March 4, 2014 again



New article by Dr. Jennifer Baumbusch
Invisible hands: the role of highly involved families in long-term residential care.
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Baumbusch J, Phinney A.
Journal of family nursing 2014 Feb;20(1):73-97

Care work by family and friends is recognized as a cornerstone of community-based care for older adults; however, the role of families in institutional-based care work has been less well understood and researched. Drawing on findings from a critical ethnographic study, this article aims to examine the unique role of highly involved family members within long-term residential care. The study took place between October 2006 and April 2008 in two facilities in British Columbia, Canada. A purposive sample of 11 highly involved family members participated in in-depth interviews and participant observations. The main themes were “Hands-On,” “Hands-Off,” “Surveillance,” and “Interlopers.” These themes illuminate the ways in which highly involved family members engaged in care work, including how they positioned themselves and were positioned by staff and administrators. Implications of the study focus on the need to include families in philosophies of care and policies that shape care work in long-term residential care.

Article recommended by Dr. Carole Estabrooks
Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial.
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Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al.
JAMA : the journal of the American Medical Association 2014 Feb 19;311(7):682-691

Agitation is common, persistent, and associated with adverse consequences for patients with Alzheimer disease. Pharmacological treatment options, including antipsychotics are not satisfactory. OBJECTIVE: The primary objective was to evaluate the efficacy of citalopram for agitation in patients with Alzheimer disease. Key secondary objectives examined effects of citalopram on function, caregiver distress, safety, cognitive safety, and tolerability. DESIGN, SETTING, AND PARTICIPANTS: The Citalopram for Agitation in Alzheimer Disease Study (CitAD) was a randomized, placebo-controlled, double-blind, parallel group trial that enrolled 186 patients with probable Alzheimer disease and clinically significant agitation from 8 academic centers in the United States and Canada from August 2009 to January 2013. INTERVENTIONS: Participants (n = 186) were randomized to receive a psychosocial intervention plus either citalopram (n = 94) or placebo (n = 92) for 9 weeks. Dosage began at 10 mg per day with planned titration to 30 mg per day over 3 weeks based on response and tolerability. MAIN OUTCOMES AND MEASURES: Primary outcome measures were based on scores from the 18-point Neurobehavioral Rating Scale agitation subscale (NBRS-A) and the modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC). Other outcomes were based on scores from the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI), ability to complete activities of daily living (ADLs), caregiver distress, cognitive safety (based on scores from the 30-point Mini Mental State Examination [MMSE]), and adverse events. RESULTS: Participants who received citalopram showed significant improvement compared with those who received placebo on both primary outcome measures. The NBRS-A estimated treatment difference at week 9 (citalopram minus placebo) was -0.93 (95% CI, -1.80 to -0.06), P = .04. Results from the mADCS-CGIC showed 40% of citalopram participants having moderate or marked improvement from baseline compared with 26% of placebo recipients, with estimated treatment effect (odds ratio [OR] of being at or better than a given CGIC category) of 2.13 (95% CI, 1.23-3.69), P = .01. Participants who received citalopram showed significant improvement on the CMAI, total NPI, and caregiver distress scores but not on the NPI agitation subscale, ADLs, or in less use of rescue lorazepam. Worsening of cognition (-1.05 points; 95% CI, -1.97 to -0.13; P = .03) and QT interval prolongation (18.1 ms; 95% CI, 6.1-30.1; P = .01) were seen in the citalopram group. CONCLUSIONS AND RELEVANCE: Among patients with probable Alzheimer disease and agitation who were receiving psychosocial intervention, the addition of citalopram compared with placebo significantly reduced agitation and caregiver distress; however, cognitive and cardiac adverse effects of citalopram may limit its practical application at the dosage of 30 mg per day.

And here’s the editorial commenting on the article above
Treating Dementia and Agitation
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Small GW.
JAMA : the journal of the American Medical Association 2014 Feb 19;311(7):677-678.

Although the results from this study support a role for citalopram in the management of agitation in dementia, when and how to prescribe the drug so that benefits are optimized and risks minimized are not straightforward. Clinicians who have treated patients who have both dementia and agitation know the considerable challenge and potential danger of these symptoms.

Article recommended by Dr. Carole Estabrooks
Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study
Aiken LH, Sloane DM, Bruyneel L, Van dH, Griffiths P, Busse R, et al.
The Lancet 2014 26/02

Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses’ educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. Methods For this observational study, we obtained discharge data for 422 730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26 516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics. Findings An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031—1·106), and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886—0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients. Interpretation Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.

New article by Dr. Peter Norton
‘Not another safety culture survey’: using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings.
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Ginsburg LR, Tregunno D, Norton PG, Mitchell JI, Howley H.
BMJ quality & safety 2014 Feb;23(2):162-170

The importance of a strong safety culture for enhancing patient safety has been stated for over a decade in healthcare. However, this complex construct continues to face definitional and measurement challenges. Continuing improvements in the measurement of this construct are necessary for enhancing the utility of patient safety climate surveys (PSCS) in research and in practice. This study examines the revised Canadian PSCS (Can-PSCS) for use across a range of care settings. METHODS: Confirmatory factor analytical approaches are used to extensively test the Can-PSCS. Initial and cross-validation samples include 13 126 and 6324 direct care providers from 119 and 35 health settings across Canada, respectively. RESULTS: Results support a parsimonious model of direct care provider perceptions of patient safety climate (PSC) with 19 items in six dimensions: (1) organisational leadership support for safety; (2) incident follow-up; (3) supervisory leadership for safety; (4) unit learning culture; (5) enabling open communication I: judgement-free environment; (6) enabling open communication II: job repercussions of error. Results also support the validity of the Can-PSCS across a range of care settings. CONCLUSIONS: The Can-PSCS has several advantages: (1) it is a theory-based instrument with a small number of actionable dimensions central to the construct of PSC; (2) it has robust psychometric properties; (3) it is validated for use across a range of care settings, therefore suitable for use in regionalised health delivery systems and can help to raise expectations about acceptable levels of PSC across the system; (4) it has been tested in a publicly funded universal health insurance system and may be suitable for similar international systems.

Special Issue of the Gerontologist on Transforming Nursing Home Culture: Evidence for Practice and Policy
Transforming Nursing Home Culture: Evidence for Practice and Policy
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Zimmerman S, Shier V, Saliba D.
What Does the Evidence Really Say About Culture Change in Nursing Homes?
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Shier V, Khodyakov D, Cohen LW, Zimmerman S, Saliba D.
A “Recipe” for Culture Change? Findings From the THRIVE Survey of Culture Change Adopters
Elliot A, Cohen LW, Reed D, Nolet K, Zimmerman S.
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Changing the Culture of Mouth Care: Mouth Care Without a Battle
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Zimmerman S, Sloane PD, Cohen LW, Barrick AL.
Culture Change and Nursing Home Quality of Care
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Grabowski DC, O’Malley AJ, Afendulis CC, Caudry DJ, Elliot A, Zimmerman S.
High-Performance Workplace Practices in Nursing Homes: An Economic Perspective
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Bishop CE.
Developing the Green House Nursing Care Team: Variations on Development and Implementation
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Bowers BJ, Nolet K.
Who Are the Innovators? Nursing Homes Implementing Culture Change
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Grabowski DC, Elliot A, Leitzell B, Cohen LW, Zimmerman S.
Medicaid Capital Reimbursement Policy and Environmental Artifacts of Nursing Home Culture Change
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Miller SC, Cohen N, Lima JC, Mor V.
Building a State Coalition for Nursing Home Excellence
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Beck C, Gately KJ, Lubin S, Moody P, Beverly C.
Implications for Policy: The Nursing Home as Least Restrictive Setting
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Bishop CE, Stone R.

Article recommended by Dr. Carole Estabrooks
Rogers’ Innovation Adoption Attributes: A Systematic Review and Synthesis of Existing Research
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Kapoor KK, Dwivedi YK, Williams MD.
Information Systems Management 2014 01/02; 2014/02;31(1):74-91.

A systematic approach is adopted to review the literature, followed by a meta-analysis of articles on Rogers’ innovation-attributes. All publications from 1996–2011 are extracted; 226 relevant innovation articles are studied to showcase the informative trends pertaining to Rogers’ five attributes—eight features of ideal innovation-attribute study (approach, dependent variable, study type, instrument, measure, attributes, innovations, adopting unit), and antecedents-descendants of Rogers’ innovation attributes. These findings, limitations, and future research suggestions are presented.

