Congratulations to Dr. Janet Squires
Janet has been appointed Research Chair in Health Evidence Implementation
As the newly appointed University Research Chair in Health Evidence Implementation, Professor Janet Squires is exploring new ways to increase the use of research evidence by healthcare professionals in order to improve the delivery of healthcare services and health outcomes for the population. Way to go Janet!!!
New article by Dr. Ali Hutchinson
Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.
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Hutchinson AM, Sales AE, Brotto V, Bucknall TK.
Implementation science 2015 May 19;10(1):70
Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals’ medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback METHODS/DESIGN: A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.
Report recommended by Dr. Carole Estabrooks
Addressing Dementia: The OECD Response
The OECD recommended higher priority being given to:
-Models of care which promote more independence, dignity and social interaction.
-Improving access to palliative care outside of hospitals, allowing people with dementia end-of-life care with dignity in a place of their choosing.
-Better handling of ethical issues behind the involvement of people with pre-symptomatic dementia in clinical trials.
-New models of consent which address concerns about privacy / confidentiality.
Grants & Awards
AIHS Cy Frank Fellowship – Impact Assessment
DEADLINE 30 June
The AIHS Cy Frank Fellowship provides an opportunity for the successful recipients to gain practice-based experience in impact assessment in the health research and innovation environment. This practice-based experience will be complemented by the mentorship of an academic advisor of the Fellow’s choosing from an Alberta university.
Designing a knowledge translation mentorship program to support the implementation of evidence-based innovations
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Gagliardi AR, Webster F, Straus SE.
BMC health services research 2015 May 14;15(1):198
Healthcare professionals require training in knowledge translation (KT) to implement evidence-based healthcare innovations. Mentorship is an effective training strategy that could be used to develop KT capacity but it has largely been used to train clinicians. The purpose of this study was to explore preferences for KT mentorship design. METHODS: Interviews were conducted with 54 Canadian researchers and research users who varied by profession, department, career stage and sex. Participants were asked about KT needs, views on mentorship as a strategy to develop KT capacity, and suggestions for program design. Grounded theory technique and thematic analysis were used to collect and analyse data. RESULTS: Participants uniformly expressed interest in mentorship over other forms of learning about KT because it would provide credible, tailored information when needed. A variety of options for program content, format and delivery were recommended, suggesting the need for flexibility according to KT needs. Leadership, infrastructure, culture change and incentives may also be needed to foster KT mentorship. Views were mixed on whether mentors should be KT experts or subject or clinical experts with KT experience, and embedded in, or external to organizations. CONCLUSIONS: These findings can be used to develop or evaluate KT mentoring programs. Further research is needed to evaluate different models in which the mentor may be an internal or external KT expert or subject expert with experience in KT, and establish the core curriculum of a training program specific to KT and how it could best be reinforced with mentoring.
The SPIRIT Action Framework: A structured approach to selecting and testing strategies to increase the use of research in policy
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Redman S, Turner T, Davies H, Williamson A, Haynes A, Brennan S, et al.
Social science & medicine 2015:147-155
The recent proliferation of strategies designed to increase the use of research in health policy (knowledge exchange) demands better application of contemporary conceptual understandings of how research shapes policy. Predictive models, or action frameworks, are needed to organise existing knowledge and enable a more systematic approach to the selection and testing of intervention strategies. Useful action frameworks need to meet four criteria: have a clearly articulated purpose; be informed by existing knowledge; provide an organising structure to build new knowledge; and be capable of guiding the development and testing of interventions. This paper describes the development of the SPIRIT Action Framework. A literature search and interviews with policy makers identified modifiable factors likely to influence the use of research in policy. An iterative process was used to combine these factors into a pragmatic tool which meets the four criteria. The SPIRIT Action Framework can guide conceptually-informed practical decisions in the selection and testing of interventions to increase the use of research in policy. The SPIRIT Action Framework hypothesises that a catalyst is required for the use of research, the response to which is determined by the capacity of the organisation to engage with research. Where there is sufficient capacity, a series of research engagement actions might occur that facilitate research use. These hypotheses are being tested in ongoing empirical work.
Developing a targeted, theory-informed implementation intervention using two theoretical frameworks to address health professional and organisational factors: a case study to improve the management of mild traumatic brain injury in the emergency department.
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Tavender EJ, Bosch M, Gruen RL, Green SE, Michie S, Brennan SE, et al.
Implementation science 2015 May 25;10(1):74-015-0264-7
Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury in the emergency department (ED), variations in practice exist. Interventions designed to implement recommended behaviours can reduce this variation. Using theory to inform intervention development is advocated; however, there is no consensus on how to select or apply theory. Integrative theoretical frameworks, based on syntheses of theories and theoretical constructs relevant to implementation, have the potential to assist in the intervention development process. This paper describes the process of applying two theoretical frameworks to investigate the factors influencing recommended behaviours and the choice of behaviour change techniques and modes of delivery for an implementation intervention. METHODS: A stepped approach was followed: (i) identification of locally applicable and actionable evidence-based recommendations as targets for change, (ii) selection and use of two theoretical frameworks for identifying barriers to and enablers of change (Theoretical Domains Framework and Model of Diffusion of Innovations in Service Organisations) and (iii) identification and operationalisation of intervention components (behaviour change techniques and modes of delivery) to address the barriers and enhance the enablers, informed by theory, evidence and feasibility/acceptability considerations. We illustrate this process in relation to one recommendation, prospective assessment of post-traumatic amnesia (PTA) by ED staff using a validated tool. RESULTS: Four recommendations for managing mild traumatic brain injury were targeted with the intervention. The intervention targeting the PTA recommendation consisted of 14 behaviour change techniques and addressed 6 theoretical domains and 5 organisational domains. The mode of delivery was informed by six Cochrane reviews. It was delivered via five intervention components : (i) local stakeholder meetings, (ii) identification of local opinion leader teams, (iii) a train-the-trainer workshop for appointed local opinion leaders, (iv) local training workshops for delivery by trained local opinion leaders and (v) provision of tools and materials to prompt recommended behaviours. CONCLUSIONS: Two theoretical frameworks were used in a complementary manner to inform intervention development in managing mild traumatic brain injury in the ED. The effectiveness and cost-effectiveness of the developed intervention is being evaluated in a cluster randomised trial, part of the Neurotrauma Evidence Translation (NET) program.
Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model.
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Moore JE, Titler MG, Kane Low L, Dalton VK, Sampselle CM.
Women’s health issues 2015 May-Jun;25(3):276-282
In response to the passage of the Affordable Care Act in the United States, clinicians and researchers are critically evaluating methods to engage patients in implementing evidence-based care to improve health outcomes. However, most models on implementation only target clinicians or health systems as the adopters of evidence. Patients are largely ignored in these models. A new implementation model that captures the complex but important role of patients in the uptake of evidence may be a critical missing link. DISCUSSION: Through a process of theory evaluation and development, we explore patient-centered concepts (patient activation and shared decision making) within an implementation model by mapping qualitative data from an elective induction of labor study to assess the model’s ability to capture these key concepts. The process demonstrated that a new, patient-centered model for implementation is needed. In response, the Evidence Informed Decision Making through Engagement Model is presented. We conclude that, by fully integrating women into an implementation model, outcomes that are important to both the clinician and patient will improve. CONCLUSIONS: In the interest of providing evidence-based care to women during pregnancy and childbirth, it is essential that care is patient centered. The inclusion of concepts discussed in this article has the potential to extend beyond maternity care and influence other clinical areas. Utilizing the newly developed Evidence Informed Decision Making through Engagement Model provides a framework for utilizing evidence and translating it into practice while acknowledging the important role that women have in the process. Published by Elsevier Inc.
Utilization of research findings for health policy making and practice: evidence from three case studies in Bangladesh.
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Walugembe DR, Kiwanuka SN, Matovu JK, Rutebemberwa E, Reichenbach L.
