November 9, 2015



Staffing is one of the biggest issues when it comes to long-term care in Alberta

According to a survey conducted by the Health Quality Council of Alberta. “What we saw primarily — in the responses from families — fell into three categories, which included high staff turnover, not enough staff, or not seeing the same staff consistently,” said council spokesman Andrew Neuner. Other priorities for families were:
-Timely help with basic needs such as eating and bathing.
-Cleaner facilities.
-Access to other health-care services like physiotherapy.
-Better food.

November TREC Newsletter

This month’s newsletter highlights latest TREC work and people.


5th European Nursing Congress 2016 Care for Older People: Are We Doing the Right Things Right?
4-7 October Rotterdam, The Netherlands
DEADLINE 31 January

This conference has four tracks: Science, Practice, Education and Management. The organisers aim to make a contribution to improving care for older people, by
-sharing knowledge
-improving the image of nursing
-enhancing nursing identity

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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology


Task-shifting Using a Pain Management Protocol in an Emergency Care Service: Nurses’ Perception through the Eye of the Rogers’s Diffusion of Innovation Theory
Non UofA Access
Fabienne Hadorn, Pascal Comte, Elaine Foucault, Diane Morin and Olivier Hugli.
Pain Management Nursing

It has been shown that over 70% of patients waiting in emergency departments (EDs) do not receive analgesics, despite the fact that more than 78% complain of pain. A clinical innovation in the form of a pain management protocol that includes task-shifting has been implemented in the ED of a university hospital in Switzerland in order to improve pain-related outcomes in patients. This innovation involves a change in clinical practice for physicians and nurses. The aim of this study is to explore nurses’ perceptions on how well this innovation is adopted. This descriptive correlational study took place in the ED of a Swiss university hospital; the hospital provides healthcare for the city, the canton, and adjoining cantons. A convenience sample of 37 ED nurses participated. They were asked to complete a questionnaire comprising 56 statements based on Rogers’s “Diffusion of Innovation” theory. Nurses’ opinions (on a 1-10 Likert scale) indicate that the new protocol benefits the ED (mean [M] = 7.4, standard deviation [SD] = 1.21), is compatible with nursing roles (M = 8.0, SD = 1.9), is not too complicated to apply (M = 2.7, SD = 1.7), provides observable positive effects in patients (M = 7.0, SD = 1.28), and is relatively easy to introduce into daily practice (M = 6.5, SD = 1.0). Further studies are now needed to examine patients’ experiences of this innovation.

Assessment of fidelity in an educational workshop designed to increase the uptake of a primary care alcohol screening recommendation.
Non UofA Access
A. Hanbury, K. Farley, C. Thompson and P. M. Wilson.
J Eval Clin Pract 2015 Oct;21(5):873-878

RATIONALE, AIMS AND OBJECTIVES: Educational workshops are a commonly used quality improvement intervention. Often delivered by credible local health professionals who do not necessarily have skills in pedagogy, it can be challenging to achieve high intervention fidelity. This paper summarizes the fidelity assessment of a workshop designed to increase the uptake of a primary care alcohol screening recommendation. METHOD: Delivered in a single health region, the workshop comprised separate sessions delivered by three local health professionals, plus two role plays delivered by a commercial company. Sessions were tailored to local barriers. Meetings were held with presenters and an outline of the barriers was provided. Two researchers attended the workshop, rating the number of specified barriers targeted by presenters and their quality of delivery. Participant responsiveness was measured through attendees’ feedback and intervention dose was calculated as the proportion of health professionals who attended and proportion of general practices represented. RESULTS: Exposure was low, with 62 of 545 health professionals from 30 of a possible 80 practices attending. Sixty-five per cent of the specified barriers were targeted. There was variability in quality of delivery and participant responsiveness; challenges included potential mixed messages, overreliance on didactic methods and certain barriers appearing easier to target than others. CONCLUSIONS: The framework provided a rounded assessment of intervention fidelity: intervention coverage was low, adherence was moderate and there was variability in the quality of delivery across presenters. Future studies testing the effectiveness of interventions delivered by local experts with and without brief training in pedagogy/behaviour change would be beneficial.

Promoting Action on Research Implementation in Health Services framework applied to TeamSTEPPS implementation in small rural hospitals.
Non UofA Access
M. M. Ward, J. Baloh, X. Zhu and G. L. Stewart.
Health Care Manage Rev 2016 Sep 23

BACKGROUND: A particularly useful model for examining implementation of quality improvement interventions in health care settings is the PARIHS (Promoting Action on Research Implementation in Health Services) framework developed by Kitson and colleagues. The PARIHS framework proposes three elements (evidence, context, and facilitation) that are related to successful implementation. PURPOSES: An evidence-based program focused on quality enhancement in health care, termed TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), has been widely promoted by the Agency for Healthcare Research and Quality, but research is needed to better understand its implementation. We apply the PARIHS framework in studying TeamSTEPPS implementation to identify elements that are most closely related to successful implementation. METHODOLOGY/APPROACH: Quarterly interviews were conducted over a 9-month period in 13 small rural hospitals that implemented TeamSTEPPS. Interview quotes that were related to each of the PARIHS elements were identified using directed content analysis. Transcripts were also scored quantitatively, and bivariate regression analysis was employed to explore relationships between PARIHS elements and successful implementation related to planning activities. FINDINGS: The current findings provide support for the PARIHS framework and identified two of the three PARIHS elements (context and facilitation) as important contributors to successful implementation. PRACTICE IMPLICATIONS: This study applies the PARIHS framework to TeamSTEPPS, a widely used quality initiative focused on improving health care quality and patient safety. By focusing on small rural hospitals that undertook this quality improvement activity of their own accord, our findings represent effectiveness research in an understudied segment of the health care delivery system. By identifying context and facilitation as the most important contributors to successful implementation, these analyses provide a focus for efficient and effective sustainment of TeamSTEPPS efforts.

Fidelity considerations in translational research: Eating As Treatment – a stepped wedge, randomised controlled trial of a dietitian delivered behaviour change counselling intervention for head and neck cancer patients undergoing radiotherapy. Canada-flat-icon
Non UofA Access
A. K. Beck, A. Baker, B. Britton, et al.
Trials 2015 Oct 15;16(1):465-015-0978-5

BACKGROUND: The confidence with which researchers can comment on intervention efficacy relies on evaluation and consideration of intervention fidelity. Accordingly, there have been calls to increase the transparency with which fidelity methodology is reported. Despite this, consideration and/or reporting of fidelity methods remains poor. We seek to address this gap by describing the methodology for promoting and facilitating the evaluation of intervention fidelity in The EAT (Eating As Treatment) project: a multi-site stepped wedge randomised controlled trial of a dietitian delivered behaviour change counselling intervention to improve nutrition (primary outcome) in head and neck cancer patients undergoing radiotherapy. METHODS/DESIGN: In accordance with recommendations from the National Institutes of Health Behaviour Change Consortium Treatment Fidelity Workgroup, we sought to maximise fidelity in this stepped wedge randomised controlled trial via strategies implemented from study design through to provider training, intervention delivery and receipt. As the EAT intervention is designed to be incorporated into standard dietetic consultations, we also address unique challenges for translational research. DISCUSSION: We offer a strong model for improving the quality of translational findings via real world application of National Institutes of Health Behaviour Change Consortium recommendations. Greater transparency in the reporting of behaviour change research is an important step in improving the progress and quality of behaviour change research. TRIAL REGISTRATION NUMBER: ACTRN12613000320752

Psychotherapy Knowledge Translation and Interpersonal Psychotherapy: Using Best-Education Practices to Transform Mental Health Care in Canada and Ethiopia. Canada-flat-icon
Non UofA Access
P. Ravitz, D. Wondimagegn, C. Pain, et al.
Am J Psychother 2014;68(4):463-488

Psychotherapies, such as Interpersonal Psychotherapy (IPT), that have proven effective for treating mental disorders mostly lie dormant in consensus-treatment guidelines. Broadly disseminating these psychotherapies by training trainers and front-line health workers could close the gap between mental health needs and access to care. Research in continuing medical education and knowledge translation can inform the design of educational interventions to build capacity for providing psychotherapy to those who need it. This paper summarizes psychotherapy training recommendations that: adapt treatments to cultural and health organizational contexts; consider implementation barriers, including opportunity costs and mental health stigma; and engage local opinion leaders to use longitudinal, interactive, case-based teaching with reflection, skills-coaching, simulations, auditing and feedback. Community-based training projects in Northern Ontario, Canada and Ethiopia illustrate how best-education practices can be implemented to disseminate evidence-supported psychotherapies, such as IPT, to expand the therapeutic repertoire of health care workers and improve their patients’ clinical outcomes.

Evidence Molded by Contact with Staff Culture and Patient Milieu: an Analysis of the Social Process of Knowledge Utilization in Nursing Homes
Non UofA Access
Christine Øye, ToneElin Mekki, Randi Skaar, Hellen Dahl, Oddvar Forland and Frode Jacobsen.
Vocations and Learning 2015 10/01;8(3):319-334

Knowledge utilization is politically “hot” because it informs decisions on improving the quality of care in nursing homes (NHs). The difficulties encountered in implementing evidence-based knowledge into practice may be explained by contextual factors. Contextual factors are crucial to understanding the process of knowledge utilization; how the evidence’ is implemented and received locally by identifying facilitators, as well as barriers to change. This article is based on an evidence-based education intervention executed by four teams of two facilitators with care staff, which aimed to prevent the use of restraint in nursing home (NH) residents with dementia in 24 NHs in Norway. The study used a mixed method design combining cluster randomized controlled trial (C-RCT), participatory action research (PAR) and ethnography, where the aim was to document and examine the success or failure of the education intervention. The empirical material for this paper is primarily based on a post –intervention ethnographic investigation in three NHs in the sample, to investigate the relationship between an education intervention and staff culture. The ethnographic investigation gave a setting and context-specific plausible explanation of why the educational intervention failed or succeeded. This study has shown that the social process of knowledge utilization is influenced by contextual factors such as staff culture, patient mix and milieu as well as structural conditions. The NH conditions are not stable, but rather moving and constantly changing as a response to variation in the staff culture, the patient mix, the resources available and the nursing homes current situation. Therefore, the evidence in connection with staff culture could be understood as “a ball of clay” molding itself differently when coming in touch with staff culture and their collective and individual experiences. Potential for a successful process of knowledge utilization has to do with timing and organizational readiness, which is difficult to foresee when planning an education intervention.

A real-world stepped wedge cluster randomized trial of practice facilitation to improve cardiovascular care. Canada-flat-icon
Non UofA Access
C. Liddy, W. Hogg, J. Singh, et al.
Implement Sci 2015 Oct 28;10(1):150-015-0341-y

BACKGROUND: Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC’s impact on adherence to processes of care delivery. METHODS: A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada ( NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention. RESULTS: Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively. CONCLUSIONS: IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice. TRIAL REGISTRATION: NCT00574808.

