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New TREC article
Impact of Symptoms and Care Practices on Nursing Home Residents at the End of Life: A Rating by Front-line Care Providers
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OBJECTIVES: Burdensome symptoms and potentially inappropriate care practices are common at the end of life for nursing home residents. Appropriately managing symptoms and limiting aggressive care practices is key to high-quality end-of-life care. Little research is available, however, on the opinions of nursing home care providers about the impact of symptoms and practices for both residents and care facilities. Our objectives were to (1) identify common burdensome symptoms and potentially inappropriate practices at the end of life for nursing home residents, (2) develop and assess the feasibility of a procedure to have various groups of nursing home care providers rate impact of symptoms and practices, and (3) generate recommendations for action and further research, with key policy and decision makers. DESIGN: Proof-of-concept study. Partnered research by researchers, health professionals, and decision makers to identify and explore the impact of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. SETTING: Thirty-six nursing homes from Alberta, Manitoba, and Saskatchewan. PARTICIPANTS: A total of 6007 residents (prevalence rating); 4 medical directors, 5 directors of care, 4 nurse practitioners, 4 registered nurses, 5 licensed practical nurses, 5 care aides (impact rating); and 13 key policy or decision makers from Alberta, British Columbia, and Manitoba (expert panel). METHODS: Based on a literature search and data in the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0, we generated lists of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. We rated prevalence of those symptoms and practices in the last quarter before death as high, medium, or low. Care providers rated the burden of symptoms and inappropriateness of practices as high, medium, or low. Directors of care rated the unnecessary cost of those symptoms and practices to a nursing home as high, medium, or low. We ranked symptoms and practices based on those ratings. We discussed our findings in an interactive expert panel and generated recommendations for action and further research. MEASUREMENTS: RAI-MDS 2.0 (symptom prevalence rating); online survey to rate symptoms and practices (impact rating). RESULTS: The 3 most prevalent symptoms were urinary incontinence (79.7%), fecal incontinence (66.7%), and responsive behaviors (63%). The 3 most prevalent practices were polypharmacy (9+ medications; 55.2%), antipsychotic use with no diagnosis of psychosis (29.2%), and physical restraint use (18.7%). The symptoms rated as having highest overall impact were pain, responsive behaviors, and urinary incontinence. Practices rated as having the most impact were polypharmacy, hospital and emergency department transitions, and antipsychotic use with no diagnosis of psychosis. CONCLUSION: Burdensome symptoms and inappropriate care practices near the end of life for residents in nursing homes are highly prevalent. Attending to those symptoms and practices is necessary to improve the quality of dying for nursing home residents. Our study provides preliminary demonstration of the feasibility and importance of engaging the spectrum of care providers in assessing the impact of symptoms and care practices on resident experience. Experiences of this proof-of-concept study will be the basis for the development of an indicator profile to monitor and improve quality of end-of-life care in nursing homes in the future.
Advice Seeking Networks Winter Newsletter
Learn more about TREC’s Advice Seeking Network project.
New article by Dr. Kim Fraser
Seniors managing multiple medications: using mixed methods to view the home care safety lens.
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BACKGROUND: Patient safety is a national and international priority with medication safety earmarked as both a prevalent and high-risk area of concern. To date, medication safety research has focused overwhelmingly on institutional based care provided by paid healthcare professionals, which often has little applicability to the home care setting. This critical gap in our current understanding of medication safety in the home care sector is particularly evident with the elderly who often manage more than one chronic illness and a complex palette of medications, along with other care needs. This study addresses the medication management issues faced by seniors with chronic illnesses, their family, caregivers, and paid providers within Canadian publicly funded home care programs in Alberta (AB), Ontario (ON), Quebec (QC) and Nova Scotia (NS). METHODS: Informed by a socio-ecological perspective, this study utilized Interpretive Description (ID) methodology and participatory photographic methods to capture and analyze a range of visual and textual data. Three successive phases of data collection and analysis were conducted in a concurrent, iterative fashion in eight urban and/or rural households in each province. A total of 94 participants (i.e., seniors receiving home care services, their family/caregivers, and paid providers) were interviewed individually. In addition, 69 providers took part in focus groups. Analysis was iterative and concurrent with data collection in that each interview was compared with subsequent interviews for converging as well as diverging patterns. RESULTS: Six patterns were identified that provide a rich portrayal of the complexity of medication management safety in home care: vulnerabilities that impact the safe management and storage of medication, sustaining adequate supports, degrees of shared accountability for care, systems of variable effectiveness, poly-literacy required to navigate the system, and systemic challenges to maintaining medication safety in the home. CONCLUSIONS: There is a need for policy makers, health system leaders, care providers, researchers, and educators to work with home care clients and caregivers on three key messages for improvement: adapt care delivery models to the home care landscape; develop a palette of user-centered tools to support medication safety in the home; and strengthen health systems integration.
New publication by Dr. Jo Rycroft Malone & Dr. Gil Harvey
Collective action for knowledge mobilisation: a realist evaluation of the Collaborations for Leadership in Applied Health Research and Care.
