with their caregivers. Four years later, the outcomes ‘institutionalization’ and ‘death’ were determined from health insurance data. Forty-one variables were examined for their predictive influence by univariate and multivariate Cox regression. RESULTS: The risk of institutionalization increased significantly (p ≤ 0.05) with older ages of patients [hazard ratio (HR) = 1.05] and caregivers (HR = 1.03), a higher educational level of the caregiver (HR = 1.83), greater use of community health services (HR = 1.59), greater caregiver burden (HR = 1.02), and when the caregiver and patient lived apart (HR = 1.97). CONCLUSION: The results show that there is a multifactorial influence on institutionalization of dementia patients by sociodemographic, health-related, and psychological aspects as well as the care situation, thus validating the predictor model by Luppa et al. [Dement Geriatr Cogn Disord 2008;26:65-78]. Caregiver burden was found to be the strongest predictor accessible to interventions.

The comparison of quality of life among people with mild dementia in nursing home and home care–a preliminary report.
Non UofA Access
Nikmat AW, Hawthorne G, Al-Mashoor SH.
Dementia (London, England) 2013 Jul 8

Living arrangements play an important role in determining the quality of life (QoL) of people with dementia. Although informal care (home-based) is favored, the transition to formal (institutional) care often becomes necessary, especially in the later stages of dementia. Nevertheless, there is currently no definitive evidence showing that informal or formal care provides a higher QoL for those with dementia.Objective: To compare the QoL of people with dementia in the nursing home and home care, and identify factors that differentiate their QoL.Design and methods: This was a cross-sectional survey. A total of 49 people with dementia ≥60 years old were recruited from government nursing homes and hospitals (home care). Consenting participants were assessed on cognitive severity, QoL, activities of daily living (ADLs), depression, and social isolation/connectedness by the Short Mini Mental State Examination (SMMSE), the WHO-8 (the EUROHIS-QOL), Short Assessment of Quality of Life (AQoL-8), Barthel Index (BI), Cornell Scale for Depression (CSDD), and Friendship Scale (FS).Results: There were significant differences in QoL, HRQoLs, ADLs, and social connectedness among people with dementia in home care (n = 19) and those in nursing homes (n = 30) (p < 0.01). No significant differences were found by socio-demographic factors, cognitive severity, or depression between the study cohorts.Conclusions: Older adults with dementia who were living at home experienced higher QoL, ADLs, and social connectedness compared with those living in institutional care. Support should be provided enabling home care and empowering caregivers to provide better care for people with dementia.

Dementia Knowledge Assessment Tool Version Two: Development of a tool to inform preparation for care planning and delivery in families and care staff.
Non UofA Access
Toye C, Lester L, Popescu A, McInerney F, Andrews S, Robinson AL.
Dementia (London, England) 2013 Jan 16

Care for the person with dementia requires understanding of the person’s perspective and preferences, integrated with knowledge of dementia’s trajectory and appropriate care. Version One of the Dementia Knowledge Assessment Tool addressed such knowledge in care workers; Version Two is for families as well as staff. Content validity was established during development. Revisions addressed clarity, time for completion, and reliability. When 671 staff completed Version One before an education intervention, internal consistency reliability estimates exceeded 0.70. Validity was supported by higher scores in professional versus nonprofessional staff and following the education. Version Two was used with 34 family carers and 70 staff members. Internal consistency reliability (Cronbach’s alpha coefficient) was promising (0.79, both groups). Completion was within 15 minutes. Median correct responses (from 21) were 14 for families (range 4-20) and 16 for the staff (range 3-21). Eighteen staff members (26%) and two family carers (6%) reported substantive dementia education. Inclusion of the person with dementia in care planning is often limited because of a late diagnosis and the progressive impacts of the condition. Establishing a shared staff-family understanding of the dementia trajectory and care strategies likely to be helpful is therefore critical to embarking upon the development and implementation of collaborative long term and end-of-life care plans. Version Two can help establish needs for, and outcomes of, education programs and informational resources in a way that is feasible, minimises burden, and facilitates comparisons across family and staff carer groups.