Health research policy and systems 2015 May 28;13(1):26
In striving to contribute towards improved health outcomes, health research institutions generate and accumulate huge volumes of relevant but often underutilized data. This study explores activities undertaken by researchers from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), an international research institution that promotes the utilization of their findings in the policymaking processes in Bangladesh. METHODS: The study used an exploratory case study design and employed qualitative methods to explore activities implemented to promote research utilization and the extent to which researchers felt that their findings contributed to the policymaking process. Data were collected between September and December 2011 through key informant interviews, focus group discussions with study investigators, and database and document reviews. We reviewed findings from 19 reproductive health studies conducted and completed by icddr,b researchers between 2001 and 2011. We interviewed 21 key informants, including 13 researchers, two policy makers, and six programme implementers. Data were entered into Microsoft Word and analyzed manually following a thematic framework approach. Following the World Health Organization/Turning Research into Practice (WHO/TRIP) framework, three case studies of how research findings were utilized in the policymaking processes in Bangladesh were documented. RESULTS: Activities implemented to promote research utilization included conducting dissemination workshops, publishing scientific papers, developing policy briefs, providing technical assistance to policymakers and programme implementers, holding one-on-one meetings, and joining advocacy networks. The majority of the researchers (12 of 13) reported that their study findings were utilized to influence policymaking processes at different levels. However, some researchers reported being unaware of whether and how their findings were utilized. As regards actual utilization of research findings, the evidence from the three case studies indicate that research findings can be utilized instrumentally, conceptually and symbolically, and at different stages within the policymaking process, including agenda setting and policy formulation and implementation. CONCLUSIONS: The results show that research findings from icddr,b were promoted and utilized in health policymaking processes in Bangladesh using a variety of utilization approaches. These results suggest a need for using multiple approaches to promote utilization of research findings in health policymaking processes.
A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs.
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Smelson DA, Chinman M, McCarthy S, Hannah G, Sawh L, Glickman M.
Implementation science 2015 May 28;10(1):79
The Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO). METHODS/DESIGN: In three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU-standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model. DISCUSSION: This project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection-via a fidelity measure embedded into the VA Computerized Patient Record System-began as each site initiated MISSION-Vet, between April 2013 and January 2014. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01430741.
Measuring the effectiveness of knowledge creation activity as a means to facilitate evidence-informed practice: a study of early years settings in Camden, London
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Brown C, Rogers S.
Evidence & Policy 2015-05-22T00:00:00;11(2):189-207
This paper has two key aims. First, it examines the authors’ attempts to use knowledge creation activity as a way of developing evidence-informed practice amongst a learning community of 36 early years practitioners in Camden, London. Second, it illustrates how the authors approached the idea of measuring evidence use and our engagement with two separate measurement scales; the trustworthiness of which are subsequently tested in interviews and observation data. Our findings are encouraging, suggesting that knowledge creation activity provides an effective way of communicating research; also, that our measurement scales provide meaningful ways to ascertain levels of expertise in evidence use.
Measuring the success of facilitated engagement between knowledge producers and users: a validated scale
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Dwan KM, McInnes P, Mazumdar S.
Evidence and Policy 2015-05-22T00:00:00;11(2):239-252
Researchers are increasingly being asked to demonstrate the impact of their research on policy. Unfortunately, evidence on what works is scarce because it is rarely reported and evaluated. This paper describes a programme of facilitated engagement between knowledge producers and users on topics of joint research and policy interest, and validates a six-item evaluation instrument. Our results confirm a simple instrument can be used to assess the effectiveness and relevance of presentations and to gauge the users’ receptivity to research. The success of our knowledge mobilisation strategy relies upon a favourable alignment of the social, political and economic contexts.
Health Care Administration and Organization
How new governance shapes changes in the long-term care sector in Ontario, Canada
Innovation Journal 2015;20(1)
This paper turns to the insights of New Governance in order to explain how law was used to promote innovations in health care governance in the Canadian province of Ontario between 2004 and 2012. New Governance refers to a family of approaches that are more flexible and less prescriptive. My research includes review of government documents, legislation and other sources in order to identify changes to regulation and governance. I also draw upon interviews with seven organizations in the sector, which were conducted as part of a larger project to help contextualize and explain the changes in law. I argue that, while the formal legal and regulatory apparatus continue to be used to regulate the provision of care and treatment, New Governance approaches represent additional processes and procedures to problem-solve challenges in the sector. Law is being used to formalize or strengthen these processes and procedures in order to allow long-term care home residents, families, friends, and workers to participate in problemsolving. This increasing emphasis on processes can be understood as an attempt to broaden the scope of possible solutions and changes that could be implemented in the sector. For future research, I suggest that more attention be paid to interrogating the relationships that enable New Governance techniques.
The relationship between patients’ perceptions of care quality and three factors: nursing staff job satisfaction, organizational characteristics and patient age.
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Kvist T, Voutilainen A, Mantynen R, Vehvilainen-Julkunen K.
BMC health services research 2014 Oct 18;14:466-6963-14-466
The relationship between nurses’ job satisfaction and their perceptions of quality of care has been examined in previous studies. There is little evidence, however, about relationships between the job satisfaction of nursing staff and quality of care perceived by the patients. The aim of this study was to analyze, how the job satisfaction of nursing staff, organizational characteristics (hospital and unit type), and patients’ age relate to patients’ perceptions of the quality of care. METHODS: The study was cross-sectional and descriptive, based on a secondary analysis of survey data acquired during the At Safe study in Finland. The study included 98 units at four acute care hospitals between autumn 2008 and spring 2009. The participants were 1909 patients and 929 nursing staff. Patients’ perceptions of quality of care were measured using the 42-item RHCS questionnaire. Job satisfaction of nursing staff was measured with the 37-item KUHJSS scale. Statistical analyses included descriptive statistics, principal component analysis, t-tests, analysis of variance, linear regression, and multivariate analysis of variance. RESULTS: Patients’ perceptions of overall quality of care were positively related to general job satisfaction of nursing staff. Adequate numbers of staff appeared to be the clearest aspect affecting quality of care. Older patients were more satisfied with staff number than younger patients. Patients cared for in outpatient departments felt more respected than patients in wards, whereas patients in wards reported better care of basic needs (e.g., hygiene, food) than outpatients. CONCLUSIONS: The evaluation of resources by nursing staff is related to patients’ perceptions of the adequacy of nursing staff levels in the unit. The results emphasize the importance of considering patients’ perceptions of the quality of care and assessments by nurses of their job satisfaction at the hospital unit level when evaluating quality of care.
Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: a systematic review of literature.
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Stalpers D, de Brouwer BJ, Kaljouw MJ, Schuurmans MJ.
International journal of nursing studies 2015 Apr;52(4):817-835
To systematically review the literature on relationships between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals. DATA SOURCES: The search was performed in Medline (PubMed), Cochrane, Embase, and CINAHL. REVIEW METHODS: Included were quantitative studies published from 2004 to 2012 that examined associations between work environment and the following patient outcomes: delirium, malnutrition, pain, patient falls and pressure ulcers. The Dutch version of Cochrane’s critical appraisal instrument was used to assess the methodological quality of the included studies. RESULTS: Of the initial 1120 studies, 29 were included in the review. Nurse staffing was inversely related to patient falls; more favorable staffing hours were associated with fewer fall incidents. Mixed results were shown for nurse staffing in relation to pressure ulcers. Characteristics of work environment other than nurse staffing that showed significant effects were: (i) collaborative relationships; positively perceived communication between nurses and physicians was associated with fewer patient falls and lower rates of pressure ulcers, (ii) nurse education; higher levels of education were related to fewer patient falls and (iii) nursing experience; lower levels of experience were related to more patient falls and higher rates of pressure ulcers. No eligible studies were found regarding delirium and malnutrition, and only one study found that favorable staffing was related to better pain management. CONCLUSIONS: Our findings show that there is evidence on associations between work environment and nurse-sensitive patient outcomes. However, the results are equivocal and studies often do not provide clear conclusions. A quantitative meta-analysis was not feasible due to methodological issues in the primary studies (for example, poorly described samples). The diversity in outcome measures and the majority of cross-sectional designs make quantitative analysis even more difficult. In the future, well-described research designs of a longitudinal character will be needed in this field of work environment and nursing quality. Copyright © 2015 Elsevier Ltd. All rights reserved.
Consistent Assignment of Nursing Staff to Residents in Nursing Homes: A Critical Review of Conceptual and Methodological Issues.