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The establishment of the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) was the culmination of a number of policy initiatives to bridge the gap between evidence and practice. CLAHRCs were created and funded to facilitate development of partnerships and connect the worlds of academia and practice in an effort to improve patient outcomes through the conduct and application of applied health research. Our starting point was to test the theory that bringing higher education institutions and health-care organisations closer together catalyses knowledge mobilisation. The overall purpose was to develop explanatory theory regarding implementation through CLAHRCs and answer the question ‘what works, for whom, why and in what circumstances?’. The study objectives focused on identifying and tracking implementation mechanisms and processes over time; determining what influences whether or not and how research is used in CLAHRCs; investigating the role played by boundary objects in the success or failure of implementation; and determining whether or not and how CLAHRCs develop and sustain interactions and communities of practice. This study was a longitudinal realist evaluation using multiple qualitative case studies, incorporating stakeholder engagement and formative feedback. Three CLAHRCs were studied in depth over four rounds of data collection through a process of hypothesis generation, refining, testing and programme theory specification. Data collection included interviews, observation, documents, feedback sessions and an interpretive forum. Knowledge mobilisation in CLAHRCs was a function of a number of interconnected issues that provided more or less conducive conditions for collective action. The potential of CLAHRCs to close the metaphorical ‘know-do’ gap was dependent on historical regional relationships, their approach to engaging different communities, their architectures, what priorities were set and how, and providing additional resources for implementation, including investment in roles and activities to bridge and broker boundaries. Additionally, we observed a balance towards conducting research rather than implementing it. Key mechanisms of interpretations of collaborative action, opportunities for connectivity, facilitation, motivation, review and reflection, and unlocking barriers/releasing potential were important to the processes and outcomes of CLAHRCs. These mechanisms operated in different contexts including stakeholders’ positioning, or ‘where they were coming from’, governance arrangements, availability of resources, competing drivers, receptiveness to learning and evaluation, and alignment of structures, positions and resources. Preceding conditions influenced the course and journey of the CLAHRCs in a path-dependent way. We observed them evolving over time and their development led to the accumulation of different types of impacts, from those that were conceptual to, later in their life cycle, those that were more direct. Most studies of implementation focus on researching one-off projects, so a strength of this study was in researching a systems approach to knowledge mobilisation over time. Although CLAHRC-like approaches show promise, realising their full potential will require a longer and more sustained focus on relationship building, resource allocation and, in some cases, culture change. This reinforces the point that research implementation within a CLAHRC model is a long-term investment and one that is set within a life cycle of organisational collaboration. The National Institute for Health Research Health Services and Delivery Research programme.
Latest TREC Newsletter is out
Read all about what the TREC team have accomplished and been up to.
Why Canada needs a national dementia strategy
Dr. Carole Estabrooks and Dr. Howard Feldman make a convincing argument about our need for a dementia strategy. This editorial was published in the Calgary Herald and appeared in newspapers across Canada.
Call for Abstracts
CALL FOR CONTENT:
Systems and Sustainability – Creating enduring Knowledge Mobilization
The Canadian Knowledge Mobilization Forum was created in 2012 as a professional development forum for practitioners, researchers, students and professionals working in knowledge mobilization across fields and sectors. The 2016 Canadian Knowledge Mobilization Forum is seeking contributions for content, which addresses the overall theme of Systems and Sustainability, and links to the subthemes of:
-Structures – What (for example: KMb across sectors; funding KMb; role of brokers)
-Processes – How (for example: KMb tool boxes; networks; communities of practice)
-Technology – Technology and Tools (for example: KMb and social media; yaffle; web 3.0)
CALL FOR ABSTRACTS:
Alzheimer’s Association International Conference (AAIC)
Each year, the world’s foremost researchers, clinicians and practitioners gather at AAIC to share the latest findings in Alzheimer’s and dementia research and practice. Submit your abstract or proposal today for the opportunity to present during the world’s leading dementia conference.
CALL FOR ABSTRACTS:
IFA’s 13th Global Conference on Ageing
The 13th IFA Conference will be the first to explore the implications for older people in natural and human-induced disasters and health emergencies, while at the same time covering the areas of interest for those across all disciplines in the ageing sectors through five (5) thematic tracks:
-Disasters and Older People
-Age Friendly Cities/Communities
-Care and Support for Older People (Community and Residential)
-Elder Abuse, Law and Rights
-Income Protection and Security
CALL FOR ABSTRACTS:
2016 Australasian Implementation Conference
Are you keen to learn more about the emerging developments in implementation science and practice, and to improve outcomes for both individuals and society? The Australasian Implementation Conference 2016 (AIC 2016), hosted by the Centre for Evidence and Implementation (Save the Children Australia) and The University of Melbourne, provides a unique and important opportunity for those in the fields of health, education, social care, and international development to discuss latest advances in implementation science and practice.
The call for abstracts is now open. Presentations will focus on six themes:
-Implementation concepts and theories
-Implementation strategies
-Scaling up service and system-wide innovation
-Measurements and tools
-Implementation and the policy process
-Implementation in international development
CALL FOR ABSTRACTS:
European Nursing Congress: Caring for Older People
Congress Board and Programme Committee cordially invite you to submit your abstracts for poster, oral presentation or symposium on any of the 14 congress themes. The organizers welcome scientific and research-based abstracts as well as abstracts on practice-based innovations.
CALL FOR ABSTRACTS:
KT Canada Annual Scientific Meeting 2016
The theme is be “Scaling up and Sustainability”.
Grants & Awards
CIHR-IA will provide travel support to eligible participants to SPA to travel to the 2016 Summer Program in Aging. All other costs with the exception of the $500 registration fee will be covered by the SPA 2016 host, Queens University.
CIHR Team Grant: Big Data on Dementia
The CIHR Dementia Research Strategy (the Strategy) is a CIHR signature initiative which aims to support research on the latest preventive, diagnostic and treatment approaches to Alzheimer’s disease and related dementia. This funding opportunity aims to support a single pan-Canadian team to generate, optimize, use, share and connect data that has been collected, and that will be generated at both the national and international level. This funding opportunity will thus allow Canadian researchers to play a role both nationally and internationally in broad (e.g., naturalistic course of aging and dementia) and deep (e.g., neuroimaging of early phases of diseases causing dementia) Big Data. It also constitutes an opportunity to leverage Canadian and international investments and thus provide Canadian researchers with access to these new Big Data resources and fast track their international efforts to find a cure for dementia by 2025.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology
Aging
KT
A survey of knowledge-to-action pathways of aging policies and programs in the Arab region: the role of institutional arrangements.