From social network to safety net:
Dementia-friendly communities in rural northern Ontario.
Non UofA Access
Wiersma EC, Denton A.
Dementia (London, England) 2013 Dec 24

Dementia-friendly communities, as communities that enable people with dementia to remain involved and active and have control over their lives for as long as possible, centrally involve social support and social networks for people living with dementia. The purpose of this research was to explore and understand the context of dementia in rural northern communities in Ontario with an emphasis on understanding how dementia friendly the communities were. Using qualitative methods, interviews were conducted with a total of 71 participants, including 37 health service providers, 15 care partners, 2 people living with dementia and 17 other community members such as local business owners, volunteers, local leaders, friends and neighbours. The strong social networks and informal social support that were available to people living with dementia, and the strong commitment by community members, families and health care providers to support people with dementia, were considered a significant asset to the community. A culture of care and looking out for each other contributed to the social support provided. In particular, the familiarity with others provided a supportive community environment. People with dementia were looked out for by community members, and continued to remain connected in their communities. The social support provided in these communities demonstrated that although fragile, this type of support offered somewhat of a safety net for individuals living with dementia. This work provides important insights into the landscape of dementia in rural northern Ontario communities, and the strong social supports that sustain people with dementia remaining in the communities.

Why do patients develop severe pressure ulcers? A retrospective case study.
Non UofA Access
Pinkney L, Nixon J, Wilson L, Coleman S, McGinnis E, Stubbs N, et al.
BMJ open 2014 Jan 2;4(1):e004303-2013-004303

We have a good understanding of patients’ risk factors for Pressure Ulcers, but a poor understanding of the role played by the organisational context in their development. SETTING: The study was undertaken in six sites in Yorkshire, England. The settings were sampled in order to maximise diversity, and included patients’ own homes, acute hospital medical and surgical wards, a community hospital and a nursing home during a period of respite care. PARTICIPANTS: Data were collected about eight individuals who developed severe pressure ulcers, using a retrospective case study design. The data sources included interviews with individuals with severe pressure ulcers, and with staff who had treated and cared for them, and clinical notes. RESULTS: 4 accounts indicated that specific actions by clinicians contributed to the development of severe pressure ulcers. Seven of the 8 accounts indicated that they developed in organisational contexts where (1) clinicians failed to listen and respond to the patients’ or carers’ observations about their risks or the quality of their treatment and care, (2) clinicians failed to recognise and respond to clear signs that a patient had a pressure ulcer or was at risk of developing one and (3) services were not effectively coordinated. CONCLUSIONS: Patient accounts could only be partially explained in terms of specific events or sequences of events. The findings support the conclusion that there was general acceptance of suboptimal clinical practices in 7 of the 8 contexts where patients developed severe pressure ulcers

Everyday decision-making in dementia: findings from a longitudinal interview study of people with dementia and family carers.
Non UofA Access
Samsi K, Manthorpe J.
International psychogeriatrics 2013 Jun;25(6):949-961

Using a phenomenological approach, we interviewed 12 dyads (one person with dementia + one carer) four times over one year to ascertain experience of decision-making, how decisions were negotiated, and how dynamics changed. Qualitative interviews were conducted in people’s own homes, and thematic analysis was applied to transcripts. RESULTS: Respecting autonomy, decision-specificity and best interests underlay most everyday decisions in this sample. Over time, dyads transitioned from supported decision-making, where person with dementia and carer made decisions together, to substituted decision-making, where carers took over much decision-making. Points along this continuum represented carers’ active involvement in retaining their relative’s engagement through providing cues, reducing options, using retrospective information, and using the best interests principle. Long-term spouse carers seemed most equipped to make substitute decisions for their spouses; adult children and friend carers struggled with this. CONCLUSIONS: Carers may gradually take on decision-making for people with dementia. This can bring with it added stresses, such as determining their relative’s decision-making capacity and weighing up what is in their best interests. Practitioners and support services should provide timely advice to carers and people with dementia around everyday decision-making, and be mindful how abilities may change.

Impact of Noncaregiving-Related Stressors on Informal Caregiver Outcomes
Non UofA Access
Austrom MG, Lu YY, Perkins AJ, Boustani M, Callahan CM, Hendrie HC.
American Journal of Alzheimer’s Disease and Other Dementias 2014