CALL FOR ABSTRACTS: BioMed Central Health Services Research: Evidence-based practice
1-3 July London, UK

Topics covered will include:
-Health Economics: Building the economic evidence base
-Health Systems: Adapting health systems to demographic and disease change
-Human Resources for Health: The mobility of health professionals in a globalized labour market
-Implementation Science: Strategies for scaling up and for sustaining interventions, development and evaluation
-Health policy

CALL FOR PAPERS: Conduct and reporting of rapid reviews and network meta-analysis
Systematic Reviews

The Editors (David Moher, Paul G. Shekelle, Lesley A. Stewart) are encouraging submissions of methodological papers concerning the conduct and reporting of rapid reviews and network meta-analysis and results papers of both types of studies. If you would like to enquire about the suitability of a study for consideration, please email

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


Establishing research in a palliative care clinical setting: Perceived barriers and implemented strategies.
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Bullen T, Maher K, Rosenberg JP, Smith B.
Applied Nursing Research : ANR 2014 Feb;27(1):78-83

There are many challenges in developing research projects in research-naïve clinical settings, especially palliative care where resistance to participate in research has been identified. These challenges to the implementation of research are common in nursing practice and are associated with attitudes towards research participation, and some lack of understanding of research as a process to improve clinical practice. This is despite the professional nursing requirement to conduct research into issues that influence palliative care practice. The purpose of this paper is to describe the process of implementing a clinical research project in collaboration with the clinicians of a palliative care community team and to reflect on the strategies implemented to overcome the challenges involved. The challenges presented here demonstrate the importance of proactively implementing engagement strategies from the inception of a research project in a clinical setting. Copyright © 2014 Elsevier Inc. All rights reserved.

Profile of evidence-based practice among respiratory therapists in Taiwan.
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Weng YH, Kuo KN, Chen C, Yang CY, Lo HL, Chiu YW.
Respiratory care 2014 Feb;59(2):281-287

Evidence-based practice (EBP) has been proposed as a core competence to improve healthcare quality. The profile of EBP among respiratory therapists (RTs) has not been explored. We investigated how RTs in Taiwan perceive the implementation of EBP. METHODS: We surveyed RTs in Taiwan’s regional hospitals during a 4-month period in 2011. RESULTS: A majority of RTs were aware of EBP (88.0%). Although most RTs held a favorable impression of EBP, their knowledge of and skill in EBP implementation were deficient. Only half of the RTs had implemented EBP. Insufficient convenient kits (59.1%), deficient designated personnel (50.0%), and lack of time (45.5%) were major barriers to implementing EBP. RTs rated MEDLINE as the most commonly used evidence-based retrieval database, followed by UpToDate, the Cochrane Library, MD Consult, ProQuest, CINAHL, DynaMed, and Micromedex. Multivariate regression analyses demonstrated sufficient skill in EBP and use of online databases as favorable factors for implementing EBP. In contrast, barriers of time constraint and insufficient knowledge were unfavorable factors for the implementation of EBP. CONCLUSIONS: EBP is not widespread among RTs in Taiwan. We have identified important factors in the implementation of EBP. The data provide valuable evidence for plotting strategies for disseminating EBP implementation.

Applying the knowledge to action framework to plan a strategy for implementing breast cancer screening guidelines: an interprofessional perspective. Canada-flat-icon
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Munce S, Kastner M, Cramm H, Lal S, Deschene SM, Auais M, et al.
Journal of cancer education 2013 Sep;28(3):481-487

Integrated knowledge translation (IKT) interventions may be one solution to improving the uptake of clinical guidelines. IKT research initiatives are particularly relevant for breast cancer research and initiatives targeting the implementation of clinical guidelines and guideline implementation initiatives, where collaboration with an interdisciplinary team of practitioners, patients, caregivers, and policy makers is needed for producing optimum patient outcomes. The objective of this paper was to describe the process of developing an IKT strategy that could be used by guideline developers to improve the uptake of their new clinical practice guidelines on breast cancer screening. An interprofessional group of students as well as two faculty members met six times over three days at the KT Canada Summer Institute in 2011. The team used all of the phases of the action cycle in the Knowledge to Action Framework as an organizing framework. While the entire framework was used, the step involving assessing barriers to knowledge use was judged to be particularly relevant in anticipating implementation problems and being able to inform the specific KT interventions that would be appropriate to mitigate these challenges and to accomplish goals and outcomes. This activity also underscored the importance of group process and teamwork in IKT. We propose that an a priori assessment of barriers to knowledge use (i.e., level and corresponding barriers), along with the other phases of the Knowledge to Action Framework, is a strategic approach for KT strategy development, implementation, and evaluation planning and could be used in the future planning of KT strategies.

How knowledge brokers emerge and evolve: The role of actors’ behaviour
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Boari C, Riboldazzi F.
Research Policy 2014

This article investigates how actors positioned in a network can evolve as knowledge brokers, as well as how they act to develop new brokerage roles. Our focus is on actor’s behaviour while previous studies concentrate more on the structural and positional determinants of brokerage roles. This research combines brokerage roles with a broker’s functions in an exploratory study of a small Italian comics publishing house. Over 20 years, the firm played different brokerage roles involving different actors at national and international levels. We find that if all brokerage roles involve transcoding functions, the ability to overcome transcoding obstacles, through the use of shared imprinting with receiving partners, could be useful for developing any brokerage role. Moreover, heterogeneity in the competences and industry experience of hired members of the management team could support the development of new brokerage roles, with differentiated effects on various brokers’ functions. If a brokerage role involves new actors with no previous allegiance, the status of the broker, signalled through network relations, can have significant impacts by indirectly communicating its superior knowledge. The proposed, emerging theoretical framework has direct implications for studies of knowledge brokers and innovation in social networks, as well as for entrepreneurship research. © 2014 Elsevier B.V. All rights reserved.

Do innovation measures actually measure innovation? Obliteration, symbolic adoption, and other finicky challenges in tracking innovation diffusion
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Nelson A, Earle A, Howard-Grenville J, Haack J, Young D.
Research Policy 2014

Although innovation diffusion is a central topic in policy and strategy, its measurement remains difficult – particularly in cases where the innovation is a complex and possibly ambiguous practice. In this paper, we develop four theoretical mechanisms that may bias diffusion markers by leading to the understatement and/or overstatement of diffusion at different points in time. Employing the case of “green chemistry,” we then compare three different diffusion markers – keywords, database index terms, and domain expert assessments – and we demonstrate how they lead to differing conclusions about the magnitude and timing of diffusion, organizational demography, publication outlets, and collaboration. We also provide suggestive evidence of extensive “greenwashing” by particular organization types and in particular countries. Building on these findings, we point to potential challenges with existing diffusion studies, and we make a case for the incorporation of practitioners in construct measurement and for the integration of comparative metrics in diffusion studies. © 2014 Elsevier B.V. All rights reserved.

Peering into the black box: a meta-analysis of how clinicians use decision aids during clinical encounters.
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Wyatt KD, Branda ME, Anderson RT, Pencille LJ, Montori VM, Hess EP, et al.
Implementation science 2014 Feb 22;9(1):26

To quantify the extent to which clinicians use clinically-efficacious decision aids as intended during implementation in practice and how fidelity to usage instructions correlates with shared decision making (SDM) outcomes. METHODS: Participant-level meta-analysis including six practice-based randomized controlled trials of SDM in various clinical settings encompassing a range of decisions. RESULTS: Of 339 encounters in the SDM intervention arm of the trials, 229 were video recorded and available for analysis. The mean proportion of fidelity items observed in each encounter was 58.4% (SD = 23.2). The proportion of fidelity items observed was significantly associated with patient knowledge (p = 0.01) and clinician involvement of the patient in decision making (p <0.0001), while no association was found with patient decisional conflict or satisfaction with the encounter. CONCLUSION: Clinicians’ fidelity to usage instructions of point-of-care decision aids in randomized trials was suboptimal during their initial implementation in practice, which may have underestimated the potential efficacy of decision aids when used as intended.

Social and organizational factors affecting implementation of evidence-informed practice in a public health department in Ontario: a network modelling approach Canada-flat-icon
Yousefi-Nooraie R, Dobbins M, Marin A.
Implementation Science 2014;9(1):29

The objective of this study is to develop a statistical model to assess factors associated with information seeking in a Canadian public health department. Methods Managers and professional consultants of a public health department serving a large urban population named whom they turned to for help, whom they considered experts in evidence-informed practice, and whom they considered friends. Multilevel regression analysis and exponential random graph modeling were used to predict the formation of information seeking and expertise-recognition connections by personal characteristics of the seeker and source, and the structural attributes of the social networks. Results The respondents were more likely to recognize the members of the supervisory/administrative division as experts. The extent to which an individual implemented evidence-based practice (EBP) principles in daily practice was a significant predictor of both being an information source and being recognized as expert by peers. Friendship was a significant predictor of both information seeking and expertise-recognition connections. Conclusion The analysis showed a communication network segregated by organizational divisions. Managers were identified frequently as information sources, even though this is not a part of their formal role. Self-perceived implementation of EBP in practice was a significant predictor of being an information source or an expert, implying a positive atmosphere towards implementation of evidence-informed decision making in this public health organization. Results also implied that the perception of accessibility and trust were significant predictors of expertise recognition.