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BACKGROUND: While population aging challenges Arab governments to ensure well-being in old age, knowledge translation is gaining support worldwide in evidence-based policymaking and service provision. This study examines the status of existing knowledge translation efforts of aging-related research in Arab countries and evaluates the additional role that institutional arrangements (such as ministry departments, national committees, etc.) play in the relationship between knowledge creation and social and health policies and programs. METHODS: Data were triangulated from two regional surveys and a supplementary desk review of academic, civil society, ministry, and UN documents. Using a set of indicators, standardized summative indices (out of 100) were generated for five constructs, namely knowledge creation, institutional arrangements, knowledge translation, and health and social policies and programs. Correlations were assessed using Spearman’s rank correlation (r s), and bootstrap multiple linear regression models were used. RESULTS: Arab countries scored highest on the institutional arrangements index (median = 69.5), followed by the knowledge creation index (median = 45.9), and lowest on the knowledge translation index (median = 30.2). Both institutional arrangements and knowledge creation significantly correlated with social and health policies and programs. However, when adjusted for knowledge translation, only institutional arrangements retained a significant association with both outcomes (r s = 0.63, p value =0.009 and r s = 0.69, p value =0.01, respectively). Adjusting for institutional arrangements and knowledge creation, the association of knowledge translation with social and health policies and programs was attenuated and non-significant (r s = 0.08, p value =0.671 and r s = 0.12, p value =0.634, respectively). CONCLUSIONS: There are two key messages from this study. Firstly, institutional arrangements play a central role in aging social and health policy and program development in the Arab region. Secondly, knowledge translation paradigms in Arab countries may be deficient in factors pertinent for promoting evidence-based decision-making and policy-relevant research. These findings call for the need of strengthening institutional arrangements on aging and for promoting knowledge production that meets policy-relevant priorities.
Transformative research as knowledge mobilization: Transmedia, bridges, and layers
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Mainstream knowledge production and communication in the academy generally reflect the tenets of positivist research and predominantly embody hierarchical processes of knowledge transfer. In contrast, a transformative research paradigm is rooted in knowledge mobilization processes involving close collaboration between researchers and community actors as co-enquirers as a part of a broader agenda for progressive social change. They also involve strategic communication strategies that mobilize knowledge beyond those directly involved in the research process. We illustrate the cyclical pattern and transgressive potential of knowledge mobilization processes through a reflective case study of a participatory action research program in the Canadian Prairies. Based on this work, we present three key knowledge mobilization strategies. These include: using transmedia to exchange knowledge across a range of communication media; building bridges to invite communication amongst diverse knowledge communities; and layering to communicate knowledge at varying levels of detail. We critically examine our own practice as a contested and partial process in tension with the institutional and cultural durability of the more linear knowledge transfer paradigm. Knowledge mobilization strategies provide a framework to implement research methods, communication processes, and outcomes that are high in impact and relevant in struggles for a more just and resilient society.
Swiss family physicians’ perceptions and attitudes towards knowledge translation practices.
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BACKGROUND: Several studies have been performed to understand the way family physicians apply knowledge from medical research in practice. However, very little is known concerning family physicians in Switzerland. In an environment in which information constantly accumulates, it is crucial to identify the major sources of scientific information that are used by family physicians to keep their medical knowledge up to date and barriers to use these sources. Our main objective was to examine medical knowledge translation (KT) practices of Swiss family physicians. METHODS: The population consisted of French- and German-speaking private practice physicians specialised in family medicine. We conducted four interviews and three focus groups (n = 25). The interview guides of the semi-structured interviews and focus groups focused on (a) ways and means used by physicians to keep updated with information relevant to clinical practice; (b) how they consider their role in translating knowledge into practice; (c) potential barriers to KT; (d) solutions proposed by physicians for effective KT. RESULTS: Family physicians find themselves rather ambivalent about the translation of knowledge based on scientific literature, but generally express much interest in KT. They often feel overwhelmed by “information floods” and perceive clinical practice guidelines and other supports to be of limited usefulness for their practice. They often combine various formal and informal information sources to keep their knowledge up to date. Swiss family physicians report considering themselves as artisans, caring for patients with complex needs. CONCLUSION: Improved performance of KT initiatives in family medicine should be tailored to actual needs and based on high quality evidence-based sources.
A process evaluation accompanying an attempted randomized controlled trial of an evidence service for health system policymakers. 
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BACKGROUND: We developed an evidence service that draws inputs from Health Systems Evidence (HSE), which is a comprehensive database of research evidence about governance, financial and delivery arrangements within health systems and about implementation strategies relevant to health systems. Our goal was to evaluate whether, how and why a ‘full-serve’ evidence service increases the use of synthesized research evidence by policy analysts and advisors in the Ontario Ministry of Health and Long-Term Care as compared to a ‘self-serve’ evidence service. METHODS: We attempted to conduct a two-arm, 10-month randomized controlled trial (RCT), along with a follow-up qualitative process evaluation, but we terminated the RCT when we failed to reach our recruitment target. For the qualitative process evaluation we modified the original interview guide to allow us to explore the (1) factors influencing participation in the trial; (2) usage of HSE, factors explaining usage patterns, and strategies to increase usage; (3) participation in training workshops and use of other supports; and (4) views about and experiences with key HSE features. RESULTS: We terminated the RCT given our 15% recruitment rate. Six factors were identified by those who had agreed to participate in the trial as encouraging their participation: relevance of the study to participants’ own work; familiarity with the researchers; personal view of the importance of using research evidence in policymaking; academic background; support from supervisors; and participation of colleagues. Most reported that they never, infrequently or inconsistently used HSE and suggested strategies to increase its use, including regular email reminders and employee training. However, only two participants indicated that employee training, in the form of a workshop about finding and using research evidence, had influenced their use of HSE. Most participants found HSE features to be intuitive and helpful, although registration/sign-in and some page formats (particularly the advanced search page and detailed search results page) discouraged their use or did not optimize the user experience. CONCLUSIONS: The qualitative findings informed a re-design of HSE, which allows users to more efficiently find and use research evidence about how to strengthen or reform health systems or in how to get cost-effective programs, services and drugs to those who need them. Our experience with RCT recruitment suggests the need to consider changing the unit of allocation to divisions instead of individuals within divisions, among other lessons. TRIAL REGISTRATION: This protocol for this study is published in Implementation Science and registered with ClinicalTrials.gov ( HHS/FHS REB 10-267 ).