Using concept mapping to identify conditions that foster knowledge translation from the perspective of school practitioners
Non UofA Access Canada-flat-icon
Christian Dagenais, Renée Pinard, Marjolaine St-Pierre, M. Briand-Lamarche, Amina Kay Cantave and Normand Péladeau.
Research Evaluation 2015 10/24

This article examines the efficacy of using concept mapping to identify the key dimensions that influence the use of research-based information by school practitioners, including teachers, educational counsellors, and school administrators. This mapping exercise was the first step in developing a competency framework for translation of research-based knowledge in education. Its aim was to provoke collective reflection of key stakeholders in the education sector who are already playing a role in knowledge transfer in their settings, to find out what should be done to make the scientific knowledge more useful to professional practices in schools. Altogether, the exercise identified eight domains that, according to respondents, influence the use of research in schools. These results were subsequently validated by three subgroups of participants and compared against the scientific literature on the topic to lay the foundation for identifying competencies that should be included in the framework. The map produced in the exercise described in this article presents a first picture of how things should be, in education, in order for teachers, educational counsellors, and school administrators to be informed by research-based information. The concept mapping methodology used in this study combined qualitative and quantitative approaches and was based on the active participation of key stakeholders. In the context of a project to develop a competency framework to foster knowledge translation, we consider this method to be appropriate and compares favourably with other group techniques.

Redesigning printed educational materials for primary care physicians: design improvements increase usability Canada-flat-icon
Non UofA Access
A. Grudniewicz, O. Bhattacharyya, K. A. McKibbon and S. E. Straus.
Implement Sci 2015 Nov 4;10(1):156-015-0339-5

BACKGROUND: Printed educational materials (PEMs) are a frequently used tool to disseminate clinical information and attempt to change behavior within primary care. However, their effect on clinician behavior is limited. In this study, we explored how PEMs can be redesigned to better meet the needs of primary care physicians (PCPs) and whether usability and selection can be increased when design principles and user preferences are used. METHODS: We redesigned a publicly available PEM using physician preferences, design principles, and graphic designer support. We invited PCPs to select their preferred document between the redesigned and original versions in a discrete choice experiment, followed by an assessment of usability with the System Usability Scale and a think aloud process. We conducted this study in both a controlled and opportunistic setting to determine whether usability testing results vary by study location. Think aloud data was thematically analyzed, and results were interpreted using the Technology Acceptance Model. RESULTS: One hundred and eighty four PCPs participated in the discrete choice experiment at the 2014 Family Medicine Forum, a large Canadian conference for family physicians. Of these, 87.7 % preferred the redesigned version. Follow-up interviews were held with a randomly selected group of seven participants. We repeated this in a controlled setting in Toronto, Canada, with a set of 14 participants. Using the System Usability Scale, we found that usability scores were significantly increased with the redesign (p < 0.001). We also found that when PCPs were given the choice between the two versions, they selected the redesigned version as their preferred PEM more often than the original (p < 0.001). Results did not appear to differ between the opportunistic and controlled setting. We used the results of the think aloud process to add to a list of end user preferences developed in a previous study. CONCLUSIONS: We found that redesigning a PEM with user preferences and design principles can improve its usability and result in the PEM being selected more often than the original. We feel this finding supports the involvement of the user, application of design principles, and the assistance of a graphic designer in the development of PEMs.

Knowledge and use of pressure ulcer preventive measures in nursing homes: a comparison of Dutch and German nursing staff.
Non UofA Access
E. Meesterberends, D. Wilborn, C. Lohrmann, J. M. Schols and R. J. Halfens.
J Clin Nurs 2014 Jul;23(13-14):1948-1958

AIMS AND OBJECTIVES: To examine the knowledge and use of pressure ulcer preventive measures among nursing staff in Dutch and German nursing homes. BACKGROUND: Studies in the Netherlands and Germany have shown a large discrepancy in pressure ulcer prevalence rates among nursing homes in both countries and concluded that some of this variance could be explained by differences in pressure ulcer prevention. DESIGN: A cross-sectional questionnaire survey nested in a prospective multicenter cohort study. METHODS: A questionnaire was distributed to nursing staff employed in 10 Dutch nursing homes (n = 600) and 11 German nursing homes (n = 578). Data were collected in January 2009. RESULTS: The response rate was 75.7% in the Netherlands (n = 454) and 48.4% in Germany (n = 283). Knowledge about useful pressure ulcer preventive measures was moderate in both countries, while nonuseful preventive measures were poorly known. On average, only 19.2% (the Netherlands) and 24.6% (Germany) of preventive measures were judged correctly as nonuseful. The same pattern could be seen with regard to the use of preventive measures, because nonuseful preventive measures were still commonly used according to the respondents. CONCLUSIONS: The results indicate that the respondents’ knowledge and use of pressure ulcer preventive measures could be improved in both countries, especially for nonuseful measures. Changes and improvements can be achieved by providing sufficient education and refresher courses for nurses and nursing assistants employed within Dutch and German nursing homes. RELEVANCE TO CLINICAL PRACTICE: Recurring education about pressure ulcer prevention is required among nursing staff employed in Dutch and German nursing homes, particularly in relation to the use of ineffective and outdated preventive measures. Obstacles regarding the implementation of preventive measures should be addressed to achieve a change in practice.

A multi-faceted knowledge translation approach to support persons with stroke and cognitive impairment: evaluation protocol Canada-flat-icon
Non UofA Access
S. E. McEwen, M. Donald, D. Dawson, et al.
Implement Sci 2015 Nov 5;10(1):157-015-0346-6

BACKGROUND: Patients with cognitive impairments following a stroke are often denied access to inpatient rehabilitation. The few patients with cognitive impairment admitted to rehabilitation generally receive services based on outdated impairment-reduction models, rather than recommended function-based approaches. Both reduced access to rehabilitation and the knowledge-to-practice gap stem from a reported lack of skills and knowledge regarding cognitive rehabilitation on the part of inpatient rehabilitation team members. To address these issues, a multi-faceted knowledge translation (KT) initiative will be implemented and evaluated. It will be targeted specifically at the inter-professional application of the cognitive orientation to daily occupational performance (CO-OP). CO-OP training combined with KT support is called CO-OP KT. The long-term objective of CO-OP KT is to optimize functional outcomes for individuals with stroke and cognitive impairments. Three research questions are posed: 1. Is the implementation of CO-OP KT associated with a change in the proportion of patients with cognitive impairment following a stroke accepted to inpatient rehabilitation? 2. Is the implementation of CO-OP KT associated with a change in rehabilitation clinicians’ practice, knowledge, and self-efficacy related to implementing the CO-OP approach, immediately following and 1 year later? 3. Is CO-OP KT associated with changes in activity, participation, and self-efficacy to perform daily activities in patients with cognitive impairment following stroke at discharge from inpatient rehabilitation and at 1-, 3-, and 6-month follow-ups? METHODS/DESIGN: Three interrelated studies will be conducted. Study 1 will be a quasi-experimental, interrupted time series design measuring monthly summaries of stroke unit level data. Study 2, which relates to changes in health care professional practice and self-efficacy, will be a single group pre-post evaluation design incorporating chart audits and a self-report survey. Study 3 will assess patient functional outcomes using a non-randomized design with historical controls. Assessments will occur during admission and discharge from rehabilitation and at 1, 3, and 6 months following discharge from rehabilitation. DISCUSSION: This project will advance knowledge about the degree to which the implementation of a supported KT initiative can sustainably change health system, knowledge, and patient outcomes.

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Health Care Administration and Organization

Key Attributes of LPN Job Satisfaction and Dissatisfaction in Long-Term Care Settings
Non UofA Access
Patricia Knecht, Paula Milone-Nuzzo, Lisa Kitko, Judith E. Hupcey and Janice Dreachslin.
Journal of Nursing Regulation 2015 7;6(2):17-24

Increasing job satisfaction and decreasing job dissatisfaction have been found to improve staff rétention, ultimately resulting in improved patient outcomes.The goal of this study was to examine job satisfaction and dissatisfaction of long-term care licensed practical nurses (LPNs). A total of 37 LPNs participated in focus-group sessions. Four themes were found to contribute to LPN job satisfaction: value, real connection, empowerment, and growth. One theme, working conditions, was found to contribute to LPN job dissatisfaction. Based on the results of this study, this article provides specific strategies to assist diverse stakeholders in addressing LPN job satisfaction.

Differentiating Scopes of Practice in Nursing Homes: Collaborating for Care
Non UofA Access
Kirsten N. Corazzini, Eleanor S. McConnell, Lisa Day, et al.
Journal of Nursing Regulation 2015 4;6(1):43-49

Hospitalizations of nursing home residents are costly and adversely affect the health of already vulnerable residents, and reducing avoidable hospitalizations has been identified as a priority quality and safety outcome by the U.S. government. However, existing interventions to reduce hospitalizations do not account for differences in scopes of practice among licensed nursing staff. This article describes the development of an educational innovation for nursing home staff members to learn to collaborate in ways that differentiate registered nurse and licensed practical/vocational nurse scopes of practice and strengthen connections among licensed and unlicensed nurses to improve detection and management of conditions associated with avoidable hospitalizations.The innovation was developed using situated learning theory and facilitated unfolding case discussions, reflecting the actual care environment. Evaluation data indicated the feasibility of this approach to staff education.

Quality Care Outcomes in Nursing Homes: The Effects of a Nurse’s Country of Origin and Education
Non UofA Access
Laura M. Wagner, Barbara L. Brush, John B. Engberg, Nicholas G. Castle and Elizabeth Capezuti.
Journal of Nursing Regulation 2015 1;5(4):49-56.

The purpose of this article is to describe differences in nursing home quality outcomes among nurses who are foreign born and foreign educated, nurses who are foreign born and U.S. educated, and nurses who are U.S. born and U.S. educated.This cross-sectional study took place in 91 nursing homes across the United States. Full- and part-time licensed practical and registered nurses were asked to complete a survey, and data on their personal characteristics were linked to facility-level quality indicators. A total of 1,476 nurses were included. The findings indicate that facilities with more responding foreign-born, foreign-educated Filipino nurses exhibit lower quality of care in pain management, prevention of pressure ulcers, and catheter use, but higher quality of care regarding physical restraint use when compared with U.S.-born, U.S-educated and non-Filipino foreign-born and foreign-educated nurses. In facilities with more responding non-Filipino foreign-born, foreign-educated nurses, care quality was better than that of other groups in pain management and physical restraint use.