How research funding agencies support science integration into policy and practice: An international overview Canada-flat-icon
Smits P, Denis J.
Implementation Science 2014;9(1):28

Funding agencies constitute one essential pillar for policy makers, researchers and health service delivery institutions. Such agencies are increasingly providing support for science implementation. In this paper, we investigate health research funding agencies and how they support the integration of science into policy, and of science into practice, and vice versa. Methods We selected six countries: Australia, The Netherlands, France, Canada, England and the United States. For 13 funding agencies, we compared their intentions to support, their actions related to science integration into policy and practice, and the reported benefits of this integration. We did a qualitative content analysis of the reports and information provided on the funding agencies’ websites. Results Most funding agencies emphasized the importance of science integration into policy and practice in their strategic orientation, and stated how this integration was structured. Their funding activities were embedded in the push, pull, or linkage/exchange knowledge transfer model. However, few program funding efforts were based on all three models. The agencies reported more often on the benefits of integration on practice, rather than on policy. External programs that were funded largely covered science integration into policy and practice at the end of grant stage, while overlooking the initial stages. Finally, external funding actions were more prominent than internally initiated bridging activities and training activities on such integration. Conclusions This paper contributes to research on science implementation because it goes beyond the two community model of researchers versus end users, to include funding agencies. Users of knowledge may be end users in health organizations like hospitals; civil servants assigned to decision making positions within funding agencies; civil servants outside of the Ministry of Health, such as the Ministry of the Environment; politicians deciding on health-related legislation; or even university researchers whose work builds on previous research. This heterogeneous sample of users may require different user-specific mechanisms for research initiation, development and dissemination. This paper builds the foundation for further discussion on science implementation from the perspective of funding agencies in the health field. In general, case studies can help in identifying best practices for evidence-informed decision making.

Perception of Spanish primary healthcare nurses about evidence-based clinical practice: a qualitative study.
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Pericas-Beltran J, Gonzalez-Torrente S, De Pedro-Gomez J, Morales-Asencio JM, Bennasar-Veny M.
International nursing review 2014 Mar;61(1):90-98

Although evidence-based clinical practice constitutes a priority for healthcare services in many countries within the last few years, there is a general lack of implementation of evidence-based clinical practice in nursing care, especially in primary health care. Few qualitative studies concerning the influencing factors on evidence-based clinical practice for community nurses have been carried out. AIM: This study examined the perception of nurses in Spanish primary health care with regard to the knowledge, advantages and barriers within the application process with evidence-based clinical practice. METHODS: We used a descriptive qualitative study with focus groups to collect data. Forty-six primary care nurses took part in this study and they were distributed into five focus groups. RESULTS: Five main topics arose from the results achieved: knowledge and development of evidence-based clinical practice, evidence searching, evidence dissemination, advantages of use of evidence-based clinical practice, and barriers for its application and implementation. Participants had a positive attitude towards evidence-based practice, although they used this infrequently because of lack of competence and organizational support for its application. CONCLUSION: Our participants are increasingly determined to take into account evidence within the decision-making processes in their usual clinical practice. We consider it advisable to develop specialized training strategies as well as provide necessary resources for the implementation of evidence-based clinical practice duly adapted to the field of primary health care. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This study highlights the existing gap in translating knowledge to practice and its potential implications in the effectiveness of nursing interventions and decision making in primary health care, and thus its implications for education policy. © 2014 International Council of Nurses.

An environmental scan of an aged care workplace using the PARiHS model: assessing preparedness for change.
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Gibb H.
Journal of nursing management 2013 Mar;21(2):293-303

The environmental scan aimed to deepen our understanding of the aged care work culture and to ascertain the readiness of the workers to advance towards team-based quality care provision. BACKGROUND: The workplace context was a high-care unit within a large residential aged care facility. METHODS: We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess workplace readiness via interviews, individual surveys and observation of practice. RESULTS: A profile of current culture emerged as mutually supportive and task focused, but at the same time lacking corporate team features of shared decision-making and feedback for practice improvement. However, latent within the frontline leaders and personal care staff, there was evidence of some embedded knowledge and capacity for corporate team performance. CONCLUSIONS: This study has validated an evidence-based method for conducting environmental scanning in aged care, recommended before any major change is introduced. IMPLICATIONS FOR NURSING MANAGEMENT: Environmental scanning helps gauge workforce capacity and limitations; this information can enable managers to capitalize on identified cultural strengths to fortify change and avoid pitfalls of personal and collective vulnerabilities. © 2012 Blackwell Publishing Ltd.

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Health Care Administration and Organization

Securing and Managing Nursing Home Resources: Director of Nursing Tactics.
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Siegel EO, Young HM, Zysberg L, Santillan V.
The Gerontologist 2014 Feb 17

Shrinking resources and increasing demands pose managerial challenges to nursing homes. Little is known about how directors of nursing (DON) navigate resource conditions and potential budget-related challenges. This paper describes the demands-resources tensions that DONs face on a day-to-day basis and the tactics they use to secure and manage resources for the nursing department. DESIGN AND METHODS: We conducted a secondary analysis of data from a parent study that used a qualitative approach to understand the DON position. A convenience sample of 29 current and previous DONs and administrators from more than 15 states participated in semistructured interviews for the parent study. Data analysis included open coding and thematic analysis. RESULTS: DONs address nursing service demands-resources tensions in various ways, including tactics to generate new sources of revenue, increase budget allocations, and enhance cost efficiencies. IMPLICATIONS: The findings provide a rare glimpse into the operational tensions that can arise between resource allocations and demands for nursing services and the tactics some DONs employ to address these tensions. This study highlights the DON’s critical role, at the daily, tactical level of adjusting and problem-solving within existing resource conditions. How DONs develop these skills and the extent to which these skills may improve nursing home quality and value are important questions for further practice-, education-, and policy-level investigation.

Retooling the RN workforce in long-term care: Nursing certification as a pathway to quality improvement.
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Cramer ME, High R, Culross B, Conley DM, Nayar P, Nguyen AT, et al.
Geriatric nursing (New York, N.Y.) 2014 Jan 17

This article describes a project to improve nursing care quality in long-term care (LTC) by retooling registered nurses’ (RN) geriatric clinical competence. A continuing education course was developed to prepare LTC RNs (N = 84) for national board certification and improve technological competence. The certification pass-rate was 98.5%. The study used a mixed methods design with retrospective pretests administered to RN participants. Multivariate analysis examined the impact of RN certification on empowerment, job satisfaction, intent to turnover, and clinical competence. Results showed certification significantly improved empowerment, satisfaction, and competence. A fixed effects analysis showed intent to turnover was a function of changes in empowerment, job dissatisfaction, and competency (F = 79.2; p < .001). Changes in empowerment (t=1.63, p=.11) and competency (t=-0.04, p=.97) did not affect changes in job satisfaction. Findings suggest RN certification can reduce persistently high RN turnover rates that negatively impact patient safety and LTC quality. Copyright © 2014 Mosby, Inc. All rights reserved.

Alone in Eden: Care Aides’ Perceptions of Consistent Assignments. Canada-flat-icon
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Andersen E, Spiers J.
Western journal of nursing research 2014 Feb 11

The Eden Alternative® is a philosophy of care and transformational model aimed at increasing quality of life for nursing home residents by enhancing institutional environments and restructuring delivery of care. Restructured care consists of three fundamental components: resident care provided primarily by care aides, enhanced responsibilities for care aides, and consistent assignment of residents to care aides. Researchers have focused on resident and family satisfaction with the model, but there is limited research evaluating the impact of the model on nursing home employees. This article is focused on their experiences. Convenience and purposive sampling were used to recruit 22 care aides from five nursing homes in a western Canadian city. Experiential interview data were collected and analyzed utilizing constant comparison to identify common themes. Although care aides initially welcomed the restructuring, they described gradually becoming overwhelmed by the work, confined by consistent assignments, and isolated from colleagues and other residents.