Engaging the Community in the Dissemination, Implementation, and Improvement of Health-Related Research.
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To help maximize the real-world applicability of available interventions in clinical and community healthcare practice, there has been greater emphasis over the past two decades on engaging local communities in health-related research. While there have been numerous successful community-academic partnered collaborations, there continues to be a need to articulate the common barriers experienced during the evolution of these partnerships, and to provide a roadmap for best practices that engage healthcare providers, patients, families, caregivers, community leaders, healthcare systems, public agencies and academic medical centers. To this end, this paper presents a summary of a forum discussion from the 2014 Southern California Dissemination, Implementation and Improvement (DII) Science Symposium, sponsored by the University of California Los Angeles (UCLA) Clinical Translational Science Institute (CTSI), University of Southern California (USC) CTSI, and Kaiser Permanente. During this forum, a diverse group of individuals representing multiple constituencies identified four key barriers to success in community-partnered participatory research (CPPR) and discussed consensus recommendations to enhance the development, implementation, and dissemination of community health-related research. In addition, this group identified several ways in which the over 60 NIH funded Clinical and Translational Science Institutes across the country could engage communities and researchers to advance DII science.
Knowledge Sharing in Health Innovation Projects: Experiential Learning from Collaborating in a Project-Based Working Group Focusing in Knowledge Transfer in Maternity Services Best Practice (COST Projects IS 0907)
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Project work in today’s organisations primarily takes place through the engagement of knowledge-based communities of practice as well as the use of embedded communication technologies, such as web-based social media. This has been highlighted as one of the ways in which health innovation research knowledge can be managed and transferred (Towards knowledge management based on harnessing collective intelligence on the web, Berlin, 350–357, 2006; Collective intelligence in healthcare, http://www.oakleigh.co.uk/page/1428/White-Papers/Whitepaper-Articles/Collective-Intelligence-in-Healthcare, 2013). Organisations are witnessing a re-shaping of their processes in terms of diminished face-to-face interactions. This chapter reviews ways in which the use of communication technologies, social media and virtual teams assist project-based work in the transfer of health innovation knowledge. The focus is on experiential learning from collaboration from the European COST Project IS 0907.
A Systematic Review of Knowledge Translation (KT) in Pediatric Pain: Focus on Health Care Providers.
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OBJECTIVE: Pain is inadequately managed in pediatric populations across health care settings. Although training programs to improve health care provider knowledge and skills have been developed and evaluated, clinical practices have not always kept pace with advancing knowledge. Consequently, the goal of this review was to systematically examine the pediatric pain literature of knowledge translation (KT) programs targeting health care providers. METHODS: Systematic searches of PubMed, Web of Science, CINAHL, and PsycINFO were undertaken. KT initiatives directed towards health care providers and in which the primary focus was on pediatric pain were included. Primary outcomes, intervention characteristics, and risk of bias were examined across studies. Study outcomes were conceptually organized and a narrative synthesis of results was conducted. RESULTS: A total of 15,191 were screened for inclusion with 98 articles retained based on pre-determined criteria. Across studies, KT approaches varied widely in format and focus. Knowledge level changes and self-reported increases in comfort or confidence in skills/knowledge were consistently achieved. Practice-level changes were achieved in many areas with varying success. Design and reporting issues were identified in the majority of studies. Examination of patient-related outcomes and of the long-term impact of pediatric pain KT programs was limited across studies. DISCUSSION: KT programs vary in quality and impact. Although several successful programs have been developed, many studies include a high risk of bias due to study quality. Evidence-based KT program implementation and a focus on sustainability of outcomes must be given greater consideration in the field of pediatric pain.
Research on knowledge mobilization in policy making has been largely focused on identifying relevant factors having an effect on the uptake of evidence by actors and organizations. However, evidence on the magnitude of those effects remains limited and existing methods allowing for this have been scarcely used in this field. In this article, we first provide a rationale for greater investigation of substantive effect sizes, using methods such as mediation analysis and conditional probabilities. Using cross-sectional data from Québec (Canada) government policy analysts, we test an absorptive capacity model and describe direct, specific indirect, and total effects estimated from a path analysis. The results show that some factors have considerable effects, such as physical access and individual field of training, whereas some mediated relations are worth considering. Finally, we discuss some practical implications with regard to policy making and policy analysis but also the methodological standards of empirical research in this field.
Elaborating on theory with middle managers’ experience implementing healthcare innovations in practice.
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BACKGROUND: The theory of middle managers’ role in implementing healthcare innovations hypothesized that middle managers influence implementation effectiveness by fulfilling the following four roles: diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. The theory also suggested several activities in which middle managers might engage to fulfill the four roles. The extent to which the theory aligns with middle managers’ experience in practice is unclear. We surveyed middle managers (n = 63) who attended a nursing innovation summit to (1) assess alignment between the theory and middle managers’ experience in practice and (2) elaborate on the theory with examples from middle managers’ experience overseeing innovation implementation in practice. FINDINGS: Middle managers rated all of the theory’s hypothesized four roles as “extremely important” but ranked diffusing and synthesizing information as the most important and selling innovation implementation as the least important. They reported engaging in several activities that were consistent with the theory’s hypothesized roles and activities such as diffusing information via meetings and training. They also reported engaging in activities not described in the theory such as appraising employee performance. CONCLUSIONS: Middle managers’ experience aligned well with the theory and expanded definitions of the roles and activities that it hypothesized. Future studies should assess the relationship between hypothesized roles and the effectiveness with which innovations are implemented in practice. If evidence supports the theory, the theory should be leveraged to promote the fulfillment of hypothesized roles among middle managers, doing so may promote innovation implementation.