Agism and burnout among nurses in long-term care facilities in Israel.
Non UofA Access
E. Iecovich and M. Avivi.
Aging Ment Health 2015 Oct 23:1-9

OBJECTIVES: The extent to which agism and professional qualifications are associated with nurses’ burnout in long-term care facilities for older adults has been barely examined. This study is aimed to examine the extent to which agism, professional education, and geriatric training explain work burnout. METHOD: The study included a convenience sample of 154 nurses working in 17 long-term care facilities in the Tel Aviv area in Israel. To examine agism, Kogan’s Attitudes toward Old People Scale was used, and to probe burnout, the Maslach Burnout Inventory was used. RESULTS: Overall burnout was significantly explained by agism, nurses’ professional education, length of working as a nurse, and type of facility ownership. When examining each dimension of burnout, agism was a significant predictor of depersonalization and personal achievement. CONCLUSION: Agism plays a role in overall burnout. Therefore, training programs that can combat agism can reduce burnout of nurses in long-term care facilities.

Mapping the UK’s Dementia Research Landscape and Workforce Capacity
RAND, 2015

The study sought to answer the following questions:
-What types of research on dementia are being carried out in the UK?
-How does the UK perform in comparison to global benchmarks?
-What does the UK dementia research workforce look like?
-What are the associated strengths and gaps in this landscape?
-What are the capacity-building priorities and how can they be met?

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Health Care Innovation and Quality Assurance

Certified Nurse Aides and Scope of Practice: Clinical Outcomes and Patient Safety.
Non UofA Access
T. L. McMullen, B. Resnick, J. C. Hansen, N. Miller and R. Rubinstein.
J Gerontol Nurs 2015 Oct 19:1-7

To understand the impact of scope of practice and allowable certified nurse aide (CNA) tasks across states, the current study compared clinical outcomes in states with a basic scope of practice versus those that allowed for an expanded scope. The current study used data from the Minimum Data Set as well as staffing data from the Centers for Medicare and Medicaid Services. Clinical outcomes included: (a) percent of residents whose need for help with daily activities has increased, (b) percent of high-risk residents with pressure ulcers, (c) percent of residents who self-report moderate to severe pain, (d) percent of residents experiencing one or more falls with major injury, and (e) CNA staffing hours. There was no difference in clinical outcomes between states with expanded or basic scopes. Many factors influence clinical outcomes among residents and additional staffing and facility characteristics should be considered in future studies.

Outcomes for implementation science: an enhanced systematic review of instruments using evidence-based rating criteria.
Non UofA Access
C. C. Lewis, S. Fischer, B. J. Weiner, C. Stanick, M. Kim and R. G. Martinez.
Implement Sci 2015 Nov 4;10(1):155-015-0342-x

BACKGROUND: High-quality measurement is critical to advancing knowledge in any field. New fields, such as implementation science, are often beset with measurement gaps and poor quality instruments, a weakness that can be more easily addressed in light of systematic review findings. Although several reviews of quantitative instruments used in implementation science have been published, no studies have focused on instruments that measure implementation outcomes. Proctor and colleagues established a core set of implementation outcomes including: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, sustainability (Adm Policy Ment Health Ment Health Serv Res 36:24-34, 2009). The Society for Implementation Research Collaboration (SIRC) Instrument Review Project employed an enhanced systematic review methodology (Implement Sci 2: 2015) to identify quantitative instruments of implementation outcomes relevant to mental or behavioral health settings. METHODS: Full details of the enhanced systematic review methodology are available (Implement Sci 2: 2015). To increase the feasibility of the review, and consistent with the scope of SIRC, only instruments that were applicable to mental or behavioral health were included. The review, synthesis, and evaluation included the following: (1) a search protocol for the literature review of constructs; (2) the literature review of instruments using Web of Science and PsycINFO; and (3) data extraction and instrument quality ratings to inform knowledge synthesis. Our evidence-based assessment rating criteria quantified fundamental psychometric properties as well as a crude measure of usability. Two independent raters applied the evidence-based assessment rating criteria to each instrument to generate a quality profile. RESULTS: We identified 104 instruments across eight constructs, with nearly half (n = 50) assessing acceptability and 19 identified for adoption, with all other implementation outcomes revealing fewer than 10 instruments. Only one instrument demonstrated at least minimal evidence for psychometric strength on all six of the evidence-based assessment criteria. The majority of instruments had no information regarding responsiveness or predictive validity. CONCLUSIONS: Implementation outcomes instrumentation is underdeveloped with respect to both the sheer number of available instruments and the psychometric quality of existing instruments. Until psychometric strength is established, the field will struggle to identify which implementation strategies work best, for which organizations, and under what conditions.

Hospitalization and Mortality Rates in Long-Term Care Facilities: Does For-Profit Status Matter? Canada-flat-icon
Non UofA Access
P. Tanuseputro, M. Chalifoux, C. Bennett, et al.
J Am Med Dir Assoc 2015 Oct 1;16(10):874-883

OBJECTIVES: To establish if proprietary status (ie, for-profit or not-for-profit) is associated with mortality and hospitalizations among publicly funded long-term care (nursing) homes. METHODS: We conducted a retrospective cohort study of new admissions in 640 publicly funded long-term care facilities in Ontario, Canada (384 for-profit, 256 not-for-profit). A population-based cohort of 53,739 incident admissions into long-term care facilities between January 1, 2010, and March 1, 2012, was observed. We measured adjusted rates of hospital admissions and mortality, per 1000 person-years (PY) of follow-up, among for-profit and not-for-profit facilities at 3, 6, and 12 months postadmission. Rates were measured postadmission and until discharge or death, whichever came first. RESULTS: One year after admission and before discharge, 11.7% of residents died and 25.7% had at least one hospitalization. After 12 months of follow-up, residents in for-profit facilities had a hospitalization rate of 462 per 1000 PY versus 358 per 1000 PY in not-for-profit facilities. During this period, the crude mortality rate in for-profit facilities was 208 per 1000 PY versus 185 per 1000 PY in not-for-profit facilities. At 3, 6, and 1 year after admission, for-profit facilities had an adjusted hazard ratio of 1.36 (95% confidence interval [CI] 1.28-1.43), 1.33 (95% CI 1.27-1.39), and 1.25 (95% CI 1.21-1.30) for hospitalizations and hazards of 1.20 (95% CI 1.11-1.29), 1.16 (95% CI 1.09-1.24), and 1.10 (95% CI 1.05-1.16) for mortality, respectively. CONCLUSIONS: Publicly funded for-profit facilities have significantly higher rates of both mortality and hospital admissions.

Predicting Adverse Health Outcomes in Nursing Homes: A 9-Year Longitudinal Study and Development of the FRAIL-Minimum Data Set (MDS) Quick Screening Tool
Non UofA Access
Hao Luo, Terry Y. S. Lum, Gloria H. Y. Wong, Joseph S. K. Kwan, Jennifer Y. M. Tang and Iris Chi.
Journal of the American Medical Directors Association 2015/10

Objectives To examine the predictive validity of a quick frailty screening tool, the FRAIL-NH, for adverse health outcomes in nursing home residents, using variables from the Minimum Data Set (MDS). The screening items were compiled from the MDS for potential direct application in long-term care facilities using this health information system.; Objectives To examine the predictive validity of a quick frailty screening tool, the FRAIL-NH, for adverse health outcomes in nursing home residents, using variables from the Minimum Data Set (MDS). The screening items were compiled from the MDS for potential direct application in long-term care facilities using this health information system.

Improving the Quality of Long-Term Care
Non UofA Access
Josephine H. Silvestre, Barbara J. Bowers and Sue Gaard.
Journal of Nursing Regulation 2015 7;6(2):52-56

Many factors affect quality care in long-term care (LTC) settings. A supportive organizational culture, strong leadership, appropriate staff and staffing, and effective training and professional development of staff members are all fundamental elements necessary for influencing quality care in LTC settings. This article discusses challenging issues confronting LTC settings and provides strategies for managing the complexities of culture change, staffing, and education in LTC.

A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care—Preliminary Data
Non UofA Access
Joshua Chodosh, Rachel M. Price, Mary P. Cadogan, et al.
J Am Geriatr Soc 2015

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.

Cost-Effectiveness of Nutrition Intervention in Long-Term Care.
Non UofA Access
S. F. Simmons, E. Keeler, R. An, et al.
J Am Geriatr Soc 2015 Oct 27

OBJECTIVES: To determine the cost-effectiveness of two nutrition interventions on food, beverage, and supplement intake and body weight. DESIGN: Randomized, controlled trial. SETTING: Five skilled nursing home facilities. PARTICIPANTS: Long-stay residents with orders for nutrition supplementation (N = 154). INTERVENTION: Participants were randomized into a usual care control group, an oral liquid nutrition supplement (ONS) intervention group, or a snack intervention group. Research staff provided ONS, according to orders or a variety of snack foods and beverages twice per day between meals, 5 days per week for 24 weeks and assistance to promote consumption. MEASUREMENTS: Research staff independently weighed residents at baseline and monthly during the 24-week intervention. Resident food, beverage and supplement intake and the amount of staff time spent providing assistance were assessed for 2 days at baseline and 2 days per month during the intervention using standardized observation and weighed intake procedures. RESULTS: The ONS intervention group took in an average of 265 calories more per day and the snack intervention group an average of 303 calories more per day than the control group. Staff time required to provide each intervention averaged 11 and 14 minutes per person per offer for ONS and snacks, respectively, and 3 minutes for usual care. Both interventions were cost-effective in increasing caloric intake, but neither intervention had a significant effect on body weight, despite positive trends. CONCLUSION: Oral liquid nutrition supplements and snack offers were efficacious in promoting caloric intake when coupled with assistance to promote consumption and a variety of options, but neither intervention resulted in significant weight gain.

Reliability of the interRAI Long Term Care Facilities (LTCF) and interRAI Home Care (HC).
Non UofA Access
H. Kim, Y. I. Jung, M. Sung, J. Y. Lee, J. Y. Yoon and J. L. Yoon.
Geriatr Gerontol Int 2015 Feb;15(2):220-228

AIM: Sharing clinical information across care settings is a cornerstone to providing quality care to older people with complex conditions. The purpose of the present study was to examine the reliability of the interRAI Long Term Care Facilities (interRAI LTCF) and the interRAI Home Care (interRAI HC), comprehensive and integrated assessment instruments with common core items, in Korea, an Asian county where comprehensive geriatric assessment is not widely used in long-term care. METHODS: The Korean version of the instruments was developed through field tests, as well as multiple iterations of translations, back-translations and expert reviews. For the reliability test, a random sample of 908 older people in 27 long-term care hospitals or nursing homes, or at home with home care, were assessed by regular staff, among which a subsample of 534 people were dually assessed. The Cronbach’s alphas of seven major composite scales in the instruments were examined for internal consistency. Interrater reliability was tested using agreement, kappa coefficients and interclass correlation coefficients. RESULTS: The internal consistencies of all key measures were adequate (Cronbach’s alpha>/=0.75). The overall mean kappa statistics of the items in the interRAI LTCF and those in the interRAI HC were 0.78 and 0.89, respectively. All key common items in the interRAI LTCF and the interRAI HC had almost perfect (kappa>/=0.81) or substantial (0.61</=kappa</=0.80) interrater reliability. CONCLUSIONS: The findings show the interRAI LTCF and the interRAI HC have adequate reliability for assessing the function and health of frail older adults across various long-term settings, which can promote continuity of care for the aged.