Nursing Home Control of Physician Resources.
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Intrator O, Lima JC, Wetle TF.
Journal of the American Medical Directors Association 2014 Feb 6

Physician services are increasingly recognized as important contributors to quality care provision in nursing homes (NH)s, but knowledge of ways in which NHs manage/control physician resources is lacking. DATA: Primary data from surveys of NH administrators and directors of nursing from a nationally representative sample of 1938 freestanding United States NHs in 2009-2010 matched to Online Survey Certification and Reporting, aggregated NH Minimum Data Set assessments, Medicare claims, and county information from the Area Resource File. METHODS: The concept of NH Control of Physician Resources (NHCOPR) was measured using NH administrators’ reports of management implementation of rules, policies, and procedures aimed at coordinating work activities. The NHCOPR scale was based on measures of formal relationships, physician oversight and credentialing. Scale values ranged from weakest (0) to tightest (3) control. Several hypotheses of expected associations between NHCOPR and other measures of NH and market characteristics were tested. RESULTS: The full NHCOPR score averaged 1.58 (standard deviation = 0.77) on the 0-3 scale. Nearly 30% of NHs had weak control (NHCOPR ≤1), 47.5% had average control (NHCOPR between 1 and 2), and the remaining 24.8% had tight control (NHCOPR >2). NHCOPR exhibited good face- and predictive-validity as exhibited by positive associations with more beds, more Medicare services, cross coverage, and number of physicians in the market. CONCLUSIONS: The NHCOPR scale capturing NH’s formal structure of control of physician resources can be useful in studying the impact of NH’s physician resources on residents’ outcomes with potential for targeted interventions by education and promotion of NH administration regarding physician staff.

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Health Care Innovation and Quality Assurance

A qualitative systematic review of studies using the normalization process theory to research implementation processes.
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McEvoy R, Ballini L, Maltoni S, O’Donnell CA, Mair FS, Macfarlane A.
Implementation science 2014 Jan 2;9:2-5908-9-2

There is a well-recognized need for greater use of theory to address research translational gaps. Normalization Process Theory (NPT) provides a set of sociological tools to understand and explain the social processes through which new or modified practices of thinking, enacting, and organizing work are implemented, embedded, and integrated in healthcare and other organizational settings. This review of NPT offers readers the opportunity to observe how, and in what areas, a particular theoretical approach to implementation is being used. In this article we review the literature on NPT in order to understand what interventions NPT is being used to analyze, how NPT is being operationalized, and the reported benefits, if any, of using NPT. METHODS: Using a framework analysis approach, we conducted a qualitative systematic review of peer-reviewed literature using NPT. We searched 12 electronic databases and all citations linked to six key NPT development papers. Grey literature/unpublished studies were not sought. Limitations of English language, healthcare setting and year of publication 2006 to June 2012 were set. RESULTS: Twenty-nine articles met the inclusion criteria; in the main, NPT is being applied to qualitatively analyze a diverse range of complex interventions, many beyond its original field of e-health and telehealth. The NPT constructs have high stability across settings and, notwithstanding challenges in applying NPT in terms of managing overlaps between constructs, there is evidence that it is a beneficial heuristic device to explain and guide implementation processes. CONCLUSIONS: NPT offers a generalizable framework that can be applied across contexts with opportunities for incremental knowledge gain over time and an explicit framework for analysis, which can explain and potentially shape implementation processes. This is the first review of NPT in use and it generates an impetus for further and extended use of NPT. We recommend that in future NPT research, authors should explicate their rationale for choosing NPT as their theoretical framework and, where possible, involve multiple stakeholders including service users to enable analysis of implementation from a range of perspectives.

A Controlled Quality Improvement Trial to Reduce the Use of Physical Restraints in Older Hospitalized Adults. Canada-flat-icon
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Enns E, Rhemtulla R, Ewa V, Fruetel K, Holroyd-Leduc JM.
Journal of the American Geriatrics Society 2014 Feb 12

To implement and evaluate an evidence-informed multicomponent strategy to reduce physical restraint use in older adults admitted to acute care medical units. DESIGN: Stepped-wedge trial. SETTING: Four acute care medical units in Calgary, Alberta, over a 4-month time period. PARTICIPANTS: Data were collected from individuals aged 65 and older present on the study units during monthly restraint audits. INTERVENTION: Development of opinion leaders among the nursing leadership, education and training of physicians and unit nurses, and implementation of least restraint rounds. MEASUREMENTS: The primary outcome was rate of restraint use as determined from walk-around audits. Secondary outcomes included number of physician orders for physical restraints on the electronic medical record and fall reports. RESULTS: Thirteen percent to 27% of individuals were being restrained on the medical units before the intervention, with the vast majority of restraints being bed rails. This decreased to 7% to 14% after the intervention. The intervention resulted in a statistically significant reduction in restraint use measured in the early mornings (P = .01), and this trend continued after adjusting for unit and month (P = .06). Similarly, the rate of restraint use trended down at all other measured time periods but was not statistically significant. A limited number of individuals had an order for physical restraint within their electronic medical record (3% before, 2% after the intervention). The median number of monthly fall reports did not change (three before, three after; P = .60). CONCLUSION: A multicomponent team-focused quality improvement intervention has the potential to decrease the use of physical restraints in older hospitalized adults. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Identification of serious and reportable events in home care: a Delphi survey to develop consensus. Canada-flat-icon
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Doran DM, Baker GR, Szabo C, McShane J, Carryer J.
International journal for quality in health care 2014 Feb 11

To assess which client events should be considered reportable and preventable in home care (HC) settings in the opinion of HC safety experts. BACKGROUND: Patient safety in acute care settings has been well documented; however, there are limited data about this issue in HC. While many organizations collect information about ‘incidents’, there are no standards for reporting and it is challenging to compare incident rates among organizations. DESIGN: A 29-item electronic survey that included potential HC safety issues was used in a two-round Delphi study. SETTING AND PARTICIPANTS: Twenty-four pan-Canadian HC safety experts participated in an electronic survey. MAIN OUTCOME MEASURES: Perceived reportability and preventability of patient safety events, HC. RESULTS: The events that were perceived as being most reportable and preventable included the following: a serious injury related to inappropriate client service plan (e.g. incomplete/inaccurate assessments, poor care plan design, flawed implementation); an adverse reaction requiring emergency room visit or hospitalization related to a medication-related event; a catheter-site infection (e.g. a new peritoneal dialysis infection or peritonitis); any serious event related to care or services that are contrary to current professional or other practice standards (e.g. incorrect treatment regimen, theft, retention of a foreign object in a wound, individual practicing outside scope or competence). CONCLUSION: These data represent an important step in the development and validation of standard metrics about client safety in HC. The results address an expanding area of health services where there is a need to improve standardization and reporting.

Patient and Public Involvement in Healthcare Quality Improvement: How organizations can help patients and professionals to collaborate
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Renedo A, Marston CA, Spyridonidis D, Barlow J.
Public Management Review 2014

Citizens across the world are increasingly called upon to participate in healthcare improvement. It is often unclear how this can be made to work in practice. This 4-year ethnography of a UK healthcare improvement initiative showed that patients used elements of organizational culture as resources to help them collaborate with healthcare professionals. The four elements were: (1) organizational emphasis on non-hierarchical, multidisciplinary collaboration; (2) organizational staff ability to model desired behaviours of recognition and respect; (3) commitment to rapid action, including quick translation of research into practice; and (4) the constant data collection and reflection process facilitated by improvement methods. © 2014 © 2014 The Author(s). Published by Taylor & Francis.

What impedes and what facilitates a quality improvement project for older hospitalized patients?
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Ijkema R, Langelaan M, van de Steeg L, Wagner C.
International journal for quality in health care 2014 Feb;26(1):41-48

To gain insight into which factors impede, and which facilitate, the implementation of a complex multi-component improvement initiative in hospitalized older patients. DESIGN: A qualitative study based on semi-structured interviews. The three dimensions of Pettigrew and Whipp’s theoretical framework, namely, Process, Content and Context, were used to undertake a structured data analysis. SETTING: The study was conducted in 19 Dutch hospitals implementing the Frail Elderly Project. PARTICIPANTS: Sixty-five members of staff, including physicians, nurses and members of the policy team. INTERVENTION: The Frail Elderly Project, a Dutch quality improvement program, aims to decrease adverse events in frail older hospitalized people by implementing screening instruments and interventions targeting delirium, falls, malnutrition and physical impairment. MAIN OUTCOME MEASURES: The management of the process of implementation, participants’ opinions of the program elements and contextual factors which influence the implementation. RESULTS: Barriers to implementation included two process factors (insufficient involvement of clinicians and lack of time), two content factors (having divergent objectives and concerns about recommended program elements) and two contextual factors (a lack of knowledge of delirium and minimal insight into the purposes and effects of the program). Facilitating factors included one process factor (leadership), one content factor (flexibility in choosing methods) and two contextual factors (the program’s guidance and the use of digital patient records). CONCLUSION: We identified the barriers and the factors which facilitate implementing complex multi-component improvement programs concerning care for older patients. These barriers must be resolved in future improvement programs in order to ensure successful implementation.