Knowledge Sharing and Public Policy Series – Method and Preliminary Results of a Literature Review
This document maps the knowledge-sharing contexts studied in the 105 documents selected for our literature review on knowledge sharing targeting public policies. The companion interactive table makes it possible to sort these documents by type of context studied. What can we learn from published research about experiences of knowledge sharing targeting public policies? We have conducted a review of the literature on this subject in order to draw lessons that may be useful to public health actors. This document presents the method that we used and maps the knowledge-sharing contexts studied in the 105 documents selected for this literature review: country/ies studied, type of political and/or public health actors interviewed, type of government and type of public policy targeted for knowledge sharing.
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Health Care Administration and Organization
A Review Exploring the Relationship Between Nursing Home Staffing and Antipsychotic Medication Use.
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Staffing level requirements for nursing homes exist at state and federal levels in the United States. While quality of care measures may include antipsychotic (AP) prescribing, the appropriate use of APs as chemical restraints in nursing homes continues to be debated. Although the two variables appear to be related, improved research methods and availability of accurate staffing data will be needed to understand causal relationships regarding AP use for facility dwelling patients.
Recommendations From the International Consortium on Professional Nursing Practice in Long-Term Care Homes.
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In response to the International Association of Gerontology and Geriatrics’ global agenda for clinical research and quality of care in long-term care homes (LTCHs), the International Consortium on Professional Nursing Practice in Long Term Care Homes (the Consortium) was formed to develop nursing leadership capacity and address the concerns regarding the current state of professional nursing practice in LTCHs. At its invitational, 2-day inaugural meeting, the Consortium brought together international nurse experts to explore the potential of registered nurses (RNs) who work as supervisors or charge nurses within the LTCHs and the value of their contribution in nursing homes, consider what RN competencies might be needed, discuss effective educational (curriculum and practice) experiences, health care policy, and human resources planning requirements, and to identify what sustainable nurse leadership strategies and models might enhance the effectiveness of RNs in improving resident, family, and staff outcomes. The Consortium made recommendations about the following priority issues for action: (1) define the competencies of RNs required to care for older adults in LTCHs; (2) create an LTCH environment in which the RN role is differentiated from other team members and RNs can practice to their full scope; and (3) prepare RN leaders to operate effectively in person-centered care LTCH environments. In addition to clear recommendations for practice, the Consortium identified several areas in which further research is needed. The Consortium advocated for a research agenda that emphasizes an international coordination of research efforts to explore similar issues, the pursuit of examining the impact of nursing and organizational models, and the showcasing of excellence in nursing practice in care homes, so that others might learn from what works. Several studies already under way are also described.
Factors influencing nursing time spent on administration of medication in an Australian residential aged care home.
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AIMS: To examine nursing time spent on administration of medications in a residential aged care (RAC) home, and to determine factors that influence the time to medicate a resident. BACKGROUND: Information on nursing time spent on medication administration is useful for planning and implementation of nursing resources. METHODS: Nurses were observed over 12 morning medication rounds using a time-motion observational method and field notes, at two high-care units in an Australian RAC home. RESULTS: Nurses spent between 2.5 and 4.5 hours in a medication round. Administration of medication averaged 200 seconds per resident. Four factors had significant impact on medication time: number of types of medication, number of tablets taken by a resident, methods used by a nurse to prepare tablets and methods to provide tablets. CONCLUSION: Administration of medication consumed a substantial, though variable amount of time in the RAC home. Nursing managers need to consider the factors that influenced the nursing time required for the administration of medication in their estimation of nursing workload and required resources. IMPLICATIONS FOR NURSING MANAGEMENT: To ensure safe medication administration for older people, managers should regularly assess the changes in the factors influencing nursing time on the administration of medication when estimating nursing workload and required resources.
A mixed methods study of the work patterns of full-time nurse practitioners in nursing homes.
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AIMS AND OBJECTIVES: The aim of this study was to explore the integration of the nurse practitioner role in Canadian nursing homes to enable its full potential to be realised for resident and family care. The objective was to determine nurse practitioners’ patterns of work activities. BACKGROUND: Nurse practitioners were introduced in Canadian nursing homes a decade ago on a pilot basis. In recent years, government and nursing home sector interest in the role has grown along with the need for data to inform planning efforts. DESIGN: The study used a sequential mixed methods design using a national survey followed by case studies. METHODS: A national survey of nurse practitioners included demographic items and the EverCare Nurse Practitioner Role and Activity Scale. Following the survey, case studies were conducted in four nursing homes. Data were collected using individual and focus group interviews, document reviews and field notes. RESULTS: Twenty-three of a target population of 26 nurse practitioners responded to the survey, two-thirds of whom provided services in nursing homes with one site and the remainder in nursing homes with as many as four sites. On average, nurse practitioners performed activities in communicator, clinician, care manager/coordinator and coach/educator subscales at least three to four times per week and activities in the collaborator subscale once a week. Of the 43 activities, nurse practitioners performed daily, most were in the clinician and communicator subscales. Case study interviews involved 150 participants. Findings complemented those of the survey and identified additional leadership activities. CONCLUSION: Nurse practitioners undertake a range of primary health care and advanced practice activities which they adapt to meet the unique needs of nursing homes. RELEVANCE TO CLINICAL PRACTICE: Knowledge of work patterns enables nursing homes to implement the full range of nurse practitioner roles and activities to enhance resident and family care.
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Health Care Innovation and Quality Assurance
Reduction in the use of potentially inappropriate drugs among old people living in geriatric care units between 2007 and 2013.
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PURPOSE: The aims of this study were to investigate trends in the prevalence of potentially inappropriate drug use among old people living in geriatric care units in the county of Vasterbotten between 2007 and 2013 using six national quality indicators and to assess the impact of medication reviews on those quality indicators. METHODS: Data were collected concerning potentially inappropriate drug use, function in the activities of daily living (ADL) and cognitive function, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). A comparison was made between the years 2007 and 2013, comprising 2772 and 1902 people, respectively, living in geriatric care in the county of Vasterbotten, Sweden. We conducted a parallel investigation of a separate corresponding population in Vasterbotten County from 2012, where potentially inappropriate drug use was measured before and after 895 medication reviews which involved a clinical pharmacist. RESULTS: After controlling for age, sex, ADL and cognitive impairment, there was a significant improvement in five out of six quality indicators between 2007 and 2013. While 44% of the people were exposed to one or more potentially inappropriate medications in 2007, this number had declined to 26% by 2013. In the separate population from 2012, the frequency of potentially inappropriate drug use was significantly reduced amongst the people who had a medication review performed. CONCLUSION: The extent of potentially inappropriate drug use declined between 2007 and 2013 according to the quality indicators used. Medication reviews involving clinical pharmacists might be an important factor in reducing potentially inappropriate drug use and improving drug treatment among old people.