Communication and effectiveness in a US nursing home quality-improvement collaborative.
Non UofA Access
P. A. Arling, K. Abrahamson, E. J. Miech, T. S. Inui and G. Arling.
Nurs Health Sci 2014 Sep;16(3):291-297

In this study, we explored the relationship between changes in resident health outcomes, practitioner communication patterns, and practitioner perceptions of group effectiveness within a quality-improvement collaborative of nursing home clinicians. Survey and interview data were collected from nursing home clinicians participating in a quality-improvement collaborative. Quality-improvement outcomes were evaluated using US Federal and State minimum dataset measures. Models were specified evaluating the relationships between resident outcomes, staff perceptions of communication patterns, and staff perceptions of collaborative effectiveness. Interview data provided deeper understanding of the quantitative findings. Reductions in fall rates were highest in facilities where respondents experienced the highest levels of communication with collaborative members outside of scheduled meetings, and where respondents perceived that the collaborative kept them informed and provided new ideas. Clinicians observed that participation in a quality-improvement collaborative positively influenced the ability to share innovative ideas and expand the quality-improvement program within their nursing home. For practitioners, a high level of communication, both inside and outside of meetings, was key to making measurable gains in resident health outcomes.

Enhancing quality and safety standards for older people in Canadian hospitals: a national collaboration. Canada-flat-icon
Non UofA Access
B. Parke, B. Liu, A. Juby and C. Jamieson.
Healthc Q 2013;16(1):23-29

In this article, the authors present quality and safety standards for older people in hospital, derived from a national dialogue involving inter-professional experts, key stakeholders and opinion leaders. They report the consensus process and present the standard statements with corresponding operational definitions, along with relevant clinical topics. This work can serve as a platform for service planners, evaluators and policy makers who are endeavouring to ensure that older people receive quality care and service when admitted to a Canadian hospital.

A programme to reduce acquired pressure ulcers in care homes.
Non UofA Access
T. M. Thompson and D. Marks-Maran.
Br J Nurs 2015 Jun 25-Jul 8;24(12):S4-6, S8, S10 passim

Prevention of pressure ulcers is a major health concern, especially for older people. Much of the literature related to prevention of pressure ulcers focuses on hospital-acquired pressure ulcers. There is less literature related to prevention of pressure ulcers in care homes. This article presents a review of the literature related to prevention of pressure ulcers in care homes and an ambitious project undertaken by one care home provider to raise awareness of pressure ulcers, provide training in prevention and monitor and evaluate pressure ulcers in over 200 care home across the UK. Known as MI SKIN, the project involves ongoing training to all levels of care staff, a robust system of monitoring pressure ulcers and a mechanism to investigate and learn from any incident of pressure ulcer using root cause analysis.

The Road to Making Patient-Centered Care Real (US)
Urban Institute, 2015

Although patient-centered care is not new, increasing emphasis on quality measurement as part of health care reform has led to a renewed focus on it. The path to achieving patient-centered care is not always clear, even to those who believe in its importance. This paper informs a discussion of federal policies affecting patient-centered care. The authors recommend that (1) federal efforts toward patient-centered care be catalogued and scrutinized, (2) better measures and information on effective implementation are used, and (3) this intervention’s ability to enhance the doctor-patient bond is emphasized.

Indicators of quality of care in general practices in England
Health Foundation

The Foundation consulted with a wide range of organisations and individuals with an interest in how information about general practice care quality is collated and published. We assessed the literature, analysed indicators currently used as well as the websites on which they are published, and worked with insight agency BritainThinks to understand the public’s views. Our review focused on publication of indicators for the purposes of supporting local improvement of care, patient choice and voice, and the accountability and performance management of general practices.

Systems Approach for Transforming Healthcare Organizations-Improving the Quality, Cost, and Value of Patient Care (US)
ThedaCare Center for Healthcare Value

After visiting hundreds of healthcare organizations across the globe, Dr. John Toussaint has used this collective experience to build a framework for delivering better customer value. These successful leadership behaviors and other operational guidelines are defined in a new white paper entitled: Systems Approach for Transforming Healthcare Organizations Improving the Quality, Cost, and Value of Patient Care.

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Research Practice and Methodology

Conceptual decomposition of complex health care interventions for evidence synthesis: a literature review.
Non UofA Access
F. Kuhne, R. Ehmcke, M. Harter and L. Kriston.
J Eval Clin Pract 2015 Oct;21(5):817-823

RATIONALE, AIMS AND OBJECTIVES: The clarity of pivotal concepts is an important prerequisite for the development, evaluation and exchange of scientific ideas. The term ‘complex intervention’ is increasingly used in the health care literature, although it often remains unclear what is actually meant by this concept. Therefore, our aim was to analyse the literature regarding definitions of the terms ‘complex intervention’ and ‘components’ of such interventions. METHOD: To identify the methodological publications, systematic and snowballing techniques were combined for the literature search. Relevant units of meaning were extracted from 68 included publications. Afterwards, we deduced categories and related frequencies by inductive and quantitative content analysis techniques. RESULTS: Several types of complexity were distinguished in the literature. Most authors viewed complex interventions as multicomponent interventions that are characterized by interactions between the components themselves, with the context or as systemic interventions. Components of complex interventions were described in the publications as having the potential to causally influence outcomes, thus being essential for achieving an effect. Other definitions and inconsistencies among the definitions are highlighted and discussed. CONCLUSIONS: From our synthesis, we derived definitions of the central health care-related concepts ‘complex intervention’ and ‘components’ of an intervention. Although we found numerous diverse definitions, they could be reduced to a defined number of core characteristics. These characteristics may facilitate communication regarding complex interventions and enable the deduction of methodological approaches for evidence synthesis.

Is Twitter a forum for disseminating research to health policy makers?
Non UofA Access
J. M. Kapp, B. Hensel and K. T. Schnoring.
Ann Epidemiol 2015 Sep 14

Findings from scientific research largely remain inside the scientific community. Research scientists are being encouraged to use social media, and especially Twitter, for dissemination of evidence. The potential for Twitter to narrow the gap on evidence translated into policy presents new opportunities. We explored the innovative question of the feasibility of Twitter as a tool for the scientific community to disseminate to and engage with health policy makers for research impact. We created a list of federal “health policy makers.” In December 2014, we identified members using several data sources, then collected and summarized their Twitter usage data. Nearly all health policy makers had Twitter accounts. Their communication volume varied broadly. Policy makers are more likely to push information via Twitter than engage with constituents, although usage varied broadly. Twitter has the potential to aid the scientific community in dissemination of health-related research to health policy makers, after understanding how to effectively (and selectively) use Twitter.

Using Qualitative Evidence in Decision Making for Health and Social Interventions: An Approach to Assess Confidence in Findings from Qualitative Evidence Syntheses (GRADE-CERQual)
Non UofA Access
S. Lewin, C. Glenton, H. Munthe-Kaas, et al.
PLoS Med 2015 Oct 27;12(10):e1001895

Qualitative evidence syntheses are increasingly used, but methods to assess how much confidence to place in synthesis findings are poorly developed. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach helps assess how much confidence to place in findings from a qualitative evidence synthesis.

How stakeholder participation can contribute to systematic reviews of complex interventions.
Non UofA Access
J. Harris, L. Croot, J. Thompson and J. Springett.
J Epidemiol Community Health 2015 Oct 16

Although patient and public involvement in research is a requirement for research funding in many countries, the knowledge base for how to effectively involve people-and evidence of the effectiveness of involvement-is weak. This article describes how methods used in participatory health research were used to involve patients, clients, providers and community health workers across all stages of a realist review. Sustained involvement enabled better identification of the components of the complex intervention of community-based peer support. It also challenged assumptions of how peer support is constructed, leading the review team to question whether the process of designing and implementing interventions has more influence on effectiveness than previously recognised in empirical studies. We conclude with a discussion on when sustained involvement should be used, and the challenges of incorporating it into the traditional researcher-led approach to systematic reviews.

Intervention Component Analysis (ICA): a pragmatic approach for identifying the critical features of complex interventions.
Non UofA Access
K. Sutcliffe, J. Thomas, G. Stokes, K. Hinds and M. Bangpan.
Syst Rev 2015 Oct 29;4(1):140-015-0126-z

BACKGROUND: In order to enable replication of effective complex interventions, systematic reviews need to provide evidence about their critical features and clear procedural details for their implementation. Currently, few systematic reviews provide sufficient guidance of this sort. METHODS: Through a worked example, this paper reports on a methodological approach, Intervention Component Analysis (ICA), specifically developed to bridge the gap between evidence of effectiveness and practical implementation of interventions. By (a) using an inductive approach to explore the nature of intervention features and (b) making use of trialists’ informally reported experience-based evidence, the approach is designed to overcome the deficiencies of poor reporting which often hinders knowledge translation work whilst also avoiding the need to invest significant amounts of time and resources in following up details with authors. RESULTS: A key strength of the approach is its ability to reveal hidden or overlooked intervention features and barriers and facilitators only identified in practical application of interventions. It is thus especially useful where hypothesised mechanisms in an existing programme theory have failed. A further benefit of the approach is its ability to identify potentially new configurations of components that have not yet been evaluated. CONCLUSIONS: ICA is a formal and rigorous yet relatively streamlined approach to identify key intervention content and implementation processes. ICA addresses a critical need for knowledge translation around complex interventions to support policy decisions and evidence implementation.

The need to balance merits and limitations from different disciplines when considering the stepped wedge cluster randomized trial design
Non UofA Access
E. de Hoop, I. van der Tweel, R. van der Graaf, et al.
BMC Med Res Methodol 2015 Oct 30;15:93-015-0090-2

BACKGROUND: Various papers have addressed pros and cons of the stepped wedge cluster randomized trial design (SWD). However, some issues have not or only limitedly been addressed. Our aim was to provide a comprehensive overview of all merits and limitations of the SWD to assist researchers, reviewers and medical ethics committees when deciding on the appropriateness of the SWD for a particular study. METHODS: We performed an initial search to identify articles with a methodological focus on the SWD, and categorized and discussed all reported advantages and disadvantages of the SWD. Additional aspects were identified during multidisciplinary meetings in which ethicists, biostatisticians, clinical epidemiologists and health economists participated. All aspects of the SWD were compared to the parallel group cluster randomized design. We categorized the merits and limitations of the SWD to distinct phases in the design and conduct of such studies, highlighting that their impact may vary depending on the context of the study or that benefits may be offset by drawbacks across study phases. Furthermore, a real-life illustration is provided. RESULTS: New aspects are identified within all disciplines. Examples of newly identified aspects of an SWD are: the possibility to measure a treatment effect in each cluster to examine the (in)consistency in effects across clusters, the detrimental effect of lower than expected inclusion rates, deviation from the ordinary informed consent process and the question whether studies using the SWD are likely to have sufficient social value. Discussions are provided on e.g. clinical equipoise, social value, health economical decision making, number of study arms, and interim analyses. CONCLUSIONS: Deciding on the use of the SWD involves aspects and considerations from different disciplines not all of which have been discussed before. Pros and cons of this design should be balanced in comparison to other feasible design options as to choose the optimal design for a particular intervention study.