The challenge of change in acute mental health services: measuring staff perceptions of barriers to change and their relationship to job status and satisfaction using a new measure (VOCALISE).
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Laker C, Callard F, Flach C, Williams P, Sayer J, Wykes T.
Implementation science 2014 Feb 20;9(1):23

Health services are subject to frequent changes, yet there has been insufficient research to address how staff working within these services perceive the climate for implementation. Staff perceptions, particularly of barriers to change, may affect successful implementation and the resultant quality of care. This study measures staff perceptions of barriers to change in acute mental healthcare. We identify whether occupational status and job satisfaction are related to these perceptions, as this might indicate a target for intervention that could aid successful implementation. As there were no available instruments capturing staff perceptions of barriers to change, we created a new measure (VOCALISE) to assess this construct. METHODS: All nursing staff from acute in-patient settings in one large London mental health trust were eligible. Using a participatory method, a nurse researcher interviewed 32 staff to explore perceptions of barriers to change. This generated a measure through thematic analyses and staff feedback (N = 6). Psychometric testing was undertaken according to standard guidelines for measure development (N = 40, 42, 275). Random effects models were used to explore the associations between VOCALISE, occupational status, and job satisfaction (N = 125). RESULTS: VOCALISE was easy to understand and complete, and showed acceptable reliability and validity. The factor analysis revealed three underlying constructs: ‘confidence,’ ‘de-motivation’ and ‘powerlessness.’ Staff with negative perceptions of barriers to change held more junior positions, and had poorer job satisfaction. Qualitatively, nursing assistants expressed a greater sense of organisational unfairness in response to change. CONCLUSIONS: VOCALISE can be used to explore staff perceptions of implementation climate and to assess how staff attitudes shape the successful outcomes of planned changes. Negative perceptions were linked with poor job satisfaction and to those occupying more junior roles, indicating a negative climate for implementation in those groups. Staff from these groups may therefore need special attention prior to implementing changes in mental health settings.

The experiences of professionals with using information from patient-reported outcome measures to improve the quality of healthcare: a systematic review of qualitative research
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Boyce MB, Browne JP, Greenhalgh J.
BMJ quality & safety 2014 Feb 6

To synthesise qualitative studies that investigated the experiences of healthcare professionals with using information from patient-reported outcome measures (PROMs) to improve the quality of care. DESIGN: A qualitative systematic review was conducted by searching PubMed, PsycINFO and CINAHL with no time restrictions. Hand searching was also performed. Eligible studies were evaluated using the Critical Appraisal Skills Programme toolkit for qualitative studies. A thematic synthesis identified common themes across studies. Study characteristics were examined to explain differences in findings. SETTING: All healthcare settings. PARTICIPANTS: Healthcare professionals. OUTCOMES: Professionals’ views of PROMs after receiving PROMs feedback about individual patients or groups of patients. RESULTS: Sixteen studies met the inclusion criteria. Barriers and facilitators to the use of PROMs emerged within four main themes: collecting and incorporating the data (practical), valuing the data (attitudinal), making sense of the data (methodological) and using the data to make changes to patient care (impact). CONCLUSIONS: Professionals value PROMs when they are useful for the clinical decision-making process. Practical barriers to the routine use of PROMs are prominent when the correct infrastructure is not in place before commencing data collection and when their use is disruptive to normal work routines. Technology can play a greater role in processing the information in the most efficient manner. Improvements to the interpretability of PROMs should increase their use. Attitudes to the use of PROMs may be improved by engaging professionals in the planning stage of the intervention and by ensuring a high level of transparency around the rationale for data collection.

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Health Care in Canada

Latest articles from ICES

Access, excess, and overdiagnosis: the case for thyroid cancer.
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Rates of thyroid cancer diagnosis vary four-fold across Ontario’s health planning regions.
The three-year incidence of fracture in chronic kidney disease
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Adults with chronic kidney disease at increased risk for bone fracture.
The impact of surgeon volume on postoperative outcomes after surgery for Crohn’s disease
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Lower surgeon volumes linked to greater risk of postsurgery hospitalization in patients with Crohn’s disease.
Association of heart rate at hospital discharge with mortality and hospitalizations in patients with heart failure
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Heart rate at hospital discharge a predictor of mortality in patients with chronic heart failure.
Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study.
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Women with schizophrenia at higher risk for pre-term birth and pregnancy complications

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Research Practice & Methodology

Living systematic reviews: an emerging opportunity to narrow the evidence-practice gap.
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Elliott JH, Turner T, Clavisi O, Thomas J, Higgins JP, Mavergames C, et al.
PLoS medicine 2014 Feb 18;11(2):e1001603

Julian Elliott and colleagues discuss how the current inability to keep systematic reviews up-to-date hampers the translation of knowledge into action. They propose living systematic reviews as a contribution to evidence synthesis to enhance the accuracy and utility of health evidence.

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A Tale of Two Methods: Chart and Interview Methods for Identifying Delirium.
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Saczynski JS, Kosar CM, Xu G, Puelle MR, Schmitt E, Jones RN, et al.
Journal of the American Geriatrics Society 2014 Feb 10

To compare chart- and interview-based methods for identification of delirium. DESIGN: Prospective cohort study. SETTING: Two academic medical centers. PARTICIPANTS: Individuals aged 70 and older undergoing major elective surgery (N = 300) (majority orthopedic surgery). MEASUREMENTS: Participants were interviewed daily during hospitalization for delirium using the Confusion Assessment Method (CAM; interview-based method), and their medical charts were reviewed for delirium using a validated chart-review method (chart-based method). Rate of agreement of the two methods and characteristics of those identified using each approach were examined. Predictive validity for clinical outcomes (length of stay, postoperative complications, discharge disposition) was compared. In the absence of a criterion standard, predictive value could not be calculated. RESULTS: The cumulative incidence of delirium was 23% (n = 68) according to the interview-based method, 12% (n = 35) according to the chart-based method, and 27% (n = 82) according to the combined approach. Overall agreement was 80%; kappa was 0.30. The methods differed in detection of psychomotor features and time of onset. The chart-based method missed delirium in individuals that the CAM identified who were lacking features of psychomotor agitation or inappropriate behavior. The CAM-based method missed chart-identified cases occurring during the night shift. The combined method had high predictive validity for all clinical outcomes. CONCLUSIONS: Interview- and chart-based methods have specific strengths for identification of delirium. A combined approach captures the largest number and broadest range of delirium cases. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Facilitating independence: The benefits of a post-diagnostic support project for people with dementia.
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Kelly F, Innes A.
Dementia (London, England) 2014 Feb 17

Providing support in the form of information, advice and access to services or social events is promoted as beneficial for people newly diagnosed with dementia and their families. This paper reports on key findings from an evaluation of a post-diagnostic support pilot project in Scotland addressing local service gaps, namely information provision, emotional and practical support and maintaining community links. Twenty-seven participants (14 people newly diagnosed with dementia and 13 family carers) were interviewed at two time points: T1 shortly after joining the pilot project and T2 approximately six months later, to ascertain their views on existing services and the support offered by the pilot project. A comparative thematic analysis revealed that the project facilitated increased independence (associated with increased motivation and self-confidence) of people with dementia. The project illustrates what can be achieved if resources are targeted at providing individualised post-diagnostic support, particularly where there are service delivery gaps.

The experience of self and threats to sense of self among relatives caring for people with Alzheimer’s disease.
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Skaalvik MW, Norberg A, Normann K, Fjelltun AM, Asplund K.
Dementia (London, England) 2014 Feb 17

This study explored how the relatives of people with Alzheimer’s disease expressed Self 2 and Self 3 according to Harré’s social constructionist theory of selfhood. Having a relative with Alzheimer’s disease affects one’s life. In this study, we concentrated on how close relatives of people with Alzheimer’s disease experienced their sense of self. This study was descriptive and qualitative. Interviews were conducted with 20 relatives of 10 people with Alzheimer’s disease from 2009 to 2011. The data were analysed according to Harré’s social constructionist theory of selfhood including Selves 2 and 3. Participants reported that Alzheimer’s disease challenged their personal attributes, relations and positioning. Understanding how Alzheimer’s disease affects the sense of self among close relatives is important, as this knowledge is pivotal for supporting these relatives who are often informal caregivers in ways that enable a fulfilling and meaningful life.