Background: Caregivers of persons with dementia are stressed. Stressors not related to care recipients’ needs impact caregiver outcomes, yet are seldom reported. The purpose of this study was to report the most stressful events experienced by spouse caregivers of older adults with Alzheimer s disease during a 6-month period. Methods: 31 caregivers completed the Most Stressful Event form, Patient Health Questionnaire (PHQ-9) and the Revised Memory Behavioral Problem Checklist (R-MBPC). Fisher’s exact test and two-sample t-test were used to compare Most Stressful Events between caregivers. ANOVA model tested whether the PHQ-9 and R-MBPC subscales differed by stressor. Results: Caregivers reported no stressors 21.5% of the time, 1-2 stressors 25% of the time, and 3 stressors 53% of the time with 318 stressors reported in total. Care recipient needs (30.2%), caregiver needs (26.7%), and decision-making (16.7%) were the most frequently reported stressors. Using a mixed effects model, there were associations between the Most Stressful Events and depression (p = 0.016), mobility (p = 0.024) and caregiver issues (p = 0.009) subscales of R-MBPC. Conclusion: Results can be used to develop targeted intervention and support strategies for spouse caregivers experiencing non-caregiving related stressorsas well as the traditional challenges with caregiving related issues.

Effectiveness of Mealtime Interventions on Behavior Symptoms of People With Dementia Living in Care Homes: A Systematic Review.
Non UofA Access
Whear R, Abbott R, Thompson-Coon J, Bethel A, Rogers M, Hemsley A, et al.
Journal of the American Medical Directors Association 2014 Jan 6

Elderly residents with dementia commonly exhibit increased agitation at mealtimes. This interferes with eating and can be distressing for both the individual and fellow residents. This review examines the effectiveness of mealtime interventions aimed at improving behavioral symptoms in elderly people living with dementia in residential care. DESIGN: Systematic review. RESULTS: A total of 6118 articles were identified in the original search. Eleven articles were finally included. Mealtime interventions were categorized into 4 types: music, changes to food service, dining environment alteration, and group conversation. Study quality was poor, making it difficult to reach firm conclusions. Although all studies showed a trend in favor of the intervention, only 6 reported a statistically significant improvement in behavioral symptoms. Four studies suggest cumulative or lingering effects of music on agitated and aggressive behaviors. CONCLUSION: There is some evidence to suggest that mealtime interventions improve behavioral symptoms in elderly people with dementia living in residential care, although weak study designs limit the generalizability of the findings. Well designed, controlled trials are needed to further understand the utility of mealtime interventions in this setting. Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.

Theoretical foundations guiding culture change: The work of the Partnerships in Dementia Care Alliance Canada-flat-icon
Non UofA Access
Dupuis S, McAiney CA, Fortune D, Ploeg J, de Witt L.
Dementia 2014

Longstanding concerns about quality care provision, specifically in the area of long-term care, have prompted calls for changing the culture of care to reflect more client-driven and relationship-centred models. Despite an increase in culture change initiatives in both Canada and the United States, there is insufficient information about the theories and approaches that guide culture change. The purpose of this paper is to describe a culture change initiative currently underway in Canada, the Partnerships in Dementia Care Alliance, and the theoretical foundations informing our work. More specifically, we describe how the theoretical and philosophical underpinnings of the Alzheimer Disease and Related Dementias framework, the authentic partnership approach, participatory action research and Appreciative Inquiry have been integrated to guide a culture change process that encourages working collaboratively, thinking and doing differently and re-imagining new possibilities for changing the culture of dementia care.

Affect Balance and Relationship With Well-Being in Nursing Home Residents With Dementia.
Non UofA Access
Kolanowski AM, Van Haitsma K, Meeks S, Litaker M.
American Journal of Alzheimer’s Disease and Other Dementias 2014 Jan 8

The purpose of this exploratory study was to determine whether the balance of positive to negative affect can discriminate states of well-being in nursing home residents with dementia and whether affect balance is associated with activity engagement. Baseline data from a randomized clinical trial were used in this secondary analysis. Participants were 128 residents recruited from 9 nursing homes located in Pennsylvania. Participants were primarily female, Caucasian, and had a mean age of 86 years. Measures of agitation and affect were taken from video recordings of 10 observational sessions. Measures of engagement and self-reported mood were taken in real time. Ten percent of participants were categorized as having high well-being. These participants had a mean ratio of positive-negative affect of 2.21 (±0.50), a ratio significantly different than that of participants with moderate or low well-being. Affect balance was related to greater engagement in activity (r = .23; P = .008).