An evaluation of harvest plots to display results of meta-analyses in overviews of reviews: a cross-sectional study Canada-flat-icon
Non UofA Access
K. Crick, A. Wingert, K. Williams, R. M. Fernandes, D. Thomson and L. Hartling.
BMC Med Res Methodol 2015 Oct 26;15:91-015-0084-0

BACKGROUND: Harvest plots are used to graphically display evidence from complex and diverse studies or results. Overviews of reviews bring together evidence from two or more systematic reviews. Our objective was to determine the feasibility of using harvest plots to depict complex results of overviews of reviews. METHODS: We conducted a survey of 279 members of Cochrane Child Health to determine their preferences for graphical display of data, and their understanding of data presented in the form of harvest plots. Preferences were rated on a scale of 0-100 (100 most preferred) and tabulated using descriptive statistics. Knowledge and accuracy were assessed by tabulating the number of correctly answered questions for harvest plots and traditional data summary tables; t-tests were used to compare responses between formats. RESULTS: 53 individuals from 7 countries completed the survey (19 %): 60 % were females; the majority had an MD (38 %), PhD (47 %), or equivalent. Respondents had published a median of 3 systematic reviews (inter-quartile range 1 to 8). There were few differences between harvest plots and tables in terms of being: well-suited to summarize and display results from meta-analysis (52 vs. 56); easy to understand (53 vs. 51); and, intuitive (49 vs. 44). Harvest plots were considered more aesthetically pleasing (56 vs. 44, p = 0.03). 40 % felt the harvest plots could be used in conjunction with tables to display results from meta-analyses; additionally, 45 % felt the harvest plots could be used with some improvement. There was no statistically significant difference in percentage of knowledge questions answered correctly for harvest plots compared with tables. When considering both types of data display, 21 % of knowledge questions were answered incorrectly. CONCLUSIONS: Neither harvest plots nor standard summary tables were ranked highly in terms of being easy to understand or intuitive, reflecting that neither format is ideal to summarize the results of meta-analyses in overviews of reviews. Responses to knowledge questions showed some misinterpretation of results of meta-analyses. Reviewers should ensure that messages are clearly articulated and summarized in the text to avoid misinterpretation.

Achieving a National Sample of Nursing Homes: Balancing Probability Techniques and Practicalities.
Non UofA Access
E. Fielding, E. Beattie, M. O’Reilly, M. McMaster and AusQoL Group.
Res Gerontol Nurs 2015 Oct 28:1-8

Sampling design is critical to the quality of quantitative research, yet it does not always receive appropriate attention in nursing research. The current article details how balancing probability techniques with practical considerations produced a representative sample of Australian nursing homes (NHs). Budgetary, logistical, and statistical constraints were managed by excluding some NHs (e.g., those too difficult to access) from the sampling frame; a stratified, random sampling methodology yielded a final sample of 53 NHs from a population of 2,774. In testing the adequacy of representation of the study population, chi-square tests for goodness of fit generated nonsignificant results for distribution by distance from major city and type of organization. A significant result for state/territory was expected and was easily corrected for by the application of weights. The current article provides recommendations for conducting high-quality, probability-based samples and stresses the importance of testing the representativeness of achieved samples.

The concept of mechanism from a realist approach: a scoping review to facilitate its operationalization in public health program evaluation.
Non UofA Access
A. Lacouture, E. Breton, A. Guichard and V. Ridde.
Implement Sci 2015 Oct 30;10(1):153

BACKGROUND: Public health interventions are complex by nature, and their evaluation requires unpacking their intervention logic and their interactions with open social systems. By focusing on the interrelationships between context, mechanism, and outcome, Pawson and Tilley’s realist approach appears a promising innovation for public health-related evaluation works. However, and as expected of any methodological innovation, this approach is being constructed gradually by answering the multiple challenges to its operationalization that fall in its path. One of these challenges, users of this approach agree on, is the necessity of clarifying its key concept of mechanism. METHOD: We first collected the definitions of mechanism from published works of Pawson and colleagues. Secondly, a scoping review was conducted to identify the ones quoted by users of the realist approach for evaluating public health interventions (1997-2012). We then appraised the clarity and precision of this concept against the three dimensions defined by Daigneault and Jacobs “term, sense and referent.” RESULTS: Of the 2344 documents identified in the scoping review, 49 documents were included. Term: Users of the realist approach use adjectives qualifying the term mechanism that were not specifically endorsed by Pawson and colleagues. Sense: None of the attributes stated by Pawson and colleagues has been listed in all of the documents analyzed, and some contributions clarified its attributes. Referent: The concept of mechanism within a realist approach can be ascribed to theory-based evaluation, complex social interventions, and critical realism. CONCLUSION: This review led us to reconsider the concept of mechanism within the realist approach by confronting the theoretical stance of its proponents to the practical one of its users. This resulted in a clearer, more precise definition of the concept of mechanism which may in turn trigger further improvements in the way the realist approach is applied in evaluative practice in public health and potentially beyond. A mechanism is hidden but real, is an element of reasoning and reactions of agents in regard to the resources available in a given context to bring about changes through the implementation of an intervention, and evolves within an open space-time and social system of relationships.

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A retrospective, longitudinal study of factors associated with new antipsychotic medication use among recently admitted long-term care residents.
Non UofA Access
A. Foebel, A. Ballokova, N. I. Wellens, et al.
BMC Geriatr 2015 Oct 19;15(1):128-015-0127-8

BACKGROUND: Use of antipsychotic (AP) medications is high and often inappropriate among institutionalized populations. Little is known about the correlates of new AP drug use following admission to long-term care (LTC) settings. This study investigated the frequency and correlates of new AP drug use among newly admitted LTC residents. METHODS: This longitudinal, retrospective study used data from the interRAI – Nursing Home Minimum Data Set version 2.0 (MDS 2.0) instrument. Data about demographic, clinical and social characteristics, and medication use, were collected in Ontario, Canada, from 2003-2011 by trained nurses. Residents with complete admission and 3-6 month follow-up data were included (N = 47,768). Multivariate logistic regression analyses, stratified by gender, explored correlates of new AP drug use upon admission to LTC. RESULTS: New AP drug users comprised 7 % of the final cohort. Severe cognitive impairment, dementia, and motor agitation were significantly associated with new AP drug use among both sexes. Additionally, behavioural problems, conflicts with staff and reduced social engagement were strong correlates of new AP drug use. CONCLUSIONS: Social factors were as strongly associated with new AP drug use after LTC admission as clinical factors. Strategies to prevent the potential misuse of AP drugs upon LTC admission should consider the social determinants of such prescribing.

Caregiver perceptions regarding the measurement of level and quality of care in Alzheimer’s disease. Canada-flat-icon
Non UofA Access
A. A. Hazzan, J. Ploeg, H. Shannon, P. Raina and M. Oremus.
BMC Nurs 2015 Oct 24;14:54

BACKGROUND: Primary informal caregivers play a critical role in the care and support of persons with Alzheimer’s disease (AD). A recent systematic review found little existing research into whether caregiver quality-of-life affects the level or quality of care that caregivers provide to their loved ones with AD. The dearth of research could be due to the absence of research questionnaires designed specifically to measure level or quality of care in AD. In the present study, we interviewed primary informal caregivers to obtain their views on the type of questionnaire that would be most suitable to assess level or quality of care in AD. METHODS: A qualitative descriptive design was used. Purposive sampling was used to select participants. Participants were primary informal caregivers who were 18 years of age and older and were directly involved in the day-to-day care of community-dwelling (residing in private homes) persons with AD. A total of 21 caregivers were interviewed using focus groups or one-on-one interviews. Data were analyzed using qualitative content analysis. RESULTS: Informal caregivers identified a number of factors that researchers should consider when developing an instrument to measure level or quality of care that informal caregivers provide to their loved ones with AD. Overall, caregivers preferred a questionnaire that would employ a case management approach that recognizes the increase in care demands as patient health deteriorates, that acknowledges the importance of social support for caregivers, and that considers the role of hired help. CONCLUSIONS: The information generated from this study can help in developing an instrument for measuring the level or quality of care provided. Such an instrument could guide nursing practice in supporting caregivers as they care for persons with AD.

Challenges in the Pharmacological Management of Nursing Home Residents with Overactive Bladder or Urinary Incontinence
Non UofA Access
Barbara J. Zarowitz, Carrie Allen, Terrence O’Shea, Eric G. Tangalos, Todd Berner and Joseph G. Ouslander.
J Am Geriatr Soc 2015

Objectives To determine the proportion of nursing home (NH) residents (NHR) with overactive bladder (OAB) or urinary incontinence (UI) with potential pharmacodynamic contraindications to antimuscarinic treatment because of concomitant anticholinergic medications or acetylcholinesterase inhibitors (AChEIs) and nonpharmacological limitations to antimuscarinic treatment. Design Cross-sectional retrospective analysis. Setting U.S. skilled nursing facilities. Participants Nursing home residents with a diagnosis of OAB or UI. Measurements Linked and deidentified pharmacy claims and Minimum Data Set (MDS) 3.0 records (October 1, 2010 to September 30, 2012). Results Of NHRs, 71.3% received at least one anticholinergic medication. Medications that can cause or worsen UI were used commonly. AChEIs and antimuscarinic treatment were prescribed concurrently in 24% of NHRs with OAB or UI. NHRs with OAB or UI were more likely to have concurrent moderate to severe cognitive impairment (MSCI) (70.1%) than those without (29.9%) (P < .001). NHRs with or without OAB or UI and with MSCI were more likely to be treated with an anticholinergic medication than those without MSCI (P = .001). When NHRs with MSCI, severe mobility impairment (SMI), and anticholinergic medication and AChEI use were excluded, only a small proportion of NHRs were potential candidates for antimuscarinic treatment (6.6% with OAB or UI, 6.2% with UI). Conclusions This study advances understanding of the challenges in prescribing antimuscarinic treatment safely and appropriately in elderly NHRs with a high prevalence of drug interactions, underlying MSCI, and SMI.