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Roberts TJ, Nolet KA, Bowers BJ.
The Gerontologist 2013 Aug 31
Consistent assignment of nursing staff to residents is promoted by a number of national organizations as a strategy for improving nursing home quality and is included in pay for performance schedules in several states. However, research has shown inconsistent effects of consistent assignment on quality outcomes. In order to advance the state of the science of research on consistent assignment and inform current practice and policy, a literature review was conducted to critique conceptual and methodological understandings of consistent assignment. DESIGN AND METHODS: Twenty original research reports of consistent assignment in nursing homes were found through a variety of search strategies. RESULTS: Consistent assignment was conceptualized and operationalized in multiple ways with little overlap from study to study. There was a lack of established methods to measure consistent assignment. Methodological limitations included a lack of control and statistical analyses of group differences in experimental-level studies, small sample sizes, lack of attention to confounds in multicomponent interventions, and outcomes that were not theoretically linked. IMPLICATIONS: Future research should focus on developing a conceptual understanding of consistent assignment focused on definition, measurement, and links to ou
Impacts of information and communication technologies on nursing care: an overview of systematic reviews (protocol).
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Rouleau G, Gagnon MP, Cote J.
Systematic reviews 2015 May 23;4(1):75
Information and communication technologies (ICTs) used in the health sector have well-known advantages. They can promote patient-centered healthcare, improve quality of care, and educate health professionals and patients. However, implementation of ICTs remains difficult and involves changes at different levels: patients, healthcare providers, and healthcare organizations. Nurses constitute the largest health provider group of the healthcare workforce. The use of ICTs by nurses can have impacts in their practice. The main objective of this review of systematic reviews is to systematically summarize the best evidence regarding the effects of ICTs on nursing care. METHODS/DESIGN: We will include all types of reviews that aim to evaluate the influence of ICTs used by nurses on nursing care. We will consider four types of ICTs used by nurses as a way to provide healthcare: management systems, communication systems, information systems, and computerized decision support systems. We will exclude nursing management systems, educational systems, and telephone systems. The following types of comparisons will be carried out: ICT in comparison with usual care/practice, ICT compared to any other ICT, and ICT versus other types of interventions. The primary outcomes will include nurses’ practice environment, nursing processes/scope of nursing practice, nurses’ professional satisfaction as well as nursing sensitive outcomes, such as patient safety, comfort, and quality of life related to care, empowerment, functional status, satisfaction, and patient experience. Secondary outcomes will include satisfaction with ICT from the nurses and patients’ perspective. Reviews published in English, French, or Spanish from 1 January 1995 will be considered. Two reviewers will independently screen the title and abstract of the papers in order to assess their eligibility and extract the following information: characteristics of the population and setting, type of interventions (e.g., type of ICTs and service provided), comparisons, outcomes, and review limitations. Any disagreements will be resolved by discussion and consensus involving the two reviewers or will involve a third review author, if needed. DISCUSSION: This overview is an interesting starting point from which to compare and contrast findings of separate reviews regarding the positive and negative effects of ICTs on nursing care.
Development of the Knowledge of Dementia Competencies Self-Assessment Tool.
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Curyto KJ, Vriesman DK.
American Journal of Alzheimer’s Disease and Other Dementias 2015 May 24
Competent dementia care requires caregivers with specialized knowledge and skills. The Knowledge of Dementia Competencies Self-Assessment Tool was developed to help direct care workers (DCWs) assess their knowledge of 7 dementia competencies identified by the Michigan Dementia Coalition. Item selection was guided by literature review and expert panel consultation. It was given to 159 DCWs and readministered to 57 DCWs in a range of long-term care settings and revised based on qualitative feedback and statistical item analyses, resulting in 82 items demonstrating good internal consistency and test-retest reliability. Performance on items assessing competencies rated as most important was significantly related to training in these competencies. The DCWs in day care obtained higher scores than those in home care settings, and their sites reported a greater number of hours of dementia training. Validation in a more diverse group of DCWs and assessing its relationship to other measures of knowledge and skill is needed.
A qualitative study of nursing assistants’ awareness of person-centred approaches to dementia care
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Hunter PV, Hadjistavropoulos T, Kaasalainen S.
Ageing & Society 2015 5;FirstView:1-27.
Recently, the number of education programmes addressing person-centred approaches to long-term residential dementia care has increased, and nursing assistants (NAs) are often the target audience. The effectiveness of employee education programmes is actively debated, and our objective is to contribute to this discussion by exploring the knowledge NAs acquire through practice. We examined approaches to person-centred care generated during a series of interviews with NAs, and compared these to the content of five frameworks for person-centred dementia care. Our results suggest that although NAs acquire significant knowledge about person-centred dementia care during the course of their work, application of person-centred care strategies varies across NAs. We propose ways of enhancing NA education in order to address gaps in knowledge. We also recommend sustained attention to organisational factors that contribute to variability in practice.
The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study.
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Wang N, Yu P, Hailey D.
International journal of medical informatics 2015 May 8
The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated. PURPOSE: To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans. METHODS: A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study. RESULTS: There was a tendency to omit ‘nursing problem’ or ‘nursing diagnosis’ in the nursing process by changing these terms (used in the paper-based care plan) to ‘observation’ in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes. CONCLUSIONS: The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses’ attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes. Copyright © 2015. Published by Elsevier Ireland Ltd.
Attitudes towards family-staff relationships in Australian residential aged care settings: development and psychometric evaluation of the ‘Family and Staff Relationship Attitude Tool’ (FASRAT).
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Bauer M, Fetherstonhaugh D, Lewis V.
Australasian journal on ageing 2014 Sep;33(3):170-173
To develop and psychometrically evaluate the Family and Staff Relationship Attitude Tool (FASRAT) for use in Australian residential aged care facilities to assess the attitudinal beliefs of residential aged care staff towards staff-family relationships. METHODS: Development and testing of the psychometric properties of the 26-item FASRAT occurred in three phases which included item development based on a systematic review of the research literature, interviews with aged care staff and families, expert panel review and testing with aged care staff. RESULTS: Content validity and internal consistency of the FASRAT support its use as an instrument to measure staff attitudinal beliefs about staff-family relationships in the residential aged care setting. CONCLUSION: The FASRAT will enable residential aged care facilities to measure the attitudinal beliefs of its staff about staff-family relationships and provide a basis for the development and implementation of interventions to address identified gaps which impact on relationship quality. © 2012 The Authors.
Successful collaboration in dementia care from the perspectives of healthcare professionals and informal carers in Germany: results from a focus group study.
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Stephan A, Mohler R, Renom-Guiteras A, Meyer G.
BMC health services research 2015 May 28;15(1):208-015-0875-3
Informal carers of persons with dementia are in contact with numerous healthcare professionals (HCP) in a complex healthcare system. Successful collaboration between the parties involved appears to be essential for good dementia care. Thus, we investigated the perceptions of both HCP and informal carers regarding successful collaboration and sought to describe obstacles and facilitators. METHODS: As part of the 7(th) framework EU project RightTimePlaceCare, five focus groups were conducted with HCP and informal carers of persons with dementia in Germany (n = 30 participants/ time: Oct/Nov 2011). A supplementary secondary data analysis was performed, applying qualitative content analysis with open coding. RESULTS: The derived categories were sorted into three overarching themes: collaboration between HCP and informal carers, collaboration among HCP and the impact of resources and healthcare system. HCP and informal carers largely agree on what facilitates or impedes successful collaboration between them. Making the initial contact appears to be a major challenge. While HCP expect to be contacted, informal carers hesitate to seek assistance, primarily due to inner barriers. Permanent contact person/institution, well-trained, empathetic HCP who can establish a trustful relationship are regarded as facilitating collaboration. The relational perspective is more clearly emphasised by HCP than by informal carers. This may be attributed to the absence of a permanent contact person in Germany. Sufficient information relay, clear responsibilities, motivation and defined aims, and a personal relationship between professionals are mentioned as facilitators. External factors, such as rapid staff turnover, insufficient time resources and conditions specified by the health and long-term care system causing financial competition between providers, are described as general barriers to successful collaboration. CONCLUSIONS: HCP and informal carers had comparable perceptions of successful collaboration among them. The initial contact seems to be particularly challenging. Better strategies are urgently needed to facilitate the access to professional support. A permanent contact person (e.g., a case manager) might improve collaboration among all the parties involved, but this is not available regularly. Constraints created by the healthcare system may considerably hinder successful collaboration.