Effects of small-scale, home-like facilities in dementia care on residents’ behavior, and use of physical restraints and psychotropic drugs: a quasi-experimental study.
Non UofA Access
Verbeek H, Zwakhalen SM, van Rossum E, Ambergen T, Kempen GI, Hamers JP.
International psychogeriatrics 2014 Jan 10:1-12

Small-scale, home-like care environments are increasingly implemented in institutional nursing care as a model to promote resident-directed care, although evidence on its effects is sparse. This study focuses on the effects of small-scale living facilities on the behavior of residents with dementia and use of physical restraints and psychotropic drugs. Methods: A quasi-experimental study was conducted comparing residents in two types of long-term institutional nursing care (i.e. small-scale living facilities and traditional psychogeriatric wards) on three time points: at baseline and follow-ups after six and 12 months. Residents were matched at baseline on cognitive and functional status to increase comparability of groups at baseline. Nurses assessed neuropsychiatric and depressive symptoms, agitation, social engagement, and use of physical restraints using questionnaires. Psychotropic drug use was derived from residents’ medical records. Results: In total, 259 residents were included: 124 in small-scale living facilities and 135 controls. Significantly fewer physical restraints and psychotropic drugs were used in small-scale living facilities compared with traditional wards. Residents in small-scale living facilities were significantly more socially engaged, at baseline and after six months follow-up, and displayed more physically non-aggressive behavior after 12 months than residents in traditional wards. No other differences were found. Conclusions: This study suggests positive effects of small-scale living facilities on the use of physical restraints and psychotropic drugs. However, the results for behavior were mixed. More research is needed to gain an insight on the relationship between dementia care environment and other residents’ outcomes.

Case management for frail older people – a qualitative study of receivers’ and providers’ experiences of a complex intervention.
Non UofA Access
Sandberg M, Jakobsson U, Midlov P, Kristensson J.
BMC health services research 2014 Jan 10;14(1):14-6963-14-14

Case management interventions have been widely used in the care of frail older people. Such interventions often contain components that may act both independently of each other and interdependently, which makes them complex and challenging to evaluate. Qualitative research is needed for complex interventions to explore barriers and facilitators, and to understand the intervention’s components. The objective of this study was to explore frail older people’s and case managers’ experiences of a complex case management intervention. METHODS: The study had a qualitative explorative design and interviews with participants (age 75-95 years), who had received the case management intervention and six case managers who had performed the intervention were conducted. The data were subjected to content analysis. RESULTS: The analysis gave two content areas: providing/receiving case management as a model and working as, or interacting with, a case manager as a professional. The results constituted four categories: (1 and 2) case management as entering a new professional role and the case manager as a coaching guard, as seen from the provider’s perspective; and (3 and 4) case management as a possible additional resource and the case manager as a helping hand, as seen from the receiver’s perspective. CONCLUSIONS: The new professional role could be experienced as both challenging and as a barrier. Continuous professional support is seemingly needed for implementation. Mutual confidence and the participants experiencing trust, continuity and security were important elements and an important prerequisite for the case manager to perform the intervention. It was obvious that some older persons had unfulfilled needs that the ordinary health system was unable to meet. The case manager was seemingly able to fulfil some of these needs and was experienced as a valuable complement to the existing health system.

Early-onset dementia: the impact on family care-givers.
Non UofA Access
Flynn R, Mulcahy H.
British journal of community nursing 2013 Dec;18(12):598-606

Rachel Flynn is a PhD student at the UofA’s Faculty of Nursing. She works with Dr. Shannon Scott
People with early-onset dementia (EOD) and their family carers remain an overlooked population within the policy and practice priorities of community health care. No standard provision of care or support currently exists for those with EOD and the family carer. Yet family members provide the majority of the full-time care required for this progressive, irreversible illness. The aim of this research was to explore the impact of care-giving on family members caring for a relative with EOD. The care-giving experiences identified in this study emphasise the need for improvement in the provision of community and specialised services for people with EOD and family carers. The key themes of this qualitative study were diagnostic problems, impact of care-giving, relationship change and lack of resources. These findings provide key directives for improving community practice, services and support for people with EOD and their family carers.

CDC: Long-Term Care Services in the United States: 2013 Overview (US)
December 2013

Provides a comprehensive look at the country’s 58,000 paid, regulated, long-term care providers as well as its 8 million long-term care consumers. The authors examine the varying sizes, staffing practices, and services provided by long-term care providers. They further look at the role of direct-care workers at such home care agencies, nursing homes, and other long-term care settings. Demographic characteristics of long-term care consumers are also analyzed.