Improving the experience of hip fracture care: A multidisciplinary collaborative approach to implementing evidence-based, person-centred practice.
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BACKGROUND: Hip fracture care is well supported by national guidelines and audit that provide evidence of safe interventions and an improved process. In the drive for organisational efficiency, complications have been reduced and length of stay shortened. Prioritising targets and performance alone can lead to poor multidisciplinary communication that potentially omits the psychosocial needs of older people recovering from hip fracture. AIM: To explore a multidisciplinary collaborative approach to implementing evidence-based, person-centred hip fracture care. DESIGN: Collaborative inquiry. METHODS: Sixteen clinical leaders (n = 16) from different disciplines, working with older people with hip fracture at different stages of the care pathway participated in eight two-hourly facilitated action meetings. Data collection included strengths and limitations of the present service, values clarification, clinical stories, review of case records and reflections on the stories of three older people and two carers. RESULTS: Hip fracture care was driven by service pressures, guidelines and audits. The care journey was divided into service delivery units. Professional groups worked independently resulting in poor communication. Time away from practice enabled collaboration and the sharing of different perspectives. CONCLUSIONS: Working together improved communication and enhanced understanding of the whole care experience. IMPLICATIONS FOR PRACTICE: Enabling teams to find evidence of safe, effective person-centred cultures requires facilitated time for reflective practice.
Quality of care in one Italian nursing home measured by ACOVE process indicators.
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OBJECTIVES: To adapt the Assessing Care of Vulnerable Elders Quality Indicators (ACOVE QIs) for use in Italy, to assess the adherence to these indicators as reported in the medical records of residents in a nursing home (NH), to compare this adherence for general medical and geriatric conditions, and eventually, to identify the relationships between patients’ characteristics and reported processes of care. METHODS: Two physicians collected the data by reviewing medical records of all NH residents in the previous 5 years, for a period of one year. Patients aged <65 years were excluded. A total of 245 patients were reviewed during the study period. The ACOVE QIs set, developed for NH processes of care, was used to assess the quality of care. Multivariate analysis was performed to identify and to assess the role of patients’ characteristics on quality of processes of care by several domains of care in general medical and geriatric conditions. RESULTS: With the exception of diabetes management, quality of processes of care for general medical conditions approached adequate adherence. Care falls substantially short of acceptable levels for geriatric conditions (pressure ulcers, falls, dementia). On the contrary, the recommended interventions for urinary incontinence were commonly performed. Adherence to indicators varied for the different domains of care and was proven worse for the screening and prevention indicators both for geriatric and general medical conditions. Statistical analysis showed disparities in provision of appropriate processes of care associated with gender, age, co-morbidities, level of function and mobility, length of stay and modality of discharge by NHs. CONCLUSIONS: Adherence to recommended processes of care delivered in NH is inadequate. Substantial work lies ahead for the improvement of care. Efforts should focus particularly on management of geriatric conditions and on preventive healthcare.
New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research
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OBJECTIVE: To synthesize new findings from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare) related to the Green House (GH) model of nursing home care and broadly consider their implications. DATA SOURCES: Interviews and observations conducted in GH and comparison homes, Minimum Data Set (MDS) assessments, Medicare data, and Online Survey, Certification and Reporting data. STUDY DESIGN: Critical integration and interpretation of findings based on primary data collected 2011-2014 in 28 GH homes (from 16 organizations), and 15 comparison nursing home units (from 8 organizations); and secondary data derived from 2005 to 2010 for 72 GH homes (from 15 organizations) and 223 comparison homes. PRINCIPAL FINDINGS: Implementation of the GH model is inconsistent, sometimes differing from design. Among residents of GH homes, adoption lowers hospital readmissions, three MDS measures of poor quality, and Part A/hospice Medicare expenditures. Some evidence suggests the model is associated with lower direct care staff turnover. CONCLUSIONS: Recommendations relate to assessing fidelity, monitoring quality, capitalizing opportunities to improve care, incorporating evidence-based practices, including primary care providers, supporting high-performance workforce practices, aligning Medicare financial incentives, promoting equity, informing broad culture change, and conducting future research.
Inside the Green House “Black Box”: Opportunities for High-Quality Clinical Decision Making.
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OBJECTIVE: To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates. DATA SOURCES/SETTINGS: Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states. STUDY DESIGN/DATA COLLECTION: The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively. PRINCIPAL FINDINGS: Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities. CONCLUSIONS: Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements.
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Research Practice and Methodology
Methodological and Epistemological Considerations in Utilizing Qualitative Inquiry to Develop Interventions.
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The purpose of this article is to discuss methodological and epistemological considerations involved in using qualitative inquiry to develop interventions. These considerations included (a) using diverse methodological approaches and (b) epistemological considerations such as generalization, de-contextualization, and subjective reality. Diverse methodological approaches have the potential to inform different stages of intervention development. Using the development of a psychosocial hope intervention for advanced cancer patients as an example, the authors utilized a thematic study to assess current theories/frameworks and interventions. However, to understand the processes that the intervention needed to target to affect change, grounded theory was used. Epistemological considerations provided a framework to understand and, further, critique the intervention. Using diverse qualitative methodological approaches and examining epistemological considerations were useful in developing an intervention that appears to foster hope in patients with advanced cancer.
Co-design and implementation research: challenges and solutions for ethics committees.