The practice of system leadership: Being comfortable with chaos (UK)
The King’s Fund, 2015
This report draws on the experiences of 10 senior leaders to look in depth at the skills needed to be a system leader. The 10 individuals are from different backgrounds and work in different contexts, and give some very candid reflections on their successes and failures. But they share a track record of having tried to bring about change (not always successfully) through using ‘soft’ power, enabling others to see and deliver the changes that are needed.
Health Care Innovation and Quality Assurance
Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study.
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Abrahamson K, Miech E, Davila HW, Mueller C, Cooke V, Arling G.
BMJ quality & safety 2015 May;24(5):311-317
Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme. METHODS: Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making. RESULTS: The term ‘data’ appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to ‘data’ in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation. CONCLUSIONS: Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.
Organizational culture change in U.S. hospitals: a mixed methods longitudinal intervention study.
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Curry LA, Linnander EL, Brewster AL, Ting H, Krumholz HM, Bradley EH.
Implementation science 2015 Mar 7;10(1):29-015-0218-0
Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL). METHODS: This manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time. CONCLUSIONS: LSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change.
Measuring health system performance: A new approach to accountability and quality improvement in New Zealand.
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Health policy (Amsterdam, Netherlands) 2015 Apr 28
In February 2014, the New Zealand Ministry of Health released a new framework for measuring the performance of the New Zealand health system. The two key aims are to strengthen accountability to taxpayers and to lift the performance of the system’s component parts using a ‘whole-of-system’ approach to performance measurement. Development of this new framework – called the Integrated Performance and Incentive Framework (IPIF) – was stimulated by a need for a performance management framework which reflects the health system as a whole, which encourages primary and secondary providers to work towards the same end, and which incorporates the needs and priorities of local communities. Measures within the IPIF will be set at two levels: the system level, where measures are set nationally, and the local district level, where measures which contribute towards the system level indicators will be selected by local health alliances. In the first year, the framework applies only at the system level and only to primary health care services. It will continue to be developed over time and will gradually be extended to cover a wide range of health and disability services. The success of the IPIF in improving health sector performance depends crucially on the willingness of health sector personnel to engage closely with the measurement process. Copyright © 2015 The Author.
Nurses’ characteristics and organisational factors associated with their assessments of individualised care in care institutions for older people.
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Rodriguez-Martin B, Stolt M, Katajisto J, Suhonen R.
Scandinavian journal of caring sciences 2015 May 15
Individualised care is considered a key attribute of the quality in clinical care. Despite the environment in which the care is delivered and the care providers can influence in this concept, perceptions of individuality in the care settings for older people are rarely studied. AIM: To identify nurses’ characteristics and organisational factors associated with nurses’ views about the provision of individualised care in care settings for older people. STUDY DESIGN: A cross-sectional multisite survey design. METHODS: A multisite survey of nursing staff (N = 1513, n = 874, response rate 58%) working in 62 different units for older people in southwest Finland was carried out using self-administered questionnaires (The Individualised Care Scale-Nurse-B and a questionnaire gathering socio-demographic and organisational variables). Data were analysed using descriptive statistics, Spearman’s correlation coefficients, paired-sample t-tests and one-way analyses of variance. RESULTS: Participants’ perceptions about the level of individualised care provided to older people were generally positive (Mean 3.92, SD 0.56). In this regard, taking into account the patients’ clinical situation (Mean 4.31, SD 0.53) and the support of older patients’ decisional control (Mean 3.80, SD 0.71) obtained the highest scores. Regarding nurses’ socio-demographic variables, a positive correlation between age and type of organisation with the assessments of individualised care provision was found. CONCLUSIONS: The findings of this study show that nurses’ age and the type of organisation where the care is delivered have an impact on the perceptions of individualised care of nurses working in institutions for older people. The participants’ assessments about individualised care delivery have practical utility as it may help managers better understand and develop areas that obtained the lowest scores. This information may lead to the reduction of barriers (structures and processes) that hinder individualised care delivery and facilitate programs aimed at developing professional environments that improve the delivery of older people’s care. © 2015 Nordic College of Caring Science.
Infection prevention and control in nursing homes: a qualitative study of decision-making regarding isolation-based practices.
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Cohen CC, Pogorzelska-Maziarz M, Herzig CT, Carter EJ, Bjarnadottir R, Semeraro P, et al.
BMJ quality & safety 2015 May 22
Isolation-based practices in nursing homes (NHs) differ from those in acute care. NHs must promote quality of life while preventing infection transmission. Practices used in NHs to reconcile these goals of care have not been characterised. PURPOSE: To explore decision-making in isolation-based infection prevention and control practices in NHs. METHODS: A qualitative study was conducted with staff (eg, staff nurses, infection prevention directors and directors of nursing) employed in purposefully sampled US NHs. Semistructured, role-specific interview guides were developed and interviews were digitally recorded, transcribed verbatim and analysed using directed content analysis. The research team discussed emerging themes in weekly meetings to confirm consensus. RESULTS: We inferred from 73 interviews in 10 NHs that there was variation between NHs in practices regarding who was isolated, when isolation-based practices took place, how they were implemented, and how they were tailored for each resident. Interviewees’ decision-making depended on staff perceptions of acceptable transmission risk and resident quality of life. NH resources also influenced decision-making, including availability of private rooms, extent to which staff can devote time to isolation-based practices and communication tools. A lack of understanding of key infection prevention and control concepts was also revealed. CONCLUSIONS AND IMPLICATIONS: Current clinical guidelines are not specific enough to ensure consistent practice that meets care goals and resource constraints in NHs. However, new epidemiological research regarding effectiveness of varying isolation practices in this setting is needed to inform clinical practice. Further, additional infection prevention and control education for NH staff may be required.
Feasibility, acceptability, and adherence of two educational programs for care staff concerning nursing home patients’ fecal incontinence: a pilot study preceding a cluster-randomized controlled trial
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Blekken LE, Nakrem S, Gjeilo KH, Norton C, Morkved S, Vinsnes AG.
Implementation science 2015 May 23;10(1):72
Fecal incontinence has a high prevalence in the nursing home population which cannot be explained by co-morbidity or anatomic and physiological changes of aging alone. Our hypothesis is that fecal incontinence can be prevented, cured, or ameliorated by offering care staff knowledge of best practice. However, it is not clear which educational model is most effective. To assess the effect of two educational programs for care staff, we planned a three armed cluster-randomized controlled trial. There is a lack of research reporting effects of interventions targeting improved continence care processes in older patients. Thus, to improve the quality of the planned trial, we decided to carry out a pilot study to investigate the feasibility of the planned design, the interventions (educational programs) and the outcome measures, and to enable a power calculation. This paper reports the results from the pilot study. Methods Three nursing homes, representing each arm of the planned trial, were recruited. Criteria for assessing success of feasibility were pre-specified. Methods, outcome measures, acceptability, and adherence of the components of the intervention were evaluated by descriptive statistical analyses and qualitative content analysis of one focus group interview (n = 7) and four individual interviews. Results The main study is feasible with one major and some minor modifications. Due to challenges with recruitment and indications supporting the assumption that a single intervention with one workshop is not sufficient as an implementation strategy, the main study will be reduced to two arms: a multifaceted education intervention and control. The components of the multifaceted intervention seemed to work well together and need only minor modification. Important barriers to consider were sub-optimal use of skill-mix, problems of communicating important assessments and care plans, and isolated nurses with an indistinct nurse identity. Conclusions Overall, the main study is feasible. The pedagogical approach needs to consider the identified barriers. Thus, it is essential to empower nurses in their professional role, to facilitate clinical reasoning and critical thinking among care staff, and to facilitate processes to enable care staff to find, report, and utilize information in the electronic patient record. Trial registration ClinicalTrials.gov: NCT01939821
Catch a Glimpse of Me: The development of staff videos to promote person-centered care.
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Gendron TL, King Seymour L, Welleford EA.