World Alzheimer’s Report 2013 Journal of Caring An Analysis of Long Term Care for Dementia

The latest World Alzheimer’s Report takes a closer look at the global trends for dementia care in residential aging facilities. The report looks at different policies, procedures and the statistics from all continents. Some of the issues discussed in the report include:
-Prevalence of dementia
-Reasons for transitions into long-term care
-End-of-life care
-Measuring quality of care
-Popularity of advance care planning
-Person-centered care
-Financing long-term care

Engaging family caregivers as partners in transitions : TC-QuIC: a quality improvement collaborative (US)
United Hospital Fund of New York, 2013

This report focuses on a major three-year initiative, the Transitions in Care–Quality Improvement Collaborative. TC–QuIC, as it is known, brought together 45 teams from a variety of health care providers—hospitals, nursing home rehab centers, home care agencies, and hospices—to learn from an expert faculty, proven quality improvement tools and techniques, and their own colleagues and peers. The goal: to take on the challenge of examining how chronically ill patients are transitioned from one care setting to the next, and how that transition could be improved by systematically involving family caregivers and arming them with better information, training, and support.

Livable Community Indicators for Sustainable Aging in Place (US)
Stanford Center on Longevity & MetLife Mature Market Institute, 2013

Sustainable aging in place involves helping older residents remain in their community while also addressing the long-term economic, social, and environmental health of both current and future generations at every age. Based on an extensive review of existing literature and interviews with aging in place experts, the MetLife Mature Market Institute in partnership with the Stanford University Center on Longevity developed an initial list of indicators that can be measured using information that is readily available and adaptable to local governments, providing a low-cost way for local governments to begin to examine the specific needs of their aging population. These indicators reflect a framework of how livable community characteristics influence aging in place.

AARP: The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers (US)

The majority of long-term services and supports are provided by family members. But the supply of family caregivers is unlikely to keep pace with future demand. The following report defines a “caregiver support ratio” as the number of potential caregivers aged 45–64 for each person aged 80 and older. The report uses this support ratio to estimate the availability of family caregivers during
the next few decades.
-In 2010, the caregiver support ratio was more than 7 potential caregivers for every person in the high-risk years of 80-plus.
-By 2030, the ratio is projected to decline sharply to 4 to 1; and it is expected to further fall to less than 3 to 1 in 2050, when all boomers will be in the high-risk years of late life.

AHRQ: Long-Term Care for Older Adults: Future Research Needs

To identify gaps in the current research on long-term care (LTC) for older adults that limited the conclusions of the comparative effectiveness review (CER) “Long-Term Care for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care” in order to inform those who conduct and fund research about the research needs on this topic. The clinical and policy context of LTC is changing. Comparative effectiveness may be less salient than understanding what makes such care effective in the first place for various client groups. Therefore, we reported research needs related to the comparison of HCBS and NH care that was the focus of the CER, and we also reported research needs from the broader set of questions that stakeholders deemed important within the current policy environment. Future research in this area will create a broader and stronger evidence base for making care and policy decisions.

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RSO: CIHR Foundation Scheme from a Theme III/IV Perspective
Tuesday 21 Jan 12:30-13:45 Classroom F (2J4.02) Walter MacKenzie Health Sciences Centre

The speakers all attended the CIHR hosted bootcamp for research leaders across Canada on Changes to CIHRs Open Program & Associated Peer Review and its impact on Theme 3/4 researchers. The speakers will be presenting their thoughts on how Theme 3/4 researchers can best prepare for the upcoming changes at CIHR.
Speakers: Dr. Tania Bubela, Associate Professor, School of Public Health; Dr. Carole Estabrooks, Professor, Faculty of Nursing; Dr. Finlay McAlister, Professor, Faculty of Medicine & Dentistry

CARE: Massage Therapy: Overview, clinical uses, and recent evidence
Tuesday 28 Jan 12:00-13:00 ECHA 3-001

Presented by Cheryl LoCicero, RMT. Cheryl is a massage therapist with the Pediatric Integrative Medicine Trial ongoing at the Stollery Children’s Hospital and has lectured for the CARE program.

Non UofA

UK Knowledge Mobilisation Forum 2014
3-4 February 2014 London UK Cost £250

Speakers include Peter Norman Levesque, President of the Institute for Knowledge Mobilisation based in Toronto; David Phipps, Executive Director of Research & Innovation Services at York University, Canada; and Trish Greenhalgh, Professor of Primary Health Care and Dean for Research Impact at Barts & the London School of Medicine and Dentistry; Cathy Howe, NIHR Knowledge Mobilisation Fellow; and Jonathan Breckon, Manager of the Alliance for Useful Evidence.