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BACKGROUND: Implementation science research, especially when using participatory and co-design approaches, raises unique challenges for research ethics committees. Such challenges may be poorly addressed by approval and governance mechanisms that were developed for more traditional research approaches such as randomised controlled trials. DISCUSSION: Implementation science commonly involves the partnership of researchers and stakeholders, attempting to understand and encourage uptake of completed or piloted research. A co-creation approach involves collaboration between researchers and end users from the onset, in question framing, research design and delivery, and influencing strategy, with implementation and broader dissemination strategies part of its design from gestation. A defining feature of co-creation is its emergent and adaptive nature, making detailed pre-specification of interventions and outcome measures impossible. This methodology sits oddly with ethics committee protocols that require precise pre-definition of interventions, mode of delivery, outcome measurements, and the role of study participants. But the strict (and, some would say, inflexible) requirements of ethics committees were developed for a purpose – to protect participants from harm and help ensure the rigour and transparency of studies. We propose some guiding principles to help square this circle. First, ethics committees should acknowledge and celebrate the diversity of research approaches, both formally (through training) and informally (by promoting debate and discussion); without active support, their members may not understand or value participatory designs. Second, ground rules should be established for co-design applications (e.g. how to judge when ‘consultation’ or ‘engagement’ becomes research) and communicated to committee members and stakeholders. Third, the benefits of power-sharing should be recognised and credit given to measures likely to support this important goal, especially in research with vulnerable communities. Co-design is considered best practice, for example, in research involving indigenous peoples in New Zealand, Australia and Canada.
Why item response theory should be used for longitudinal questionnaire data analysis in medical research.
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BACKGROUND: Multi-item questionnaires are important instruments for monitoring health in epidemiological longitudinal studies. Mostly sum-scores are used as a summary measure for these multi-item questionnaires. The objective of this study was to show the negative impact of using sum-score based longitudinal data analysis instead of Item Response Theory (IRT)-based plausible values. METHODS: In a simulation study (varying the number of items, sample size, and distribution of the outcomes) the parameter estimates resulting from both modeling techniques were compared to the true values. Next, the models were applied to an example dataset from the Amsterdam Growth and Health Longitudinal Study (AGHLS). RESULTS: The results show that using sum-scores leads to overestimation of the within person (repeated measurement) variance and underestimation of the between person variance. CONCLUSIONS: We recommend using IRT-based plausible value techniques for analyzing repeatedly measured multi-item questionnaire data.
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Aging
Depressive symptomatology and associated factors in dementia in Europe: home care versus long-term care.
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BACKGROUND: This study forms part of a larger European programme investigating the transition from home care to long-term care (LTC) facility in people with dementia (PwD) at the margins of LTC. The aim of this study was to explore the factors associated with depressive symptomatology in PwD in different settings. METHODS: A total of 1,538 PwD, of which 957 received home care and 581 lived in a LTC facility, and their carers were interviewed. The Cornell Scale for Depression in Dementia (CSDD) measured depressive symptomatology. PwD completed measures of cognition and quality of life (QoL), and informal or formal carers completed measures on the PwD’ QoL, neuropsychiatric behavior, activities of daily living, comorbidities, pain, and falls. Logistic regression was used to assess which factors contributed to depressive symptomatology in the two settings. RESULTS: Those receiving home care, living in Germany, and with severe dementia, showed the highest prevalence of depressive symptomatology. In the home care group, high levels of pain, neuropsychiatric behavior, and comorbidity, as well as low self- and proxy-rated QoL were factors associated with depressive symptomatology. In the LTC group, low proxy-rated QoL, more severe neuropsychiatric behavior, being a male informal carer and living in Germany were associated with depressive symptomatology. CONCLUSIONS: Evidence highlights the need for targeting different aspects in the management of depression in dementia, including offering improved pain management for those living in the community. Further research needs to explore cultural variations and carer gender factors associated with higher levels of depressive symptomatology.
Factors associated with increased hospitalisation risk among nursing home residents in Sweden: a prospective study with a three-year follow-up.
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BACKGROUND: Hospitalisation of nursing home residents might lead to deteriorating health. AIM: To evaluate physical and psychological factors associated with hospitalisation risk among nursing home residents. DESIGN: Prospective study with three years of follow-up. METHODS: Four hundred and twenty-nine Swedish nursing home residents, ages 65-101 years, from 11 nursing homes in three municipalities were followed during three years. The participants’ physical and psychological status was assessed at baseline. A Cox proportional hazards model was used to evaluate factors associated with hospitalisation risk using STATA. RESULTS: Of the 429 participants, 196 (45.7%) were hospitalised at least once during the three-year follow-up period, and 109 (25.4%) during the first six months of the study. The most common causes of hospitalisation were cardiovascular diseases or complications due to falls. A Cox regression model showed that residents who have had previous falls (P < 0.001), are malnourished (P < 0.001), use a greater number of drugs (P < 0.001) and have more diseases (P < 0.001), are at an increased risk of hospitalisation. CONCLUSION: Nursing home residents are frequently hospitalised, often due to falls or cardiovascular diseases. Study results underscore the relationships between malnutrition, previous falls, greater numbers of drugs and diseases and higher risk of hospitalisation. IMPLICATIONS FOR PRACTICE: Preventive interventions aimed at malnutrition and falls at the nursing home could potentially reduce the number of hospitalisations. With improved education and support to nurses concerning risk assessment at the nursing homes, it may be possible to reduce the numbers of avoidable hospitalisation among nursing home residents and in the long run improve quality of life and reduce suffering.
Completeness of assisted bathing in nursing homes related to dementia and bathing method: results from a secondary analysis of cluster-randomised trial data.