US Prevalence And Predictors Of Informal Caregiving For Dementia.
Non UofA Access
E. M. Friedman, R. A. Shih, K. M. Langa and M. D. Hurd.
Health Aff (Millwood) 2015 Oct 1;34(10):1637-1641

In 2010, 5.5 million US adults ages seventy and older received informal care, including 3.6 million with cognitive impairment or probable dementia. Adults with probable dementia received 171 hours of monthly informal care, versus 89 hours for cognitively impaired adults without dementia and 66 hours for cognitively normal adults.

Hospitalization and Mortality Rates in Long-Term Care Facilities: Does For-Profit Status Matter?
Non UofA Access
P. Tanuseputro, M. Chalifoux, C. Bennett, et al.
J Am Med Dir Assoc 2015 Oct 1;16(10):874-883

OBJECTIVES: To establish if proprietary status (ie, for-profit or not-for-profit) is associated with mortality and hospitalizations among publicly funded long-term care (nursing) homes. METHODS: We conducted a retrospective cohort study of new admissions in 640 publicly funded long-term care facilities in Ontario, Canada (384 for-profit, 256 not-for-profit). A population-based cohort of 53,739 incident admissions into long-term care facilities between January 1, 2010, and March 1, 2012, was observed. We measured adjusted rates of hospital admissions and mortality, per 1000 person-years (PY) of follow-up, among for-profit and not-for-profit facilities at 3, 6, and 12 months postadmission. Rates were measured postadmission and until discharge or death, whichever came first. RESULTS: One year after admission and before discharge, 11.7% of residents died and 25.7% had at least one hospitalization. After 12 months of follow-up, residents in for-profit facilities had a hospitalization rate of 462 per 1000 PY versus 358 per 1000 PY in not-for-profit facilities. During this period, the crude mortality rate in for-profit facilities was 208 per 1000 PY versus 185 per 1000 PY in not-for-profit facilities. At 3, 6, and 1 year after admission, for-profit facilities had an adjusted hazard ratio of 1.36 (95% confidence interval [CI] 1.28-1.43), 1.33 (95% CI 1.27-1.39), and 1.25 (95% CI 1.21-1.30) for hospitalizations and hazards of 1.20 (95% CI 1.11-1.29), 1.16 (95% CI 1.09-1.24), and 1.10 (95% CI 1.05-1.16) for mortality, respectively. CONCLUSIONS: Publicly funded for-profit facilities have significantly higher rates of both mortality and hospital admissions.

Prognosis of patients with dementia: results from a prospective nationwide registry linkage study in the Netherlands.
Non UofA Access
I. E. van de Vorst, I. Vaartjes, M. I. Geerlings, M. L. Bots and H. L. Koek.
BMJ Open 2015 Oct 28;5(10):e008897-2015-008897

OBJECTIVE: To report mortality risks of dementia based on national hospital registry data, and to put these risks into perspective by comparing them with those in the general population and following cardiovascular diseases. DESIGN: Prospective cohort study from 1 January 2000 through 31 December 2010. SETTING: Hospital-based cohort. PARTICIPANTS: A nationwide hospital-based cohort of 59 201 patients with clinical diagnosis of dementia (admitted to a hospital or visiting a day clinic) was constructed (38.7% men, 81.4 years (SD 7.0)). MAIN OUTCOMES AND MEASURES: 1-year and 5-year age-specific and sex-specific mortality risks were reported for patients with dementia visiting a day clinic compared with the general population; for patients hospitalised with dementia compared with patients hospitalised for acute myocardial infarction (AMI), heart failure or stroke, these were presented as absolute and relative risks (RRs). RESULTS: 1-year mortality was 38.3% in men and 30.5% in women. 5-year risk was 65.4% and 58.5%, respectively. Mortality risks were significantly higher in patients with dementia admitted to the hospital than in those visiting a day clinic (1-year RR 3.29, 95% CI 3.16 to 3.42; and 5-year RR 1.79, 95% CI 1.76 to 1.83). Compared with the general population, mortality risks were significantly higher among patients visiting a day clinic (1-year RR for women 2.99, 95% CI 2.84 to 3.14; and for men 3.94, 95% CI 3.74 to 4.16). 5-year RRs were somewhat lower, but still significant. Results were more pronounced at younger ages. Mortality risks among admitted patients were comparable or even exceeded those of cardiovascular diseases (1-year RR for women with dementia vs AMI 1.24, 95% CI 1.19 to 1.29; vs heart failure 1.05, 95% CI 1.02 to 1.08; vs stroke 1.07, 95% CI 1.04 to 1.10). 5-year RRs were comparable. For men, RRs were slightly higher. CONCLUSIONS: Dementia has a poor prognosis as compared with other diseases and the general population. The risks among admitted patients even exceeded those following cardiovascular diseases.

From wandering to wayfaring: Reconsidering movement in people with dementia in long-term care Canada-flat-icon
Non UofA Access
M. E. Graham.
Dementia (London) 2015 Oct 29

The movement of people with dementia in long-term care continues to be an issue of concern among clinicians, caregivers and families. This article will examine the social construction “wandering” and its association with pathology, risk discourse and surveillance technologies. Further, the article will explore the recent shift from the term “wanderer” to the phrase “people who like to walk” in person-centred dementia care. Engaging with Ingold’s concept of movement as wayfaring, an alternative becoming-centred understanding of movement and its significance for people with dementia will be presented and illustrated through a case study. The paper concludes that depathologizing movement opens the possibility to see movement in people with dementia as an intention to be alive and to grow, rather than as a product of disease and deterioration. Suggestions for future research and implications for care interventions are discussed.

Music therapy: A nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia.
Non UofA Access
K. D. Ray and M. S. Mittelman.
Dementia (London) 2015 Oct 29

Depression, agitation, and wandering are common behaviors associated with dementia and frequently observed among nursing home residents. Even with pharmacological treatment, behaviors often persist, hindering quality of life for elders, their family, and paid caregivers. This study examined the use of music therapy for treatment of these symptoms among 132 people with moderate to severe dementia in nursing homes. Participants were evaluated for depressive symptoms, agitation, and wandering to determine their predominate behavior. There were two assessments, two weeks apart, prior to intervention, followed by a two-week intervention, and two follow-up assessments, also two weeks apart. A repeated measures ANOVA determined that after two weeks of music therapy, symptoms of depression and agitation were significantly reduced; there was no change for wandering. Multivariate analyses confirmed a relationship between music therapy and change in neuropsychiatric symptoms associated with dementia. Results suggest widespread use of music therapy in long-term care settings may be effective in reducing symptoms of depression and agitation.

Evidence-Based Practice Guideline: Depression Detection in Older Adults With Dementia.
Non UofA Access
E. L. Brown, P. J. Raue and K. Halpert.
J Gerontol Nurs 2015 Nov 1;41(11):15-21

Depression and dementia are the two most common psychiatric syndromes in the older adult population. Depression in older adults with and without dementia often goes unrecognized and untreated. The current guideline recommends a three-step procedure that can be used across health care settings to screen for the presence of depressive symptoms. Implementation of the evidence-based guideline requires administration of the Mini-Mental State Examination and either the Geriatric Depression Scale Short Form or Cornell Scale for Depression in Dementia, depending on level of cognitive functioning. The algorithm provided is designed to be used by nurses, physicians, and social workers for the purpose of depression screening in older adults with dementia. Detection of depression in individuals with dementia is hindered by a lack of a validated, brief screening tool. More research is needed on the use of such screenings among older adults with cognitive impairment.

Oral healthcare protocols in a nursing home.
Non UofA Access
K. Hollands and J. Burns.
Evid Based Dent 2015 Sep;16(3):93-94

Design Cluster-randomised controlled trial, in Belgian nursing homes.Intervention Supervised implementation of the ‘Oral health care Guideline for Older people in Long-term care Institutes’ (OGOLI) and the daily oral healthcare protocol derived from the guideline. This included appointing project supervisors and oral healthcare teams responsible for the implementation process, a three stage educational programme and oral healthcare records for each resident.Outcome measureThe primary outcome variables were the knowledge and attitudes of nurses and nurses’ aides towards oral health and oral hygiene. This was collected through a 15-item self-reported knowledge questionnaire and a four item attitude survey administered both at baseline and six months after the start of the study.Results Of the 651 participants who completed the initial survey 259 had complete data at six months. There were no significant differences between the control and intervention groups at baseline or follow up for baseline characteristics, knowledge or attitudes (p=0.42, p=0.37). At six months the intervention group showed higher knowledge scores (p<0.0001) but no difference in attitude scores (p=0.78).Conclusion sSignificant improvements in knowledge followed an educational programme where participants’ initial knowledge was low and no improvement in knowledge was found in the intervention group. Educational activities alone had no impact on attitudes and further research on how to improve attitudes is required.

Exploring access to care among older people in the last phase of life using the behavioural model of health services use: a qualitative study from the perspective of the next of kin of older persons who had died in a nursing home.
Non UofA Access
A. Condelius and M. Andersson.
BMC Geriatr 2015 Oct 26;15:138-015-0126-9

BACKGROUND: There is little investigation into what care older people access during the last phase of their life and what factors enable access to care in this group. Illuminating this from the perspective of the next of kin may provide valuable insights into how the health and social care system operates with reference to providing care for this vulnerable group. The behavioural model of health services use has a wide field of application but has not been tested conceptually regarding access to care from the perspective of the next of kin. The aim of this study was to explore the care accessed by older people during the last phase of their life from the perspective of the next of kin and to conceptually test the behavioural model of health services use. METHODS: The data collection took place in 2011 by means of qualitative interviews with 14 next of kin of older people who had died in a nursing home. The interviews were analysed using directed content analysis. The behavioural model of health services use was used in deriving the initial coding scheme, including the categories: utilization of health services, consumer satisfaction and characteristics of the population at risk. RESULTS: Utilization of health services in the last phase of life was described in five subcategories named after the type of care accessed i.e. admission to a nursing home, primary healthcare, hospital care, dental care and informal care. The needs were illuminated in the subcategories: general deterioration, medical conditions and acute illness and deterioration when death approaches. Factors that enabled access to care were described in three subcategories: the organisation of care, next of kin and the older person. These factors could also constitute barriers to accessing care. Next of kin’s satisfaction with care was illuminated in the subcategories: satisfaction, dissatisfaction and factors influencing satisfaction. One new category was constructed inductively: the situation of the next of kin. CONCLUSIONS: A bed in a nursing home was often accessed during what the next of kin regarded as the last phase of life. The needs among older people in the last phase of life can be regarded as complex and worsening over time. Most enabling factors lied within the organisation of care but the next of kin enabled access to care and contributed significantly to care quality. More research is needed regarding ageism and stigmatic attitudes among professionals and informal caregivers acting as a barrier to accessing care for older people in the last phase of their life. The behavioural model of health services use was extended with a new category showing that the situation of the next of kin must be taken into consideration when investigating access to care from their perspective. It may also be appropriate to include informal care as part of the concept of access when investigating access to care among older people in the last phase of their life. The results may not be transferable to older people who have not gained access to a bed in a nursing home or to countries where the healthcare system differs largely from the Swedish.