Canadian Agency for Drugs and Technologies in Health (CADTH) 2014 Symposium
6-8 April Gatineau PQ

Workshops include:
-An Introduction to the Fundamentals of Health Evidence
-Critical Appraisal 101 for Non-Researchers – PART 1: A Look at Randomized Controlled Trials and Qualitative Research
-Applying Value Frameworks to Health Technology Assessment and Decision-Making
-Navigating the Maze: Finding Regulatory Information on Pharmaceuticals
-Innovative Approaches to Strengthening Patient Input Submissions
-Utilities: What Are They? Why Do They Matter?
-Critical Appraisal of Network-Meta-Analysis for Health Technology Assessments
-Critical Appraisal 101 for Non-Researchers: PART 2 — Systematic Reviews and Clinical Practice Guidelines
-Introduction to the Joanna Briggs Institute Methodology
-Incorporating Patient-Reported Outcome Measures in Reimbursement Decision-Making: Measuring and Valuing Health Using the EuroQol-5 Dimension
-An Interactive Workshop on Network Meta-Analysis: From Idea Inception to Policy Decision
-Knowledge Mobilization and Social Media: What You Need to Know

RIA: Walk with Me Changing Culture of Aging in Canada
24-25 March Toronto ON
Early Bird Deadline extended to 31 January

The first national conference on culture change, “Walk With Me: Changing the culture of aging in Canada”, is being hosted by the Schlegel-University of Waterloo Research Institute for Aging (RIA), the Schlegel Centre for Learning, Research and Innovation in Long-Term Care (Schlegel CLRI), and many other partners who are participating in planning committees. The purpose of this inaugural conference is to bring 400 diverse stakeholders together, including older adults/residents, family members, professionals, educators, policy-makers and researchers, to learn with and from each other about how to support culture change in Canada. There are many exciting initiatives and projects underway in Canada that are shifting, in significant and positive ways, the culture of aging and long-term care.


NCCMT: Defining a Problem Using Evidence: A SUPPORT Tool
Wednesday 22 Jan 10:00-11:30 MT

Do you need to prepare an evidence brief on this issue? Clearly defining the problem is a key step that will determine how it will be addressed. The Defining a Problem Using Evidence: A SUPPORT Tool can help! The tool is written for people involved in making and supporting decisions about health policies and programmes (e.g., front line staff, program managers, directors in public health).

NCCMT: Knowledge Translation (KT) Planning Primer
Tuesday 11 Feb 11:00-12:30 MT

The Knowledge Translation Planning Primer was designed for people who are new to KT and/or have limited resources to do KT. This plain-language tool builds on existing KT resources and is a starting point for those developing a KT plan. Some features of the KT Planning Primer include:
-a visual overview of the KT planning process
-a fillable worksheet with guiding questions to support the KT planning process
-a User Guide with tips and resources to complete the worksheet

CFHI: Improving Care: Avoiding Hospitalization for Long-Term Care Residents
Wednesday 29 January 10:00-11:00 MT Cost $99/organization

Marilyn R. El Bestawi, a Fellow of CFHI’s EXTRA program for healthcare improvement believes the best way to avoid deterioration in health status among LTC residents is to avoid unnecessary hospitalizations in the first place. For her EXTRA improvement project, Ms. El Bestawi developed and applied a model which reduced preventable emergency department visits among long-term care residents by 57 percent in just three months. If applied across the province, her PREVIEWED-ED© (Practical Routine Elder Variants Indicate Early Warning for ED) model could realize potential savings in the order of $6.2 million annually.

Translating Emergency Knowledge for Kids: Bridging the Research to Practice Gap
Wed 12 February 09:00 AM-10:30 MT
Presenters: Drs. Terry Klassen & Shannon Scott

Translating Emergency Knowledge for Kids (TREKK) is a Knowledge Mobilization Initiative funded by the Government of Canada’s Networks of Centres of Excellence. It brings together paediatric and general emergency health care providers, researchers, parents and knowledge mobilization experts from across Canada to find better ways to share the latest knowledge, bridge the ‘research to practice’ gap and raise the overall standard of care in paediatric emergency medicine. The first of two presentations will tell the story of TREKK – why the Network was started and its progress to date. A focus will be on the results of the first phase – the Needs Assessment – which included a national iPad survey of over 2850 health providers and consumers at 32 general emergency departments to determine their knowledge needs and preferences. The results will be discussed and how they are guiding future plans, as TREKK moves forward into the Knowledge Synthesis and Implementation Phases of the initiative.