Dementia (London, England) 2015 May 26
Catch a Glimpse of Me is an ongoing project that uses video to help staff deliver more person-centered care for people with dementia living in long-term care. Focus groups consisting of residents, family and staff members were conducted to develop a template for the development of the videos. The five themes they identified as being important to include are: family; interests and hobbies; memories and moments; life space and getting personal. The article describes the process of developing the videos and discusses the ongoing potential of the Catch a Glimpse of Me project. © The Author(s)
Functional Improvement Among Short-Stay Nursing Home Residents in the MDS 3.0.
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Wysocki A, Thomas KS, Mor V.
Journal of the American Medical Directors Association 2015 Jun 1;16(6):470-474
To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0. DESIGN: Retrospective analysis of MDS admission and discharge assessments. SETTING: Nursing homes from July 1, 2011, to June 30, 2012. PARTICIPANTS: New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less. MEASUREMENTS: ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge. RESULTS: The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home residents with conditions such as cognitive impairment, delirium, dementia, heart failure, and stroke showed less improvement in ADL performance during their stay. CONCLUSION: The discharge assessment data in the MDS 3.0 provide new information to researchers and providers to examine and track ADL performance. Nursing homes can identify and track patients who require more intensive therapies or targeted interventions to achieve functional improvement during their stay. Future research can examine facility-level measures to better understand how ADL improvement varies across facilities. Copyright © 2015 AMDA
Clinical burden, quality of care, organizational context: different lenses to optimize care for older people.
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Journal of the American Medical Directors Association 2015 Jun 1;16(6):444-445.
For many practitioners in geriatrics, the primary mission in caring for frail older people (especially those with dementia) is to optimize their quality of life. This is often achieved, at least in part, by reducing their clinical symptom burden, which is particularly relevant in end-of-life care. Although recent advances have focused on improving the pharmacologic and nonpharmacologic modalities of symptom reduction at the level of an individual patient, we must remember that a system-based approach to improve the quality-of-care provision can have a larger impact on groups of patients, and when such quality improvement results in an organizational or contextual change, the impact can become more sustainable over time.
Person-centered Climate Questionnaire-Patient in English: A psychometric evaluation study in long-term care settings.
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Yoon JY, Roberts T, Grau B, Edvardsson D.
Archives of Gerontology and Geriatrics 2015 Apr 6
There is increasing evidence that person-centered care improves nursing home residents’ quality of life. Despite the clear focus of person-centered care on enhancing care for residents and engaging residents in care, there are few options available for measuring person-centered care from the perspective of the elder residents. OBJECTIVE: The aim of this study was to assess the psychometric properties of the English version of the Person-centered Climate Questionnaire-Patient (PCQ-P) in U.S. long-term care settings. METHODS: A total of 189 older adults from six nursing homes in the Midwestern United States were included. Convergent validity and known-group comparison were examined for construct validity. Exploratory factor analysis and second-order confirmatory factor analysis were utilized to examine the factor structure. Reliability was tested using Cronbach’s alpha values for internal consistency. RESULTS: This study demonstrated a substantial convergent validity of the PCQ-P in English as higher scores correlated significantly with higher resident life satisfaction (r=0.459), and the satisfactory construct validity as evidenced by a significantly higher mean PCQ-P score from residents in higher quality nursing homes. Factor analysis demonstrated that the PCQ-P had three factors (hospitality, safety, and everydayness) in U.S. nursing home residents. The PCQ-P showed satisfactory internal consistency reliability (α=0.89). CONCLUSION: The English version of the PCQ-P is a valid and reliable tool to directly measure the perceptions of the person-centered climate in the U.S nursing homes. The simple and straightforward PCQ-P items are easy to administer to nursing home residents. Consequently, clinical staff can utilize the PCQ-P to assess the unit climate, and evaluate outcomes of person-centered interventions. Copyright © 2015 Elsevier Ireland Ltd.
Geriatric care boot cAMP: an interprofessional education program for healthcare professionals.
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Solberg LB, Solberg LM, Carter CS.
Journal of the American Geriatrics Society 2015 May;63(5):997-1001
In response to the need for interprofessional geriatrics education, a half-day geriatric care boot camp for healthcare professionals was held that covered core concepts in geriatric medicine: delirium and dementia, medication management, palliative care, ethics, and a general overview of older adults. Aspects of the curriculum focused on interprofessional education, and the attendees and presenters were healthcare professionals from a wide variety of fields. Primary objectives were to determine changes in knowledge of core concepts in geriatrics and level of comfort in caring for older adults. Secondary objectives assessed whether participants found the interprofessional approach beneficial and whether they used or shared this information with others in their professional activities. Participants completed pre- and postassessment surveys. Changes in participant understanding of each core concept were statistically significant, as was the change in comfort level of participants in caring for older adults. Furthermore, attendees found the multidisciplinary perspective of the boot camp beneficial. A 3-month follow-up survey assessed whether attendees applied and shared information learned in their own professional activities. Half of the respondents who reported sharing universally shared core concepts. Delirium and dementia information was most frequently shared. Information was most frequently shared with students, nurses, and patients’ families. Attendees less frequently shared, or did not share, with physicians, physician assistants, social workers, physical and occupational therapists, nutritionists, and dentists. The healthcare professionals who may benefit greatly from future education programs are those with whom the boot camp information was least frequently shared; thus, they are appropriate targets for advertisements for future programs. © 2015, Copyright the Authors
Research Practice and Methodology
How to study improvement interventions: a brief overview of possible study types.
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Portela MC, Pronovost PJ, Woodcock T, Carter P, Dixon-Woods M.
BMJ quality & safety 2015 May;24(5):325-336
Improvement (defined broadly as purposive efforts to secure positive change) has become an increasingly important activity and field of inquiry within healthcare. This article offers an overview of possible methods for the study of improvement interventions. The choice of available designs is wide, but debates continue about how far improvement efforts can be simultaneously practical (aimed at producing change) and scientific (aimed at producing new knowledge), and whether the distinction between the practical and the scientific is a real and useful one. Quality improvement projects tend to be applied and, in some senses, self-evaluating. They are not necessarily directed at generating new knowledge, but reports of such projects if well conducted and cautious in their inferences may be of considerable value. They can be distinguished heuristically from research studies, which are motivated by and set out explicitly to test a hypothesis, or otherwise generate new knowledge, and from formal evaluations of improvement projects. We discuss variants of trial designs, quasi-experimental designs, systematic reviews, programme evaluations, process evaluations, qualitative studies, and economic evaluations. We note that designs that are better suited to the evaluation of clearly defined and static interventions may be adopted without giving sufficient attention to the challenges associated with the dynamic nature of improvement interventions and their interactions with contextual factors. Reconciling pragmatism and research rigour is highly desirable in the study of improvement. Trade-offs need to be made wisely, taking into account the objectives involved and inferences to be made.
Systematic review of vision-related quality of life questionnaires for older institutionalised seniors with dementia.
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Bedard E, Kergoat H, Kergoat MJ, Leclerc BS.
Ophthalmic & physiological optics 2015 May 18
In view of our interest in helping older institutionalised adults with co-existing visual and cognitive deficits, our objective was to review vision-related quality of life (VRQoL) questionnaires developed for people with dementia. METHODS: A systematic literature search was performed in seven relevant databases, limited to peer-reviewed journals published in English, French, Spanish, Italian or German languages, between 1982 and 2012. The retained VRQoL questionnaires were described. Only relevant articles that fully meet our target population and interest criteria were eligible for psychometric properties rating. RESULTS: The literature search identified 461 potentially relevant articles, from which 69 were isolated and reviewed. Eight articles presented questionnaires that were administered to older institutionalised individuals with dementia. Three VRQoL questionnaires were identified, from which only one was designed and validated for those with mild to moderate dementia and none for individuals with more advanced dementia. CONCLUSIONS: There is a pressing need to build and validate a questionnaire for assessing VRQoL in older institutionalised individuals with dementia, to provide a research tool capable of evaluating how changes in vision impact their QoL. © 2015 The Authors
Effectiveness of the Liverpool care pathway for the dying in residential care homes: An exploratory, controlled before-and-after study.