Effects of a cognitive stimulation program on psychological well-being in a sample of elderly long-term care hospital inpatients.
Non UofA Access
A. Castel, C. Lluch, J. Ribas, L. Borras and E. Molto.
Aging Ment Health 2015 Oct 23:1-7

OBJECTIVES: The primary objective of this work is to report the observed changes in psychological well-being in a sample of long-term medically hospitalized patients, after attending a cognitive stimulation program. The secondary aim is to determine if the observed changes were related to previous cognitive level. METHODS: Inclusion criteria for study participation were to be a long-term care hospital inpatient, to be 65 years old or older, and to be cognitively preserved or with mild cognitive impairment. A total of 176 participants were included and distributed in two groups: Cognitive Stimulation Group (N = 123) and Non-Cognitive Stimulation Group (N = 53). Measures were applied just before the beginning of the program and just when it finished, two months later. Participants of the Non-Cognitive Stimulation Group were re-assessed again after two months. RESULTS: No differences were found between the two groups in the measures assessed at baseline. After treatment, participants of the Cognitive Stimulation Group improved significantly more in psychological well-being (p < .001) than the ones of the Non-Cognitive Stimulation Group. When unimpaired and mild cognitively impaired participants of the Cognitive Stimulation Group were studied separately, both groups improved their psychological well-being, but the unimpaired experienced a greater effect. CONCLUSION: Cognitive stimulation plays a role in the improvement of psychological well-being of elderly medically hospitalized patients unimpaired or with mild cognitive impairment. The improvements in psychological well-being were related to the previous cognitive status and to the number of sessions that had been attended.

Use of physical restraints in nursing homes: a multicentre cross-sectional study.
Non UofA Access
H. Hofmann, E. Schorro, B. Haastert and G. Meyer.
BMC Geriatr 2015 Oct 21;15:129-015-0125-x

BACKGROUND: Although many countries have implemented strict legal rules, the prevalence of physical restraints in nursing homes seems to remain high. In Switzerland, data related to the frequency of physical restraints are scarce and little is known about associations with resident and nursing home characteristics. The aim of this study was to investigate the prevalence and types of physical restraints in nursing homes in two Swiss cantons and to explore whether resident-related and organisational factors are associated with the use of physical restraints. METHODS: We conducted a multicentre cross-sectional study. Twenty nursing homes with 1362 residents from two culturally different cantons were included. Data on physical restraints and residents’ characteristics were extracted from residents’ records (11/2013 to 2/2014). Organisational data were collected by questionnaires addressing nursing home directors or nursing managers. Sample size calculation and outcome analysis took cluster-adjustment into account. Descriptive statistics and multiple logistic regression analysis with nursing homes as random effect were used for investigation. RESULTS: The prevalence of residents with at least one physical restraint was 26.8 % (95 % confidence interval [CI] 19.8-33.8). Centre prevalence ranged from 2.6 to 61.2 %. Bilateral bedrails were most frequently used (20.3 %, 95 % CI 13.5-27.1). Length of residence, degrees of care dependency and mobility limitation were significantly positively associated with the use of physical restraint, but none of the organisational characteristics was significantly associated. CONCLUSION: Approximately a quarter of the nursing home residents included in our study experienced physical restraints. Since variation between nursing homes was pronounced, it seems to be worthwhile to explore nursing homes with particularly low and high use of physical restraints in future research, especially by using qualitative methods. There is a need for effective interventions aiming at restraint-free nursing care. Development of interventional approaches should consider specific residents’ characteristics associated with restraint use.

Interventions for preventing, delaying the onset, or decreasing the burden of frailty: An Overview of Systematic Reviews Canada-flat-icon
Non UofA Access
M. G. Wilson, F. Beland, D. Julien, et al.
Syst Rev 2015 Sep 25;4(1):128-015-0110-7

BACKGROUND: Many systematic reviews have evaluated the effectiveness of interventions to prevent, delay, or decrease frailty symptoms, but no effort has been made to identify, map, and synthesize the findings from reviews across the full spectrum of interventions. Our objectives are to (1) synthesize findings from all existing systematic reviews evaluating interventions for preventing, delaying the onset, or decreasing the burden of frailty symptoms; (2) examine different conceptualizations of frailty that have been used in the development and implementation of interventions; and (3) inform policy by convening a stakeholder dialogue with Canadian health-system leaders. METHODS/DESIGN: We will conduct an overview of systematic reviews to identify and synthesize all of the systematic reviews addressing interventions to preventing, delaying the onset, or decreasing the burden of frailty symptoms. To identify relevant systematic reviews, we will conduct database searches for published and grey literature as well as contact key experts and search reference lists of included reviews. Two reviewers will independently review all search results for inclusion and then conceptually map, extract key findings (including the conceptualization/definition of frailty used) and assess the methodological quality of all included reviews. We will then synthesize the findings by producing a ‘gap map’ (i.e. mapping reviews in a matrix according to the interventions and outcomes assessed), and narratively synthesize the key messages across reviews related to type of interventions. DISCUSSION: Following the completion of the synthesis, we will use the findings to develop an evidence brief that mobilizes the best available evidence about the problem related to preventing, delaying the onset, or decreasing the burden of frailty symptoms in older adults, policy and programmatic options to address the problem and implementation considerations. The evidence brief will then be used as the input into a stakeholder dialogue, which will engage 18-22 Canadian health-system leaders (including policymakers, health providers, researchers, and other stakeholders) in ‘off-the-record’ deliberations to inform future actions and policymaking. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015022082.

Choosing Healthcare Options by Involving Canada’s Elderly: a protocol for the CHOICE realist synthesis project on engaging older persons in healthcare decision-making. Canada-flat-icon
Non UofA Access
P. Stolee, J. Elliott, H. McNeil, et al.
BMJ Open 2015 Nov 3;5(11):e008190-2015-008190

INTRODUCTION: While patient and citizen engagement has been recognised as a crucial element in healthcare reform, limited attention has been paid to how best to engage seniors-the fastest growing segment of the population and the largest users of the healthcare system. To improve the healthcare services for this population, seniors and their families need to be engaged as active partners in healthcare decision-making, research and planning. This synthesis aims to understand the underlying context and mechanisms needed to achieve meaningful engagement of older adults in healthcare decision-making, research and planning. METHODS AND ANALYSIS: The CHOICE Knowledge Synthesis Project: Choosing Healthcare Options by Involving Canada’s Elderly aims to address this issue by synthesising current knowledge on patient, family, and caregiver engagement. A realist synthesis will support us to learn from other patient and citizen engagement initiatives, from previous research, and from seniors, families and caregivers themselves. The synthesis will guide development or adaptation of a framework, leading to the development of best practice guidelines and recommendations for engagement of older people and their families and caregivers in clinical decision-making, healthcare delivery, planning and research. ETHICS AND DISSEMINATION: The components of this protocol involving consultation with patients or caregivers have received ethics clearance from the University of Waterloo, Office of Research Ethics (ORE#19094). After completion of the project, we will amalgamate the information collected into a knowledge synthesis report which will include best practice guidelines and recommendations for patient, family and caregiver engagement in clinical and health system planning and research contexts. RESULTS: Will be further disseminated to citizens, clinicians, researchers and policymakers with the help of our partners. TRIAL REGISTRATION NUMBER: CRD42015024749.

The Burden of Health Care Costs for Patients With Dementia in the Last 5 Years of Life.
Non UofA Access
A. S. Kelley, K. McGarry, R. Gorges and J. S. Skinner.
Ann Intern Med 2015 Oct 27

Background: Common diseases, particularly dementia, have large social costs for the U.S. population. However, less is known about the end-of-life costs of specific diseases and the associated financial risk for individual households. Objective: To examine social costs and financial risks faced by Medicare beneficiaries 5 years before death. Design: Retrospective cohort. Setting: The HRS (Health and Retirement Study). Participants: Medicare fee-for-service beneficiaries, aged 70 years or older, who died between 2005 and 2010 (n = 1702), stratified into 4 groups: persons with a high probability of dementia or those who died because of heart disease, cancer, or other causes. Measurements: Total social costs and their components, including Medicare, Medicaid, private insurance, out-of-pocket spending, and informal care, measured over the last 5 years of life; and out-of-pocket spending as a proportion of household wealth. Results: Average total cost per decedent with dementia ($287 038) was significantly greater than that of those who died of heart disease ($175 136), cancer ($173 383), or other causes ($197 286) (P < 0.001). Although Medicare expenditures were similar across groups, average out-of-pocket spending for patients with dementia ($61 522) was 81% higher than that for patients without dementia ($34 068); a similar pattern held for informal care. Out-of-pocket spending for the dementia group (median, $36 919) represented 32% of wealth measured 5 years before death compared with 11% for the nondementia group (P < 0.001). This proportion was greater for black persons (84%), persons with less than a high school education (48%), and unmarried or widowed women (58%). Limitation: Imputed Medicaid, private insurance, and informal care costs. Conclusion: Health care expenditures among persons with dementia were substantially larger than those for other diseases, and many of the expenses were uncovered (uninsured). This places a large financial burden on families, and these burdens are particularly pronounced among the demographic groups that are least prepared for financial risk. Primary Funding Source: National Institute on Aging.

Family Satisfaction With Nursing Home Care: The Role of Facility Characteristics and Resident Quality-of-Life Scores.
Non UofA Access
T. P. Shippee, C. Henning-Smith, J. E. Gaugler, R. Held and R. L. Kane.
Res Aging 2015 Nov 3

This article explores the factor structure of a new family satisfaction with nursing home care instrument and determines the relationship of resident quality of life (QOL) and facility characteristics with family satisfaction. Data sources include (1) family satisfaction interviews (n = 16,790 family members), (2) multidimensional survey of resident QOL (n = 13,433 residents), and (3) facility characteristics (n = 376 facilities). We used factor analysis to identify domains of family satisfaction and multivariate analyses to identify the role of facility-level characteristics and resident QOL on facility-mean values of family satisfaction. Four distinct domains were identified for family satisfaction: “care,” “staff,” “environment,” and “food.” Chain affiliation, higher resident acuity, more deficiencies, and large size were all associated with less family satisfaction, and resident QOL was a significant (albeit weak) predictor of family satisfaction. Results suggest that family member satisfaction is distinct from resident QOL but is associated with resident QOL and facility characteristics.

Evaluating the systematic implementation of the ‘Let Me Decide’ advance care planning programme in long term care through focus groups: staff perspectives.
Non UofA Access
N. Cornally, C. McGlade, E. Weathers, et al.
BMC Palliat Care 2015 Nov 3;14(1):55-015-0051-x

BACKGROUND: The ‘Let Me Decide’ Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes. METHODS: Focus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis. RESULTS: Five key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff. DISCUSSION: A number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict. CONCLUSION: The introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment.