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AIHS: Scientist Knowledge Translation Training
13-14 March

This highly-regarded, two-day workshop helps participants build essential skills in knowledge translation. Join trainers Dr. Melanie Barwick and Dr. Donna Lockett to:
· learn how to develop knowledge translation plans
· understand evidence-based knowledge translation strategies and evaluation methods
· understand the theory behind knowledge translation
· communicate research findings to multiple audiences including the media
· link with policy and decision-makers

SickKids Research Institute: Innovative Trial Design Short Course
21-23 May Toronto Fee $1295 (early bird last day 31 Jan)/$1495

This three day intermediate-level course takes an integrative approach to trial design by teaching a conceptual framework that includes outcome selection and measurement, value of information, cost effectiveness, risk of bias, appropriate trials designs, and choice of comparators. Mastery of these concepts enables students to prepare winning grant proposals in the face of uncertainty. Each day will include a mix of plenary sessions, group discussion, breakout sessions, and computer-based tutorials. The course will also feature an interactive half-day session for consultation where attendees can discuss their clinical trial design questions with leading trial methodologists in child health: Professor’s Martin Offringa, Terry Klassen, Andy Willan, Wendy Ungar and Maarten Boers.

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Ontario releases plan for new campuses Canada-flat-icon

The Ontario government has released a Major Capacity Expansion Policy Framework that outlines a selection process in which institutions are to submit expansion proposals to the Ministry of Training, Colleges and Universities (MTCU) following a call for proposals in “early 2014.”

Growing number of seniors caring for other seniors

As demand for senior services provided by nurses’ aides, home health aides and other such workers grows with the aging of baby boomers, so are those professions’ employment of other seniors. The new face of America’s network of caregivers is increasingly wrinkled.

Alberta Cancer Research Ethics Committee transfers from AHS to AIHS Canada-flat-icon

The Alberta Cancer Research Ethics Review Committee has relocated from Alberta Health Services (AHS) to Alberta Innovates – Health Solutions (AIHS) as part of the new HREBA. The HREBA committees are being further streamlined as they transition onto the Institutional Research Information Services Solution (IRISS). This is a secure online platform that enables a paperless approach for submitting, reviewing and managing ethics applications, from study submission to closure.

Being seen as a ‘senior’ Canada-flat-icon

News stories about the growing phenomenon of elder abuse — most recently, the lopsidedly low percentage of charges laid after reported incidents — usually spark the same outraged reaction. Who could possibly do something like that?

What hospitals need: peace and quiet Canada-flat-icon

For anyone unaccustomed to daily life in a hospital, the sustained churn of conversation, floor-cleaning machines, banging doors and other auditory sensations are a jarring intrusion.

IOM to Study the Public Health Dimensions of Cognitive Aging

The Institute of Medicine will conduct a study to examine cognitive health and aging, as distinct from Alzheimer’s disease. The committee will make recommendations focused on the public health aspects of cognitive aging with an emphasis on the following: definitions and terminology, epidemiology and surveillance, prevention and interventions opportunities, education of health professionals, public awareness and education.

Exporting Grandma to care homes abroad

Sending elderly relatives to a care home can be a tough and emotional decision. But is booking a one-way flight to a destination 8,000 miles away a step too far?

Cochrane forms partnership with Wikipedia

Cochrane has formed a partnership with Wikipedia via the Wiki Project Med Foundation to promote the use of independent, high-quality evidence in Wikipedia articles. Wikipedia’s impact and global reach easily surpass all other knowledge resources in the world today, providing an unparalleled opportunity for Cochrane to reach new audiences. To kick-off the new partnership, Wiley, has provided 100 full Cochrane Library licences free to Wikipedia medical editors to enable them to use Cochrane evidence to edit Wikipedia articles in health and medicine topics. Additionally, Cochrane is now in the process of appointing a Wikipedian-in-Residence (WiR) to work with Cochrane contributors and groups who want to get involved, to teach authors how to edit Wikipedia articles with the evidence they have produced; and to advocate Wikipedia within the Cochrane community as a key tool for disseminating Cochrane evidence.