Medication reviews for nursing home residents to reduce mortality and hospitalisation: systematic review and meta-analysis.
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Wallerstedt SM, Kindblom JM, Nylen K, Samuelsson O, Strandell A.
British journal of clinical pharmacology 2014 Feb 18

Medication reviews by a third party have been introduced as a method to improve drug treatment in older people. We assessed if this intervention reduces mortality and hospitalisation for nursing home residents. METHODS: Systematic literature searches were performed (January 1990 to June 2012) in Medline, EMBASE, Cochrane Library, ProQuest Nursing & Allied Health Sources, and Health Technology Assessment databases. We included randomised and non-randomised controlled trials (RCTs and non-RCTs) of medication reviews compared with standard care or other type of medication reviews in nursing home residents. The outcome variables were mortality and hospitalisation. Study quality was assessed systematically. We performed meta-analyses using random effects models. RESULTS: Seven RCTs and five non-RCTs fulfilled the inclusion criteria. The mean age of included patients varied between 78 and 86 years. They were treated with a mean of four to twelve drugs. The study quality was assessed as high (n=1), moderate (n=4), or low (n=7). Eight studies compared medication reviews with standard care. In six of them, pharmacists were involved in the intervention. Meta-analyses of RCTs revealed a risk ratio (RR) for mortality of 1.03 (medication reviews vs. standard care; 5 trials; 95% confidence interval (CI): 0.85; 1.23). Corresponding RR for hospitalisation was 1.07 (2 trials; 95% CI: 0.61; 1.87). CONCLUSIONS: Our findings indicate that medication reviews for nursing home residents do not reduce mortality or hospitalisation. More research in the setting of controlled trials remains to be done in order to clarify how drug treatment can be optimised for these patients.

Best practices interventions to improve quality of care of people with dementia living at home.
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Zabalegui A, Hamers JP, Karlsson S, Leino-Kilpi H, Renom-Guiteras A, Saks K, et al.
Patient education and counseling 2014 Jan 30

To identify effective interventions which improve quality of care for people with dementia (PwD) living at home. METHODS: MEDLINE-(via PubMed), CINAHL, PsycINFO and ISI Web of Science databases were searched. Inclusion criteria: (1) randomized controlled trials; (2) published in English-language, peer-reviewed journals between 1990 and 2012; (3) evaluated strategies to improve quality of care for PwD cared at home; and (4) participants older than 65. RESULTS: 23 studies met inclusion criteria. All the studies aimed to improve PwD quality of care and most of them focused on PwD caregivers. Psychoeducational programs are the most frequently assessed interventions and multicomponent interventions produced the most promising results. CONCLUSION: Due to the great variety of interventions describing specific samples and contexts, comparison of practice effectiveness is difficult. However, cognitive rehabilitation in PwD is effective when applied at an early stage of the disease. Case managers have demonstrated to reduce PwD institutionalization and the use of other community services. The studies were limited by sample heterogeneity, short follow-up or insufficiently detailed description. PRACTICE IMPLICATIONS: To improve PwD homecare, health professionals should educate and support caregivers. Before specific interventional recommendations can be made, further research addressing the limitations of current studies is needed. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Factors associated with quality of life of people with dementia in long-term care facilities: a systematic review.
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Beerens HC, Zwakhalen SM, Verbeek H, Ruwaard D, Hamers JP.
International journal of nursing studies 2013 Sep;50(9):1259-1270

Quality of life has become an important outcome measure in dementia research. Currently there is no convincing evidence about which factors are associated with quality of life of people with dementia living in long-term care facilities. OBJECTIVE: This study aims to investigate which factors are associated with quality of life, including factors associated with change over time, of people with dementia living in long-term care facilities. DESIGN: A systematic literature review was performed. DATA SOURCES: Cochrane, Pubmed, CINAHL, Web of Science, and PsycINFO were searched. REVIEW METHODS: Three researchers independently assessed studies for eligibility. The inclusion criteria were: (1) the primary focus was on factors related to quality of life; (2) the study was performed in long-term care facilities; (3) the study regarded quality of life as multidimensional construct. Methodological quality of studies included in the review was assessed with a quality criteria checklist. RESULTS: Ten cross-sectional and three longitudinal articles were included in the review. In cross-sectional studies, depressive symptoms were negatively related to self-rated quality of life of people with dementia. The association between depressive symptoms and proxy-rated quality of life was less clear. Behavioural disturbances, especially agitation, appeared to be negatively related to proxy-rated quality of life. There appeared to be a negative relation between quality of life, activities of daily living and cognition, although this could not be confirmed in all studies. In longitudinal studies, depressive symptoms were negatively related and cognition was positively related to self-rated quality of life, whereas dependency and depressive symptoms were negatively related to proxy-rated quality of life. CONCLUSIONS: There are only few high quality studies that investigate associations of (change in) quality of life of people with dementia living in long-term care facilities. Our results suggest that depressive symptoms and agitation are related to lower quality of life. Perspective of quality of life measurement, i.e. self- or proxy rating, may influence its associations. Longitudinal studies are needed to determine which factors are related to change in quality of life over time. This information is essential for the development of interventions that aim to improve quality of life. Copyright © 2013 Elsevier Ltd. All rights reserved.

Intensive Care Utilization among Nursing Home Residents with Advanced Cognitive and Severe Functional Impairment.
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Fulton AT, Gozalo P, Mitchell SL, Mor V, Teno JM.
Journal of palliative medicine 2014 Feb 3

Dementia is a progressive terminal illness which requires decisions around aggressiveness of care. Objective: The study objective was to examine the rate of intensive care unit (ICU) utilization and its regional variation among persons with both advanced cognitive and severe functional impairment. Methods: We utilized the Minimum Data Set (MDS) to identify a cohort of decedents between 2000 and 2007 who (1) were in a nursing home (NH) 120 days prior to death and (2) had an MDS assessment indicating advanced cognitive and functional impairment as identified by cognitive performance scale (CPS) ≥5 and total dependence or extensive assistance in seven activities of daily living (ADLs). ICU utilization in the last 30 days of life was determined from Medicare claims files. A multivariate logistic regression model examined the likelihood of ICU admission in 2007 versus 2000 adjusting for sociodemographics, orders to limit life sustaining treatment, and health status. Results: Among 474,829 Medicare NH residents with advanced cognitive impairment followed during 2000-2007, we observed an increase in ICU utilization from 6.1% in 2000 to 9.5% in 2007. After adjustment for sociodemographic characteristics, orders to limit life sustaining treatment, and measures of health status, the likelihood of a resident being admitted to an ICU was higher in 2007 compared to 2000 (adjusted odds ratio [OR] 1.71, 95% CI 1.60-1.81). Additionally, substantial regional variation was noted in ICU utilization, from 0.82% in Montana to 22% in the District of Columbia. Conclusions: Even among patients with advanced cognitive and functional impairment, ICU utilization in the last 30 days increased and varied by geographic region.

Does Self-Neglect Occur Among Older Adults With Dementia When Unsupervised in Assisted Living? An Exploratory, Observational Study.
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Caspi EP.
Journal of Elder Abuse & Neglect 2014 March-May;26(2):123-149

The phenomenon of older adults with dementia who develop behavioral expressions when they are unsupervised in assisted living residences is understudied. This qualitative study aimed to bridge this gap in the literature by focusing on 12 residents in various stages of dementia. Grounded Theory was followed to guide data collection and analysis. Data were collected in two special care units of an assisted living residence for 10 months. Participant observation was the primary data collection strategy. Semistructured interviews with staff and managers and review of clinical records augmented the observation data. While unsupervised, residents exhibited a wide spectrum of negative emotional states, behavioral expressions, functional difficulties, wayfinding difficulties, serious hygiene problems, and safety risks. More than half of the identified incidents represented self-neglectful behaviors. The study highlights the need for enhanced supervision and targeted interventions for residents with dementia who are susceptible to self-neglect.

Lessons learned from a Canadian province-wide age-friendly initiative: the age-friendly Manitoba initiative. Canada-flat-icon
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Menec VH, Novek S, Veselyuk D, McArthur J.
Journal of aging & social policy 2014;26(1-2):33-51

he Age-Friendly Manitoba Initiative was launched in 2008. A formative evaluation we conducted in 2011 with 44 participating rural and urban communities demonstrates considerable progress, with virtually all communities having formed an Age-Friendly Committee and conducting a community assessment to identify priorities for action. The majority of communities implemented one or more age-friendly projects. Major barriers to becoming age-friendly identified by participants included lack of funding; lack of capacity, particularly in small communities; and lack of leadership or direction. The study highlights the importance of strong leadership at all levels of government (municipal, provincial, federal); the need to support communities, particularly rural ones, as they try to become more age-friendly; and the importance of ongoing promotion of age-friendliness locally and more broadly (e.g., provincially).