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Brannstrom M, Furst CJ, Tishelman C, Petzold M, Lindqvist O.
Palliative medicine 2015 May 18
Clinical pathways aim to ensure that individuals receive appropriate evidence-based care and interventions, with the Liverpool Care Pathway for the Dying Patient focusing on end of life. However, controlled studies of the Liverpool Care Pathway for the Dying Patient, particularly outside of cancer settings, are lacking. AIM: To compare the effects of the Liverpool Care Pathway for the Dying Patient and usual care on patients’ symptom distress and well-being during the last days of life, in residential care homes. DESIGN: Exploratory, controlled before-and-after study. During a 15-month baseline, usual care was carried out in two areas. During the following 15-months, usual care continued in the control area, while residential care home staff implemented Liverpool Care Pathway for the Dying Patient use in the intervention area. The intervention was evaluated by family members completing retrospective symptom assessments after the patient’s death, using the Edmonton Symptom Assessment System and Views of Informal Carers – Evaluation of Services. SETTINGS/PARTICIPANTS: Patients who died at all 19 residential care homes in one municipality in Sweden. RESULTS: Shortness of breath (estimate = -2.46; 95% confidence interval = -4.43 to -0.49) and nausea (estimate = -1.83; 95% confidence interval = -3.12 to -0.54) were significantly reduced in Edmonton Symptom Assessment System in patients in the intervention compared to the control area. A statistically significant improvement in shortness of breath was also found on the Views of Informal Carers – Evaluation of Services item (estimate = -0.47; 95% confidence interval = -0.85 to -0.08). CONCLUSION: When implemented with adequate staff training and support, the Liverpool Care Pathway for the Dying Patient may be a useful tool for providing end-of-life care of elderly people at the end of life in non-cancer settings. © The Author(s) 2015.
Increasing enjoyable activities to treat depression in nursing home residents with dementia: A pilot study.
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Dementia (London, England) 2015 May 12
This pilot study aimed to assess the feasibility and acceptability of a behavioral activities intervention (BE-ACTIV) in Australian nursing homes. BE-ACTIV was developed by researchers at the University of Louisville, USA, to improve mood and quality of life (QOL) in nursing home residents with mild to moderate dementia. An eight-week trial was conducted and 10 residents with mild to moderate dementia received the BE-ACTIV intervention while eight residents received a Walking and Talking intervention. Measures of depression (GDS-12R) and QOL (QOL-AD-NH) were administered prior to and following the interventions. Qualitative feedback indicated residents benefited from BE-ACTIV, evident by improved mood, although no statistically significant treatment effect was found. Moreover, the intervention was found to be feasible and acceptable to Australian nursing home staff and our findings highlight the importance of individualizing activities for people with dementia, of which 1:1 staff attention was a key component. © The Author(s)
Evidence of what works to support and sustain care at home for people with dementia: a literature review with a systematic approach.
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Dawson A, Bowes A, Kelly F, Velzke K, Ward R.
BMC geriatrics 2015 May 13;15(1):59
This paper synthesises research evidence about the effectiveness of services intended to support and sustain people with dementia to live at home, including supporting carers. The review was commissioned to support an inspection regime and identifies the current state of scientific knowledge regarding appropriate and effective services in relation to a set of key outcomes derived from Scottish policy, inspection practice and standards. However, emphases on care at home and reduction in the use of institutional long term care are common to many international policy contexts and welfare regimes. METHODS: Systematic searches of relevant electronic bibliographic databases crossing medical, psychological and social scientific literatures (CINAHL, IngentaConnect, Medline, ProQuest, PsychINFO and Web of Science) in November 2012 were followed by structured review and full-text evaluation processes, the latter using methodology-appropriate quality assessment criteria drawing on established protocols. RESULTS: Of 131 publications evaluated, 56 were assessed to be of ‘high’ quality, 62 of ‘medium’ quality and 13 of ‘low’ quality. Evaluations identified weaknesses in many published accounts of research, including lack of methodological detail and failure to evidence conclusions. Thematic analysis revealed multiple gaps in the evidence base, including in relation to take-up and use of self-directed support by people with dementia, use of rapid response teams other multidisciplinary approaches, use of technology to support community-dwelling people with dementia, and support for people without access to unpaid or informal support. CONCLUSIONS: In many areas, policy and practice developments are proceeding on a limited evidence base. Key issues affecting substantial numbers of existing studies include: poorly designed and overly narrowly focused studies; variability and uncertainty in outcome measurement; lack of focus on the perspectives of people with dementia and supporters; and failure to understanding the complexities of living with dementia, and of the kinds of multifactorial interventions needed to provide holistic and effective support. Weaknesses in the evidence base present challenges both to practitioners looking for guidance on how best to design and deliver evidence-based services to support people living with dementia in the community and their carers and to those charged with the inspection of services.
Food security: who is being excluded? A case of older people with dementia in long-term care homes.
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Vahabi M, Schindel Martin L.
The journal of nutrition, health & aging 2014 Jul;18(7):685-691
To explore the extent of food security among older people, particularly those with cognitive impairments residing in Canadian long-term care homes (LTCHs) through a focused review of literature. METHOD: Databases including Medline, Nursing and Health Sciences (SAGE), Psych Info, Social Sciences Abstract, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and HealthSTAR were searched for peer-reviewed articles related to food experiences of older individuals in industrialized countries including Canada. Only articles that were published in English between 1997-2012 were included. RESULTS: Sixty two studies met the inclusion criteria. Of those 17 focused on older adults in LTCHs. The review found that food security has rarely been examined among older persons living in LTCHs, and has never been examined within the context of cognitive impairment. While a few studies have focused on residents’ satisfaction with foods that are provided to them in LTCHs, none have explored the extent of food security in this population. Furthermore, food satisfaction surveys in the LTCH are limited to the assessment of foods that are served to residents, and do not capture residents’ food accessibility beyond the food dispensing routines of the organization. Thus, food quality, food preferences, and the traditional meanings and rituals associated with food consumption are not purposefully evaluated. In addition, LTCHs are not required to monitor residents’ food satisfaction using a consistent, regular, and standardized approach and there is no regulation in the LTCH Act that requires LTCHs to assess their residents’ food security. CONCLUSIONS: The findings highlight the need for: 1) expansion of food security research to non-community-based settings including LTCHs; 2) re-conceptualization of food security and modification of measurement tools to assess the extent and determinants of food security among older adults in LTCHs; 3) mandatory monitoring of food security via standardized and regular surveys tailored to meet the unique preferences and needs of the older population, particularly those with dementia; and 4) education of healthcare professionals regarding food security and its assessment in LTCHs.
Antipsychotic medication use in nursing homes: a proposed measure of quality.
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Lucas JA, Chakravarty S, Bowblis JR, Gerhard T, Kalay E, Paek EK, et al.
International journal of geriatric psychiatry 2014 Oct;29(10):1049-1061
The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed-upon measure of guideline-inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms. METHODS: The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure. RESULTS: We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure. CONCLUSION: The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available. Copyright © 2014 John Wiley & Sons, Ltd. Copyright © 2014 John Wiley & Sons, Ltd.
Medication Use Among Nursing Home Residents With Severe Dementia: Identifying Categories of Appropriateness and Elements of a Successful Intervention.
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Kroger E, Wilchesky M, Marcotte M, Voyer P, Morin M, Champoux N, et al.
Journal of the American Medical Directors Association 2015 May 13
Seniors with severe dementia residing in nursing homes (NHs) frequently receive large numbers of medications. With disease progression, the medications’ harm-benefit ratio changes and they need to be reviewed, adjusted, or discontinued. Evidence on successful interventions to optimize medication use among these residents is lacking. OBJECTIVES: The objective of the study was to identify categories of appropriateness for medications as well as successful interventions or elements thereof to improve medication use in NH residents with severe dementia, suitable for use in Canada. METHODS: A scoping literature review was performed to identify criteria and categories of appropriateness of medications for these residents as well as elements of successful interventions to optimize medication use. A 15-member multidisciplinary Delphi panel was convened to evaluate the applicability of these findings for NHs in a Canadian province. RESULTS: The scoping review identified 1 study presenting categories of appropriateness specific to residents with severe dementia and 35 interventions aimed at reducing drug-drug interactions, inappropriate use of specific drug classes, inappropriate drug use overall, or polypharmacy. Regarding appropriateness, the Delphi panel agreed on the categorization of 63 medications or medication classes as “generally,” “sometimes,” or “rarely appropriate.” The main elements of interventions successful in improving appropriate medication use in NH residents with dementia also were approved by the Delphi panel (ie, medication reviews using criteria of appropriateness, educational and training sessions, and interdisciplinary case conferences). CONCLUSIONS: These results may be used to develop an intervention to optimize medication use in NH residents with severe dementia. Copyright © 2015 AMDA
Severe Impairment Rating Scale: A Useful and Brief Cognitive Assessment Tool for Advanced Dementia for Nursing Home Residents.