Living at the farm, innovative nursing home care for people with dementia – study protocol of an observational longitudinal study.
Non UofA Access
B. de Boer, J. P. Hamers, H. C. Beerens, S. M. Zwakhalen, F. E. Tan and H. Verbeek.
BMC Geriatr 2015 Nov 2;15:144-015-0141-x

BACKGROUND: In nursing home care, new care environments directed towards small-scale and homelike environments are developing. The green care farm, which provides 24-h nursing home care for people with dementia, is one such new care environment. Knowledge is needed on the relation between environmental features of green care farms such as nature, domesticity and offering care in small groups and the influence on the daily lives of residents. The aim of this study is to explore (1) the daily lives of residents, (2) the quality of care and (3) the experiences of caregivers on green care farms compared with other nursing home care environments. METHODS/DESIGN: An observational longitudinal study including a baseline and a six-month follow-up measurement is carried out. Four types of nursing home care environments are included: (1) large scale nursing home ward, (2) small scale living facility on the terrain of a larger nursing home (3) stand-alone small scale living facility and (4) green care farm. Quality of care is examined through structure, process and outcome indicators. The primary outcome measure is the daily life of residents, assessed by ecological momentary assessments. Aspects of daily life include (1) activity (activity performed by the resident, the engagement in this activity and the degree of physical effort); (2) physical environment (the location of the resident and the interaction with the physical environment); (3) social environment (the level and type of social interaction, and with whom this social interaction took place) and (4) psychological well-being (mood and agitation). In addition, social engagement, quality of life, behavioral symptoms and agitation are evaluated through questionnaires. Furthermore, demographics, cognitive impairment, functional dependence and the severity of dementia are assessed. Semi-structured interviews are performed with caregivers regarding their experiences with the different nursing home care environments. DISCUSSION: This is the first study investigating green care farms providing 24-h nursing home care for people with dementia. The study provides valuable insight into the daily lives of residents, the quality of care, and the experiences of caregivers at green care farms in comparison with other nursing home care environments including small-scale care environments and large scale nursing home wards.

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Non UofA

IHE & AIHS Health Policy Speaker Series: Makoto Suematsu
Monday 23 November 07:30-09:00 MT Westin, Edmonton AB $25 (includes breakfast)

Dr. Makoto Suematsu is the President of the Japan Agency for Medical Research and Development. His role as President is to fast track medical R&D in Japan to improve the quality of life for people. To this end, his challenge is to tackle obstacles in previous funding systems.


NCCHPP Webinar – Tackling Wicked Problems in Healthy Public Policy
Thursday 26 November 26 12:00-13:00 MT

The term ‘wicked problems’ is increasingly used to describe a particularly complex type of problem that is difficult, persistent, and resistant to solution. Frequently encountered in both public health and public policy, wicked problems present a high level of difficulty because, among other things, they are often intertwined with other complex problems. Health inequalities are a good example because they can be linked to a number of other issues such as income, education and/or race and ethnicity, to name a few. These types of problems are not easily solved with traditional approaches and require context-specific actions that take this complexity into account.

brainXchange webinar: Corticobasal Degeneration 101
Thursday 12 November 10:00-11:00 MT

The purpose of this integrated webinar event is to review the presentation and diagnosis of corticobasal degeneration, a rare cause of dementia.

Getting into the improvement habit
Health Foundation, Friday 27 November 06:00-07:00 MT

For the past three decades there has been an interest in improving the quality of products and services. More recently, we have seen this quality improvement taking root in health and social care, with increasing interest in improving quality as part of the professional role of all who work in health care services. This webinar comes at a time when the Academy of Medical Royal colleges are exploring the subject. Drawing on new thinking about the habits of effective improvers this webinar will explore how quality improvement could become more embedded and, critically, become a mainstream part of initial training and continuing professional development (CPD).

CFHI Webinar: Enhancing Data Quality for Improvement
Wednesday November 18 10:00-11:00 MT

Participants will learn about:
-Strategies for enhancing the use of available healthcare data sources for improvement, including knowing the context and purpose of your data and the key drivers behind improvement initiatives;
-How to evaluate, improve and achieve higher data quality that leads to better data-driven management decision-making and performance improvement; and
-Using data effectively, starting with measuring the right things the right way, performing necessary data preparation and processing and disseminating data to improvement stakeholders.

The Northern Cultural Assessment of Memory (N-CAM): A Protocol Designed to Detect Cognitive Change in Indigenous Peoples
brainXchange Pre-Recorded Session Available on Demand

Presentation Goals:
~To review the development of the N-CAM, including a summary of results from a Saskatoon inner city Indigenous community and clinical use with non English speaking patients at the Rural and Remote Memory Clinic, with reference to diagnostic criteria and behavioral indicators for cognitive impairment and dementia.
~To review the administration, scoring, and interpretation of the Caregiver Interview and Cognitive Screen components of the Northern-Cultural Assessment of Memory (N-CAM). Administration materials and scoring/interpretation guidelines can be made available to those interested in using the N-CAM in their communities.
~To include attendees in a discussion of the strengths and limitations of the N-CAM for culturally fair assessment of age-related cognitive functioning and the early detection of dementia.

Discussing dementia: building an inclusive society
Pre-Recorded Session Available on Demand

The “Building a Dementia Friendly Society” webinar, hosted by Bupa UK, held on Tuesday October 20th 2015, arrived at the following conclusions:
-While the focus in the UK is on building a dementia-friendly society, we need to start thinking about dementia-inclusive societies.
-Education will eradicate stigma and prejudices around dementia.
-Dementia informed workplaces are crucial as the number of people with working age dementia is increasing.
-Concerns for carers of people living with dementia are primarily anxiety, agitation and sleeplessness (not memory loss per se).
-Assistive technology can help, but ethical issues exist.

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‘Real-World’ Evaluation: Ten Key Principles for Evaluating Complex Health and Social Interventions
8th AND 15th January School of Health and Related Research (ScHARR), University of Sheffield £450

The course is primarily focused on evaluations in complex ‘real-world’ situations, in which the evaluator has limited control over the intervention or context, and traditional experimental methods are inappropriate.

Systematic Review & Meta-Analysis Course – Jan. – April, 2016
Knowledge Translation Program, Li Ka Shing Knowledge Institute Toronto

St. Michael’s Hospital, in collaboration with the University of Toronto, is pleased to offer this online course in Systematic Reviews and Meta-Analyses.

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New Alberta Health Services Board features strong health care expertise Canada-flat-icon

Minister of Health Sarah Hoffman has created a new board to govern Alberta Health Services and further stabilize Alberta’s health-care system.

Why is healthcare innovation taking so long?

Think about it: You can access more information on your phone today than existed in every library combined 10 years ago. But if you want access to your medical record, you still might have to wait a week for your doctor to fax it to you.

No Spouse, No Kids, No Caregiver: How to Prepare to Age Alone

A growing population of ‘elder orphans’ lack a built-in support system. What to do if you become one.

Long-Term Care film captures common experience Canada-flat-icon

Leaving a parent on the first night after moving them into a long-term care home is a difficult moment that many in this province have experienced. It’s a moment that filmmaker Lisa Vatcher wanted to capture accurately in the new short film “Long Term Care.”

Caregiving stress likely to rise in Alberta, survey finds Canada-flat-icon

An aging population is set to bring big changes to the lives of Albertans, many of whom are destined to become unpaid caregivers to their loved ones, newly published survey results show.

Withdrawing dementia drug doubles risk of nursing home placement

Withdrawing a commonly-prescribed Alzheimer’s disease drug from people in the advanced stages of the disease doubles their risk of being placed in a nursing home within a year, according to research published in The Lancet Neurology.

Using mobile apps to improve clinical practice

We recently spoke with Dr. Tadahiro Takada, founding President of the Japanese Society of Hepato-Biliary-Pancreatic Surgery, to get his insights on the use of mobile apps to facilitate clinicians’ decision making and improve clinical practice.

So you’ve been rejected, now what? On appeals in peer-reviewed publications

Getting rejected stinks. Wouldn’t it be great if we could appeal people’s decisions in life? Imagine asking someone on a date and getting rejected. What if you could submit an appeal letter explaining your argument with data to back it up? If only. Well, in science, you can.

Reducing the use of antipsychotics in long-term care: 1 facility’s journey Canada-flat-icon

In 2013–2014, about 1 in 3 (30%) residents in an LTC facility was potentially prescribed antipsychotics inappropriately, according to CIHI data available in the Your Health System: In Depth web tool. After looking at this data, the Canadian Foundation for Healthcare Improvement (CFHI), a not-for-profit organization dedicated to accelerating health care improvement in Canada, decided to take action.

The Editor Made Me Sound Inane

What to do when you loathe the changes made to your manuscript.

Visual reasoning through information design

The visual communication of complex or less known topics (e.g. science, medicine, mathematics) in simpler and clearer ways appeals to users and readers’ visual reasoning.

Healthcare support workers to be given ‘mandatory career frameworks’ to strengthen their on-the-job development (UK)

Healthcare support workers in Wales are set to be given a “mandatory career framework” in a bid to strengthen training standards and improve levels of patient care.

Long-term care and dementia spaces get green light in Alberta Canada-flat-icon

Twenty-five new supportive living projects will deliver needed long-term care and dementia care spaces across Alberta.

End-of-life care vastly more expensive for dementia patients than for others (US)

Care in the last five years of life costs much more for patients with dementia than for those who die of heart disease, cancer, or other causes, a new study shows.

It’s not a vote: How editors use peer reviews

How editors handle differing peer reviews.

Government to launch ratings system to help improve dementia health care (UK)

The new ratings will be broken down by Clinical Commissioning Groups (CCG) and will be based on local data as well as being verified by experts in each field. The measures will mean that for the first time patients in England will be able to see how their local health service is performing with the aim to drive improvements.

Empowering the elderly in Japan: lessons for home care in Canada Canada-flat-icon

It’s a question that’s been weighing on the minds of health care managers in Canada and many countries around the world: how will society meet the home and community care needs of an aging population?

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Pills: Reviewing medication in care homes (film)
Health Foundation

This film tells the story of how the wellbeing of older care home residents is enhanced by making sure they are only prescribed the medicine they really need, and the positive impact this has had on the people who work on the project too.

Writing for Professional Journals
University of Utah College of Nursing

The “Writing for Professional Journals” course can be used by an individual learner or can be adapted in any way for a course in a college’s program of study. The course also may be helpful to practicing nurses in a professional development program. The course content includes twelve modules. Each module has accompanying video instruction, PowerPoint slides, reflection assignments, activity log workbook assignments, and suggested reading lists.

Think Check Submit

Sharing research results with the world is key to the progress of your discipline and career. But with so many publications, how can you be sure you can trust a particular journal? Follow this check list to make sure you choose trusted journals for your research.

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