Effects of a home visiting nurse intervention versus care as usual on individual activities of daily living: a secondary analysis of a randomized controlled trial.
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Friedman B, Li Y, Liebel DV, Powers BA.
BMC geriatrics 2014 Feb 20;14(1):24

Home visiting nurses (HVNs) have long been part of home and community-based care interventions designed to meet the needs of functionally declining older adults. However, only one of the studies including HVNs that have demonstrated successful impacts on Activities of Daily Living (ADL) has reported how those interventions affected individual ADLs such as bathing, instead reporting the effect on means of various ADL indices and scales. Reporting impacts on means is insufficient since the same mean can consist of many different combinations of individual ADL impairments. The purpose of our study was to identify which individual ADLs were affected by a specific HVN intervention. METHODS: This is a secondary analysis comparing two arms of a randomized controlled study that enrolled Medicare patients (mean age = 76.8 years; 70% female) with considerable ADL impairment. At baseline difficulty with individual ADLs ranged from a low of 16.0% with eating to a high of 78.0% with walking. Through monthly home visits, the HVN focused on empowering patients and using behavior change approaches to facilitate chronic disease self-management. Three categories of analyses were used to compare difficulty with and dependence in 6 individual ADLs between the HVN (n = 237) and care as usual (n = 262) groups (total N = 499) at 22 months after study entry: (1) unadjusted analyses that strictly depend on random assignment, (2) multinomial logistic regression analyses adjusting for baseline risk factors, and (3) multinomial regression analyses that include variables reporting post-randomization healthcare use as well as the baseline risk factors. RESULTS: Compared to care as usual, patients receiving the HVN intervention had less difficulty performing bathing at 22 months. However, there were no effects for difficulty performing the other 5 ADLs. While no effects were found for lower levels of dependence for any ADLs, impacts were detected for the most dependent levels of 4 ADLs: patients experienced less dependence in walking and transferring, a substitution effect for toileting, and more dependence in eating. CONCLUSIONS: Future research is needed to confirm these findings and determine how HVN interventions affect individual ADLs of older adults with multiple ADLs.

Translation of function-focused care to assisted living facilities.
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Resnick B, Galik E, Vigne E.
Family & community health 2014 Apr-Jun;37(2):155-165

Assisted livings settings are residential settings that provide housing and supportive services for older and disabled adults. Although individuals in assisted living settings are less functionally impaired than those in nursing home settings, they engage in limited amounts of physical activity and decline functionally more rapidly than their peers in nursing homes. Function-focused care for assisted living (FFC-AL) was developed to prevent decline, improve function, and increase physical activity among residents living in these settings. The purpose of this study was to translate the previously established, effective FFC-AL intervention to 20 assisted living facilities. Evidence of our ability to successfully translate function-focused care into these 20 assisted living facilities was determined using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) model. Our findings supported our ability to translate FFC-AL effectively into 18 of these 20 settings, using our dissemination and implementation approach.

A Comparative Analysis of Comprehensive Geriatric Assessments for Nursing Home Residents Receiving Palliative Care: A Systematic Review.
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Hermans K, De Almeida Mello J, Spruytte N, Cohen J, Van Audenhove C, Declercq A.
Journal of the American Medical Directors Association 2014 Feb 22

Nursing homes become important locations for palliative care. By means of comprehensive geriatric assessments (CGAs), an evaluation can be made of the different palliative care needs of nursing home residents. This review aims to identify all CGAs that can be used to assess palliative care needs in long term care settings and that have been validated for nursing home residents receiving palliative care. The CGAs are evaluated in terms of psychometric properties and content comprehensiveness. DESIGN: A systematic literature search in electronic databases MEDLINE, Web of Science, EMBASE, Cochrane, CINAHL, and PsycInfo was conducted for the years 1990 to 2012. SETTING: Nursing homes. PARTICIPANTS: Nursing home residents with palliative care needs. MEASUREMENTS: Psychometric data on validity and reliability were extracted from the articles. The content comprehensiveness of the identified CGAs was analyzed, using the 13 domains for a palliative approach in residential aged care of the Australian Government Department of Health and Aging. RESULTS: A total of 1368 articles were identified. Seven studies met our inclusion criteria, describing 5 different CGAs that have been validated for nursing home residents with palliative care needs. All CGAs demonstrate moderate to high psychometric properties. The interRAI Palliative Care instrument (interRAI PC) covers all domains for a palliative approach in residential aged care of the Australian Government Department of Health and Aging. The McMaster Quality of Life Scale covers nine domains. All other CGAs cover seven domains or fewer. CONCLUSIONS: The interRAI PC and the McMaster Quality of Life Scale are considered to be the most comprehensive CGAs to evaluate the needs and preferences of nursing home residents receiving palliative care. Future research should aim to examine the effectiveness of the identified CGAs and to further validate the CGAs for nursing home residents with palliative care needs. Copyright © 2014 American Medical Directors Association, Inc. All rights reserved. Published by Elsevier Inc. All rights reserved.

Joseph Rowntree Foundation: Are older people in care homes missing out on quality time with staff because workers are preoccupied with paperwork? (UK)
February 2014

Care homes have to regularly complete more than 100 separate items of paperwork, often duplicating the same information, this study found. Researchers visited care homes and spoke to staff who felt they were judged more on their ability to produce paperwork than deliver care. The research recommends that the sector rethinks its priorities and makes changes to the way it deals with administration so older people can be given more compassionate, personalised care.

NHS: Safe, compassionate care for frail older people using an integrated care pathway (UK)

NHS England has released practical guidance on the implementation of a care pathway for frail older people. This document summarises evidence on the effects of an integrated pathway of care.

Reshaping Care for Older People (Scotland)
Auditor General, Audit Scotland February 2014

This audit from the Auditor General for Scotland assesses progress by NHS boards and councils in Scotland in improving health and care services for older people, looking particularly at developments through the Reshaping Care for Older People (RCOP) programme. It examines the extent to which care for older people has moved towards communities i.e. away from hospitals and care homes.

Alzheimer’s Disease International: Nutrition and dementia A review of available research: Introduction (UK)

In this first summary document (prepared by Martin Prince and Matthew Prina from the King’s College London Institute of Psychiatry Global Observatory for Ageing and Dementia Care) we have introduced a number of areas of research on the relevance of nutritional factors to primary and secondary prevention of dementia, undernutrition in dementia and interventions to improve the nutrition of people with dementia.

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Health Research Data Symposium: An Alberta Perspective on Access, Management and Linkage
29 May Lister Hall, University of Alberta

This one-day symposium will explore aspects of health research data access, management, and linkage in Alberta. Ample time will be provided after presentations for questions and group discussion.
Plenary and panel sessions to include:
-Privacy issues in health research data
-Provincial perspectives on how data is currently being managed and how it will be managed in the future to improve access.
-Innovative health research projects in Alberta using data linkage.
-Alberta projects using administrative data
Call for posters and Registration will be coming soon!

Improving Dementia Care Conference
24 April London UK

The programme for this conference focuses on the following key areas:
• Assessment and achieving earlier diagnosis
• Prevention and intervention
• Improving services for those living with dementia
• Dementia education and training to help develop dementia friendly communities
• Personalising services to patient’s specific needs and achieving more patient-centred care
• Boosting and increasing dementia research

Non UofA

CFHI: Spreading healthcare innovations in a land of pilot projects
Banff AB 4 June $195

The Canadian Foundation for Healthcare Improvement (CFHI) presents a one-day workshop that will help you put into practice what you learn at the 2014 NHLC. The workshop, supported by world-class faculty, will provide participants with knowledge, skills and strategies to spread innovations across institutions, regions, provinces and territories.


CFHI Webinar: Making Improvement Meaningful: Learn How Storytelling Can Help You Spread Healthcare Improvement
Tuesday 11 March 10:00-11:00 MT

Everyone likes a good story, but when used well, storytelling can be an effective motivational tool and inspire change. Healthcare professionals can use storytelling to communicate improvements, or simply to reflect a set of values in their organization that contribute to making improvements. By learning how to choose the right story for your purpose and delivering it with conviction, you can spark action and prepare others for what lies ahead. Join CFHI Senior Director Collaboration, Jennifer Verma and guest storyteller Scott Robertson,‎ Senior Project Manager (Medical Travel) and former Chief Nursing Officer with the Northwest Territories Department of Health and Social Services, as they share the art of the story, and how it can help you spread healthcare improvement.

ISRN: Improvement Science: Getting to “HOW”
Monday 24 March 12:00 MT

This session will be presented by Dr. Carolyn M. Clancy, MD is the Assistant Deputy Under Secretary for Health for Quality, Safety and Value at the Veterans Health Administration and Improvement Science Research Network Steering Council member.