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Yeo C, Lim WS, Chan M, Ho XQ, Anthony PV, Han HC, et al.
American Journal of Alzheimer’s Disease and Other Dementias 2015 May 24
To investigate the utility of the Severe Impairment Rating Scale (SIRS) as a cognitive assessment tool among nursing home residents with advanced dementia, we conducted a cross-sectional study of 96 residents in 3 nursing homes with Functional Assessment Staging Test (FAST) stage 6a and above. We compared the discriminatory ability of SIRS with the Chinese version of Mini-Mental State Examination, Abbreviated Mental Test, and Clock Drawing Test. Among the cognitive tests, SIRS showed the least “floor” effect and had the best capacity to distinguish very severe (FAST stages 7d-f) dementia (area under the curve 0.80 vs 0.46-0.76 for the other tools). The SIRS had the best correlation with FAST staging (r = -.59, P < .01) and, unlike the other 3 tools, exhibited only minimal change in correlation when adjusted for education and ethnicity. Our results support the utility of SIRS as a brief cognitive assessment tool for advanced dementia in the nursing home setting. © The Author(s) 2015.
Nonpharmacologic Interventions to Heal Pressure Ulcers in Older Patients: An Overview of Systematic Reviews (The SENATOR-ONTOP Series).
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Velez-Diaz-Pallares M, Lozano-Montoya I, Abraha I, Cherubini A, Soiza RL, O’Mahony D, et al.
Journal of the American Medical Directors Association 2015 Jun 1;16(6):448-469
Pressure ulcers (PUs) are more frequent in older patients, and the healing process is usually challenging. Nonpharmacologic interventions may play a role in the treatment of older people with PUs, but most systematic reviews (SRs) have not addressed this specific population using convincing outcome measures. OBJECTIVE: To summarize and critically appraise the evidence from SRs of the primary studies on nonpharmacologic interventions to treat PUs in older patients. DESIGN: SR and meta-analysis of comparative studies. METHODS: PubMed, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL (from inception to October 2013) were searched. A new search for updates in the Cochrane Database was launched in July 2014. SRs that included at least 1 comparative study evaluating any nonpharmacologic intervention to treat PUs in older patients, in any health care setting, were included. Any primary study with experimental design was then identified and included. From each primary study, quality assessment was undertaken as specified by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation working group. Interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis, using complete ulcer healing as the outcome measure. RESULTS: One hundred ten SRs with 45 primary studies satisfied the inclusion criteria. The most frequent interventions explored in these trials were support surfaces (13 studies), nutrition (8), and electrotherapy (6). High or moderate quality of evidence was found in none of the interventions, mainly because of the very serious risk of bias of most studies and imprecision in the treatment effect. Evidence grade is very low or insufficient to support the use of any support surface, nutrition intervention, multicomponent interventions, repositioning or other adjunctive therapy (ultrasound, negative pressure, laser, electromagnetic, light, shock wave, hydrotherapy, radiofrequency, or vibration therapy) to increase the rates of PU healing in older patients. Electrotherapy showed some beneficial effect in the treatment of PUs, although the quality of evidence is low. CONCLUSIONS: In older patients with PUs, evidence to use any nonpharmacologic therapy to increase the rates of wound healing is inconclusive, except for low quality evidence that supports the use of electrotherapy. This situation is especially alarming for interventions that are usually standard clinical practice (repositioning, support surfaces). Although there is some evidence in younger populations and other types of ulcers, studies in older populations with PUs using sound methodology are needed. Copyright © 2015 AMDA
Frailty as a predictor of the incidence and course of depressed mood.
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Collard RM, Comijs HC, Naarding P, Penninx BW, Milaneschi Y, Ferrucci L, et al.
Journal of the American Medical Directors Association 2015 Jun 1;16(6):509-514
Late-life depression and physical frailty are supposed to be reciprocally associated, however, longitudinal studies are lacking. OBJECTIVES: This study examines whether physical frailty predicts a higher incidence of depression, as well as a less favorable course of depression. METHODS: A population-based cohort study of 888 people aged 65 years and over with follow-up measures at 3, 6, and 9 years. Cox proportional hazards models adjusted for age, sex, education, smoking, alcohol usage, and global cognitive functioning were applied to calculate the incidence of depressed mood in those nondepressed at baseline (n = 699) and remission in those with depressed mood at baseline (n = 189). Depressed mood onset or remission was defined as crossing the cut-off score of 20 points on the Center for Epidemiological Studies-Depression Scale combined with a relevant change in this score. Physical frailty was based on the presence of ≥3 out of 5 components (ie, weight loss, weakness, slowness, exhaustion, and low physical activity level). RESULTS: A total of 214 out of 699 (30.6%) nondepressed persons developed depressed mood during follow-up. Physical frailty predicted the onset of depressed mood with a hazard rate of 1.26 (95% confidence interval 1.09-1.45, P = .002). Of the 189 persons with depressed mood at baseline, 96 (50.8%) experienced remission during follow-up. Remission was less likely in the presence of a higher level of physical frailty (hazard rate = 0.72, 95% confidence interval 0.58-0.91, P = .005). CONCLUSIONS: Because physical frailty predicts both the onset and course of late-life depressed mood, physical frailty should receive more attention in mental health care planning for older persons as well as its interference with treatment. Future studies into the pathophysiological mechanisms may guide the development of new treatment opportunities for these vulnerable patients. Copyright © 2015 AMDA
Dying without dignity: Investigations by the Parliamentary and Health Service Ombudsman into complaints about end of life care. (UK)
Parliamentary and Health Service Ombudsman, 2015
Dying Without Dignity reveals several examples of where patients and their families had negative experiences at the end of their life due to such things such as poor communication, a lack of out of hours support and a lack of recognition that the person was dying. Chief Inspector of Hospitals at the Care Quality Commission, Professor Sir Mike Richards, said: “The PHSO’s report Dying without dignity is timely to understand what can go wrong when people do not receive safe, effective and compassionate care at the end of their life, and in identifying learning from these examples of poor care. “During our inspections, we have found some examples of excellent end of life care where the dying person received individual care based on their needs, delivered with compassion and sensitivity by health and care professionals. This needs to become the standard across all health and care services.
Ontario Policy Document
Patients First: A Roadmap to Strengthen Home and Community Care
Ministry of Health and Long-Term Care, 2015
Ontario is making it easier for patients and their caregivers to access better care at home and in the community through Patients First: A Roadmap to Strengthen Home and Community Care – a new plan to improve and expand home and community care.
Looking for Balance: Antipsychotic medication use in Ontario long-term care homes
Health Quality Council of Ontario
Looking for Balance provides a snapshot of the current state of antipsychotic medication use in Ontario long-term care homes and reveals there is wide variation across homes in the percentage of residents being prescribed these medications. Many residents are given antipsychotic medications to improve their quality of life, but use of these medications has sparked debate because of their potential to cause serious side effects. The report identifies opportunities to learn from patients and families, and long-term care teams too who have made changes to improve the lives of Ontarians living in long-term care. In homes across the province, care teams are addressing antipsychotic medication use by applying a range of approaches such as tracking medication data, assessing residents on a person-by-person basis, and engaging families.
Digital Academic Workflow
Monday 8 June 12:00-13:00 ECHA 5-140
KUSP’s own Ferenc Toth will teach us how to use technology for paperless and mobile academic research and writing. Welcome to the 21st century everyone!!!
Speed Networking: Find Your ‘Research on Aging’ Match!