Latest newsletter from AHS: Seniors Health Strategic Clinical Network is available Canada-flat-icon

In this issue:
-Highlights of Recent Work and Update to Platforms and Projects
-Leading Practice: Prevent Catheter Associated Urinary Tract Infections (CAUTI) Initiative
-CAUTI Training Opportunity January 23rd (telehealth)
-Research In Motion: Preventing Physical Decline through Mobilization of hospitalized seniors
-Announcement of the PRIHS Grant Competition Results
-AUA Project Update

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Students 4 Best Evidence

Students 4 Best Evidence is a project that was initiated at the United Kingdom Cochrane Centre (UKCC) to encourage students to become interested in evidence-based decision-making. The UCKK created an online community and website, Students 4 Best Evidence, meant for all students, of any age, in any healthcare discipline, or just students with an interest in evidence.

AHRQ: Managing Care for Adults with Long-Term Medical Illnesses

This consumer health summary clearly discusses helping manage care with the assistance of a case manager for patients/caregivers of persons with long-term medical illnesses, such as congestive heart failure, cancer, diabetes, dementia, or tuberculosis.

Alzheimer Society: Ambiguous Loss & Grief in Dementia

This resource is meant primarily to help caregivers gain a better understanding of how loss and grief can affect themselves and the person with dementia. It provides valuable information as well to help people with dementia deal with their own losses and grief, and live as well as possible with the disease. In addition, you will find useful strategies and tips to help you cope with the multiple losses and grief, and stay connected to the person with dementia while remaining healthy and resilient through the progression of the disease.

Alzheimer’s Society: This is Me Tool (UK)

This is me leaflet – tool for people with dementia receiving professional care. Our popular tool, This is me, has recently been updated and is now relevant for people with dementia who are receiving professional care in any setting – at home, in hospital, in respite care or a care home. It was originally developed for people with dementia who were going into hospital. This is me is a simple and practical tool that people with dementia can use to tell staff about their needs, preferences, likes, dislikes and interests.

Caring for Smiles: Better Oral Care for Dependent Older People (UK)

Developing good oral health care plans for residents in long-term care can be challenging. To assist care home staff in delivering good oral health care, the NHS Health Scotland has developed the guide Caring for Smiles: Guide for Care Homes. This guide is part of a series of oral health care pamphlets aimed at dependent older people, caregivers and long-term care staff.

RACGP Best Practice Guide for Collaborative Care between General Practitioners and Residential Aged Care Facilities (Australia)

This ‘Best Practice Guide’ and accompanying ‘Information Form’ serve to provide GPs, general practice staff and RACF staff with advice regarding best practice for collaborative arrangements for the care of older persons in RACFs (‘residents’) in Australia, and has been designed to be read in conjunction with the RACGP ‘Silver book’ The Medical Care of Older Persons in Residential Aged Care Facilities.

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3 Faculty Positions in Child Health Evaluative Sciences Canada-flat-icon
SickKids Research Institute Toronto ON
DEADLINE 30 January

The Child Health Evaluative Sciences (CHES) Program is seeking exceptional Scientists in the following research areas:
a) Clinical Trials Methodology,
b) Health outcomes selection and measurement,
c) Health Economics / Policy,
who are interested in exploiting the unique research environment provided by Canada’s largest paediatric hospital-based research institute.

3 post-doc positions at the SickKids Research Institute
Toronto ON
DEADLINE 22 January

Three (3) post-doctoral positions are available immediately in the Enhancing Research in International Child Health (EnRICH) Lab within the Child Health Evaluative Sciences (CHES) Program to work on analytic methodology and advanced issues in child health clinical trial methodology. This is a unique opportunity for those who are interested in exploiting the unique research environment provided by Canada’s largest paediatric hospital-based research institute, The Hospital for Sick Children, affiliated with the University of Toronto. The successful candidate will be supervised by Dr. Martin Offringa, a paediatric clinical epidemiologist and trialist.

Research Associate/Senior Research Associate
University College London – Department of Applied Health Research /Institute of Epidemiology & Health Care, London UK
DEADLINE 5 February

Applications are invited for this exciting opportunity to join a research team evaluating the implementation of an organisational intervention with senior hospital leaders to develop their quality improvement strategies. The Senior Research Associate/Research Associate (depending on experience) will fulfil a pivotal role in this innovative project which builds on the recently completed QUASER project funded through the European Commission’s 7th Framework Programme (www.ucl.ac.uk/dahr/quaser). The QUASER project undertook research in five European countries and produced a guide for senior hospital leaders across Europe to develop and implement organisation-wide quality improvement strategies. This project (iQUASER) will evaluate the implementation of the guide by an organisational development consultancy with a group of NHS Trusts.

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