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Bayesian Methods in Health Economics
12-14 March Cameron Library Room 1-30

This 3 day course is intended to provide an introduction to Bayesian analysis and MCMC methods using R and BUGS, as applied to cost-effectiveness analysis and typical models used in health-economic evaluations. The emphasis throughout will be on practical examples: software and code to carry out all the analyses will be provided. Participants are encouraged to bring their own laptops for the practicals.

Developing Complex Public Health Interventions
23-24 June, Cardiff University, Cardiff UK £400

The aim of this two-day day course is to provide you with an introduction to the socio-ecological model of health and how it can be used as a framework for designing public health improvement interventions. You will also learn about different research methods used for developing new interventions, how to develop an intervention “logic model”, and how DECIPHer works with policy-makers, health professionals and the public to co-produce interventions.

Evaluating Complex Public Health Interventions
25-27 June, Cardiff University, Cardiff UK £600

The aim of this three-day course is to provide you with a working knowledge of the key frameworks and methodologies currently used to evaluate complex interventions. Teaching will be delivered by experts in the field of public health evaluation, including Professor Laurence Moore, and you will learn about how to work with other scientists, policy-makers, practitioners and the public to apply for funding to pilot and evaluate the effectiveness of complex interventions.

IWH: Spring 2014 Systematic Review Workshop
30 April-2 May Toronto $1500/$500 (student)

The systematic review workshops offered by the Institute for Work & Health are designed to teach participants how to plan, conduct and communicate the results of a systematic review.

University of York: Introducing Research Implementation and Knowledge Transfer in Health Services
8-10 July York, UK

This groundbreaking course taught by leading academics and NHS experts, will introduce you to the ideas, theories and techniques of research implementation. It will help you really get to grips with current changes in research implementation, quality and NHS innovation adoption.

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South Asian communities to receive tailored dementia support

A new initiative which aims to provide South Asian families and the wider community with culturally-tailored information about dementia has been launched by Alzheimer’s Society (UK).

CFHI Healthcare Needs Survey Canada-flat-icon

Please take a moment to fill out a survey that will help CFHI continue to design programming that meets your improvement needs.

CIHR: Pan-Canadian Vision and Strategy for Health Services and Policy Research Canada-flat-icon

The CIHR-Institute of Health Services and Policy Research, provincial health research funding organizations and many national health charities are working together and with the community to develop the first-ever pan-Canadian vision and strategy for health services and policy research (HSPR). The results of a strategic analysis of Canada’s assets and resources in HSPR are available in a comprehensive report and interactive asset map which illustrate Canada’s total investments in health services and policy research, priority research areas, people and knowledge translation at a provincial and national level. These results will inform a Priorities Forum in April 2014 that will bring together partners, policy leaders, citizens and representatives of the HSPR community to develop the inaugural pan-Canadian Vision and Strategy for Health Services and Policy Research.

New App May Help Dementia Patients Better Communicate Their Needs and Wants

Talking Mats is an easy-to-use, low-technology solution for facilitating expression and comprehension. It uses three sets of picture symbols—topics, options, and a visual scale. Once a topic picture is chosen (eg, choice of activities or people), participants are given the options one at a time and then express how they feel about each option by placing its picture in a column in the visual scale, indicating “happy,” “unsure,” or “unhappy,” for example.

Dr. Joy Johnson named SFU’s new VP Research Canada-flat-icon

Dr. Johnson is SFU’s fifth VP, Research and joins the university after serving as the Scientific Director at IGH since January of 2008. A professor in the School of Nursing at the University of British Columbia, Johnson was recognized as one of BC’s 100 Women of Influence in 2010. Dr. Johnson was among the first nursing Doctoral students at the University of Alberta. She received her PhD in 1993. And was first admitted into the doctoral program as a ‘special case’ student prior to the nursing PhD program’s official approval and funding.

Quebec to introduce patient-based funding Canada-flat-icon

The Quebec government plans to introduce patient-based funding in the health sector, Finance Minister Nicolas Marceau announced Thursday. The reform — which would fund institutions based on their actual patient loads, not through global budgets based on previous years’ data — is a long time coming. It was recommended by successive health department commissions: in the Clair report in 2001 and the Bédard report in 2002. And it’s in line with what Ontario, B.C. and Alberta are doing to make tax dollars go where the needs are.

A Shortage of Caregivers

If you want fresh evidence of the caregiving crisis that lies in the not-too-distant future, look no further than the employment projections released by the Bureau of Labor Statistics late last year. Topping the list of occupations expected to grow between 2012 and 2022 are personal care aides, in the No. 1 slot (580,800 new positions); home health aides, No. 4 (424,200 jobs); and nursing assistants, No. 6 (312,200 jobs).

Seth Rogen testifies at Senate hearing on Alzheimer’s

Actor Seth Rogen testified on Wednesday at a Senate subcommittee hearing on the outlook for Alzheimer’s biomedical research.

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BPSD Algorithm Website Canada-flat-icon

This is a practical, electronic, interactive tool intended to support interdisciplinary, evidence-based, person-centred care for persons with behavioural and psychological symptoms of dementia (BPSD). The algorithm is intended to be combined with the BPSD Best Practice Guideline.

One Hundred Years of Service Canada-flat-icon
Canadian Nurses Association

Canadian Nurses Association: One Hundred Years of Service is a chronicle of the history and achievements of CNA since its inception in 1908. The main narrative is supported by an extensive collection of documents that record CNA’s history and other major nursing, health and societal events taking place in the world around CNA.

Alzheimer Society of Canada: PC P.E.A.R.L.S. 7 key elements of person-centred care Canada-flat-icon

Through its research, ASC learned about seven common key elements to begin and sustain a culture change to provide person-centred care. These elements are outlined and explained
in seven information sheets entitled PC P.E.A.R.L.S.™, under the following headings:
Person and Family Engagement, Care, Processes, Environment, Activity & Recreation, Leadership, & Staffing.

Cochrane Connect

Cochrane Connect is the Cochrane Collaboration’s international newsletter bringing you each month the newest health evidence, news about Cochrane projects and impact, training and event alerts, and more. Subscribe and receive Cochrane Connect delivered straight to your inbox.

Economic & Social Science Research Council: Impact toolkit

The Impact Toolkit gives you everything you need to achieve the maximum impact for your work. The toolkit includes information on developing an impact strategy, promoting knowledge exchange, public engagement and communicating effectively with your key stakeholders.

Culture Change Living Toolkit Canada-flat-icon

The Culture Change Living Toolkit, created by Partnerships in Dementia Care, part of the University of Waterloo’s MAREP program, is intended for organizations undergoing a culture change process, particularly organizations providing healthcare for persons with dementia. The toolkit includes a narrative description of the culture change process, as well as exercises and activities that have been designed to help groups move through the culture change process. The creation of this toolkit is ongoing, and updated regularly.

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Post-Doctoral Fellowship
Canada Research Chair in Implementation of Shared Decision Making in Primary Care, Laval Univ, Québec City, PQ

The Canada Research Chair in Implementation of Shared Decision Making in Primary Care invites applications for a Postdoctoral Fellowship in knowledge translation regarding the improvement of clinical practice in health care. We are seeking a highly motivated and talented researcher to work in “Knowledge Translation and Practice Improvement in Primary Care.” Specifically, we are looking for a postdoctoral fellow to lead a project aiming at the development and evaluation of knowledge translation tools and strategies. The fellow will be a member of the Canada Research Chair in Implementation of Shared Decision Making in Primary Care, working under the supervision of Dr. France Légaré and her co-researchers. The fellow will work with the supervisory team to define and pursue a project targeting improvement of clinical practice in health care. The position is for one year with opportunity for extension.

Assistant Professor Canada-flat-icon
Alberta Research Centre for Health Evidence, University of Alberta, Edmonton AB
Position to remain open until filled

ARCHE desires to recruit an Investigator with an interest and experience in knowledge synthesis (e.g. systematic reviews), research methods, epidemiology and/or statistics, and evidence-based medicine. The position will include:
-independent and collaborative research in the area of knowledge synthesis (e.g. systematic reviews)
-leadership within the research center, including administration, management, and staff supervision and training
-education of graduate and postgraduate trainees, including teaching a graduate level course in systematic reviews

Editor-in-Chief Journal of Nursing Management

The successful candidate for the position of Editor-in-Chief will be recognized internationally as a leading member of the nursing profession, will have worked at a strategic level within academia or healthcare, and will have an impressive track record of publications and conference presentations arising from research and scholarship.

CIHR Recruitment of New IAB Members Canada-flat-icon

The Canadian Institutes of Health Research (CIHR) is renewing membership for its thirteen Institute Advisory Boards (IABs) and invites you to assist by encouraging excellent candidates to apply. On average, each Institute appoints 1 to 2 members who will serve 3 year terms, effective September 1, 2014.

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