Friday 5 June 09:00-13:00 Rm 301 Human Ecology Building, UofA
Researchers, community partners, and students are invited to come together & share interests in research on aging.
Is Implies Ought: Are There Ethical Cognitive Biases?
Friday 5 June 12:00-13:00pm Dvorkin Centre (2G2.07 WMC)
The discovery of cognitive biases, which are systematic, observable, and predictable errors in judgement and decision-making, has, remarkably, yet to be fully recognized and appreciated as a significant source of error and harm in healthcare systems. I will argue that we need not look far to demonstrate how this same variety of biases influence clinical ethical judgement. I will demonstrate and discuss a variety of these scenarios and allow the audience to assess whether these examples properly demonstrate a traditionally conceived bias and to what extent we can mitigate the impact of such judgements. There will also be monkeys.
Stand up for science!
Saturday 20 June 9:00–16:30 1-135 ECHA $140
Join Dr. Arya M. Sharma (Professor, Dept. of Medicine, Stop Being a Yo-Yo) and award-winning stand-up comic and TV host Barbara North (CBC TV “Army Brats,” CityTV “A Total Write-Off!”, “Sex and the Prairies”) for an interactive 1-day workshop that will help you:
-Gain confidence in presentation
-Find “the funny” and delivery
-Craft memorable punch lines to drive your message home
-Obey the rule of threes (oops)
IIQM Thinking Qualitatively Workshops
15-19 June ECHA
Over 40 different workshops available for all levels including graduate students and those new to qualitative research! Workshop Topics Include: Foundations of Qualitative Inquiry, Grounded Theory, Approaching Qualitative Data Analysis, Managing Data, Writing Qualitative Proposals, Innovation in Qualitative Research, Interviewing, Visual Analysis, Community Based PAR, Indigenous Research Methodologies, Arts-based Research, Rigour, Hermeneutic Phenomenology, Duo-ethnography, Publishing in Impactful Journals, Ethnography, Mixed Methods Research, Discourse Analysis, Advanced Phenomenology, Using Video Technology, Focus Groups, Qualitative Searches, Qualitative Research for Clinicians and more!
Evidence Syntheses for Complex Interventions
Presenter: Dr. Gill Harvey
Friday 12 June 11:00 ECHA 4-001
Come and learn more about realist review methodology from an expert.
The Integrated PARHIS Framework
Prsenter: Dr. Alison Kitson
Tuesday 16 June 12:00 ECHA 5-001
Come and here Dr. Alision Kitson speak more about the integrated PARIHS framework from a leading KT researcher.
Anti-Psychotics in Older Adults
brainXchange & Alzheimer Society of Canada
Thursday 4th June 10:00-11:00 MT
This presentation will describe antipsychotic drug therapies, and their use in older adults. We will also discuss alternative management strategies.
Influencing Public Policy Through Sharing Public Health Knowledge: How Does It (possibly) Work?
Thursday 11 June 12:00-13:00 MT
Have you ever tried putting forward public health knowledge in the hope of shaping public policy, with results falling short of your expectations? The political sphere has characteristics that one should be aware of in order to share knowledge more effectively and to understand the scope of achievable outcomes. Who are the major stakeholders to consider when sharing knowledge, and how does knowledge circulate among them? This interactive presentation will address these questions, focusing on factors that public health professionals and researchers can act upon to facilitate the outcomes of knowledge sharing.
Choosing Wisely Canada: Evidence-Based Medicine and Changing the Canadian Health Care Environment
CADTH Lecture Series
Tuesday 9 June 12:00 MT In person Helliwell Centre, Toronto General OR online via webinar.
Choosing Wisely Canada is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments, and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care. The campaign is grassroots and physician-led. It aims to change provider and patient culture and dispel the false notion that “more care is better care.” Join Dr. Levinson as she gives a brief overview of Choosing Wisely Canada, describes the “epidemic of overuse,” and discusses the efforts of various health care organizations to implement Choosing Wisely recommendations within the Canadian health care environment.
UK EQUATOR Centre Publication School
6-10 July, St Anne’s College, Oxford UK £1,300
Fit for purpose: The secrets of success in writing, publishing, and disseminating research articles It is a truth universally acknowledged that a large number of published research articles are reported badly. They often don’t provide enough information, or they provide misleading and ambiguous information, and their usefulness is severely compromised. In response to this, the UK EQUATOR Centre is delighted to offer a unique new week-long course for both new and more experienced health researchers who wish to make their research articles fit for purpose.
Strategies for success in academic writing
3 June 2015–3 July 2015 £345
This course aims to take you through the key steps involved in completing a writing project. Expected learning outcomes: The main topics covered are: planning research writing, submitting publications, conducting peer review, revising texts, and enhancing your productivity as an academic writer. You will be develop confidence and competence in these areas. Course participants: This course is designed to support your completion of a publication or other project you are near to finishing, but it will also be useful to kick-start your academic writing, or help you overcome the challenges of juggling writing with a busy professional life.
Canadian Longitudinal Study on Aging Webinar: Estimating Dementia Prevalence in Canada
Monday 15 June 11:00-12:00 MT
The webinar will focus on dementia prevalence estimates that are based on national surveys, and discuss how methodological differences influence survey-based prevalence estimates and projections. She will also discuss how data from the CLSA could potentially be used to develop estimates of dementia prevalence in Canada.
A new study finds mixed results for the health of America’s aging “Baby Boom” generation, with nearly half of people ages 55 to 64 taking a prescription heart drug and about 1 in 5 dealing with diabetes.
MLA Jenny Kwan says people are calling her for help; health authority says it’s following the rules
Stigma is a common and serious challenge faced by people living with dementia. While there are many ways to define stigma, stigmatized individuals are stereotyped by others and often treated as inferior.
Usually when you’re discharged from hospital, you breathe a sigh of relief. You’re on the mend and on the road to recovery. But a new and disturbing trend is emerging with frail elderly patients with more and more of them dying within days of being sent home from hospital.
It’s been 15 years in the making but the Babayagas’ House, a name taken from Slavic mythology meaning “witch”, has just been inaugurated in Montreuil, on the east side of Paris.
Care is good but there isn’t enough staff. Those are two common themes in Saskatchewan’s long-term care facilities, according to the 2014 CEO tour reports released Wednesday.
Funding for an additional 80,000 hours of nursing care is part of the 2015 Budget commitment to increase investment in home and community care by more than $750 million over the next three years. These extra hours of care will make it possible for individuals with complex conditions to receive care where they want to be – in their home and community, instead of in a hospital or in long-term care.
In California nursing homes, just over 15 percent of dementia patients are on anti-psychotic drugs. That’s far more than advocates say is necessary. But that is actually down from almost 22 percent just three years ago. That’s when the federal government began regulating their use for dementia patients in nursing homes. This came in response to several studies warning the medicines had serious risks, including strokes, falls and even death.
A new Canadian Centre for Aging and Brain Health Innovation will target the causes of cognitive decline in seniors.
Navigating the Evidence: Communicating Canadian Health Policy in the Media
Free e-book from EvidenceNetwork.ca
Navigating the Evidence: Communicating Canadian Health Policy in the Media is a snapshot of the complex and controversial health policy issues currently debated in the Canadian press. The volume is a compilation of the EvidenceNetwork.ca commentaries published in major newspapers in 2014, written by experts in the health policy field.
Departmental Lecturer in Evidence-Based Social Intervention and Policy Evaluation (2 positions)
Department of Social Policy & Intervention, Oxford University
DEADLINE 18 June
The Department of Social Policy & Intervention, Oxford University, wishes to appoint two full-time Departmental Lecturers in Evidence-Based Social Intervention and Policy Evaluation from 1 September 2015 or as soon as possible thereafter. These are excellent opportunities to join a vibrant research centre within a top-rated department (REF 2014), and contribute to the continuing growth of teaching and research in evidence-based social intervention and policy evaluation.
The OSN SPOR Research Project Manager (RPM) will assist the OSN Best Practice Leader (BPL) by providing project management and administrative support for the OSN SPOR Demonstration Project initiatives. A major component of this work is building and managing internal and external relationships and providing pro-active assistance and executive support in an effective and efficient manner.