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BACKGROUND: Bathing assistance is a core element of essential care in nursing homes, yet little is known for quality of assisted bathing or its determinants. AIM: To explore differences in completeness of assisted bathing in relation to bathing method and resident characteristics. METHODS: Secondary analysis of a cluster randomised trial including 500 nursing home residents designed to compare traditional bathing methods for skin effects and cost-consequences; GlinicalTrials.gov ID [NCT01187732]. Logistic mixed modelling was used to relate resident characteristics and bathing method to bathing completeness. RESULTS: Bathing completeness was highly variable over wards. Apart from a large effect for ward, logistic mixed modelling indicated bathing was more often complete in case of washing without water (using disposable skin cleaning and caring materials; estimate 2.55, SE 0.17, P < 0.0001) and less often complete in residents with dementia (estimate -0.22, SE 0.08, P = 0.0040). CONCLUSIONS: Introduction of washing without water is likely to lead to more bathing completeness in nursing homes. However, inequity in care was also identified with a view to highly variable bathing completeness over wards and more incomplete bathing by care staff in residents with dementia. IMPLICATIONS FOR PRACTICE: Monitoring the performance of assisted bathing in nursing homes is indicated for the identification of undesirable variation in essential care and poorly performing teams. The introduction of washing without water could serve the promotion of bathing completeness in nursing homes overall, but will not solve inequity issues for residents.
Feasible modalities and long-term effects of elastic band exercises in nursing home older adults in wheelchairs: A cluster randomized controlled trial.
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BACKGROUND: Physical activity holds promise for mobility-impaired older adults to prevent further disabilities and improve their health. However, staffing constraints have made it challenging to promote physical activity in long-term care facilities. OBJECTIVES: To test the feasibility and effects of 12 months Wheelchair-bound Senior Elastic Band (WSEB) group-exercises that were led by volunteers for the first six months followed by the DVD-guided for another six months on functional fitness, activities of daily living (ADL), and sleep quality of nursing home older adults in wheelchairs. DESIGN: Cluster randomized controlled trial with two groups, pre-test and post-tests. SETTINGS: Ten nursing homes, Taiwan. PARTICIPANTS: 127 participants participated voluntarily; 107 of them completed the study. INCLUSION CRITERIA: (1) aged 65 years and over, (2) using wheelchairs for mobility, (3) living in facility for at least three months, (4) cognitively intact, and (5) heavy or moderate dependency in ADL. Majority of participants were middle-old older adults (75-84 years old, 53.2%), female (51.4%), and had chronic illnesses (98.1%). METHODS: Participants were randomly assigned by facility to either the experimental (five nursing homes, n=56) or control group (five nursing homes, n=51). The WSEB program was conducted three times per week and 40min per session in two stages: volunteer-led for the first six months (stage I) followed by the DVD-guided modality for another six months (stage II). The primary outcomes (functional fitness: lung capacity, body flexibility, range of joint motion, and muscle strength and endurance) and the secondary outcomes (ADL measured by the Barthel Index; sleep quality measured by the Pittsburgh Sleep Quality Index) of the participants were measured at three time points: pre-test, at the six-month interval, and at the end of 12 months of the study. No blinding was applied. RESULTS: All of the functional fitness indicators of the experimental group participants improved significantly (p<.05), and were all better than the control group at six-month and 12-month of the study (p<.05). No symptoms of discomfort occurred during interventions. CONCLUSIONS: Nursing home older adults in wheelchairs who received WSEB exercise training had better functional fitness, ADL, and sleep quality than those who did not. It was a feasible way of carrying out this exercise program by using the volunteer-led followed by the DVD-guided modalities. The program can be applied in institutional settings routinely.
CARE-PACT: a new paradigm of care for acutely unwell residents
in aged care facilities.
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BACKGROUND: Ageing population trends create a strong imperative for healthcare systems to develop models of care that reduce dependence on hospital services. People living in residential aged care facilities (RACFs) currently have high rates of presentation to emergency departments. The care provided in these environments may not optimally satisfy the needs of frail older persons from RACFs. OBJECTIVE: To describe the Comprehensive Aged Residents Emergency and Partners in Assessment, Care and Treatment (CARE-PACT) program: a hospital substitutive care and demand management project that aims to improve, in a fiscally efficient manner, the quality of care received by residents of aged care facilities when their acute healthcare needs exceed the scope of the aged care facility staff and general practitioners to manage independently of the hospital system. DISCUSSION: The project delivers high-quality gerontic nursing and emergency specialist assessment, collaborative care planning, skills sharing across the care continuum and an individualised, resident-focused
Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study
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BACKGROUND: Healthcare professionals engage in discharge planning of people with dementia during hospitalisation, however plans for transitioning the person into community services can be patchy and ineffective. The aim of this study was to report acute, community and residential care health professionals’ (HP) perspectives on the discharge process and transitional care arrangements for people with dementia and their carers. METHODS: A qualitative descriptive study design and purposive sampling was used to recruit HPs from four groups: Nurses and allied health practitioners involved in discharge planning in the acute setting, junior medical officers in acute care, general practitioners (GPs) and Residential Aged Care Facility (RACF) staff in a regional area in NSW, Australia. Focus group discussions were conducted using a semi-structured schedule. Content analysis was used to understand the discharge process and transitional care arrangements for people with dementia (PWD) and their carers. RESULTS: There were 33 participants in four focus groups, who described discharge planning and transitional care as a complex process with multiple contributors and components. Two main themes with belonging sub-themes derived from the analysis were: Barriers to effective discharge planning for PWD and their carers – the acute care perspective: managing PWD in the acute care setting, demand for post discharge services exceeds availability of services, pressure to discharge patients and incomplete discharge documentation. Transitional care process failures and associated outcomes for PWD – the community HP perspective: failures in delivery of services to PWD; inadequate discharge notification and negative patient outcomes; discharge-related adverse events, readmission and carer stress; and issues with medication discharge orders and outcomes for PWD. CONCLUSIONS: Although acute care HPs do engage in required discharge planning for people with dementia, participants identified critical issues: pressure on acute care health professionals to discharge PWD early, the requirement for JMOs to complete discharge summaries, the demand for post discharge services for PWD exceeding supply, the need to modify post discharge medication prescriptions for PWD, the need for improved coordination with RACF, and the need for routine provision of medication dose decision aids and home medicine reviews post discharge for PWD and their carers.
Clostridium difficile Infections in Veterans Health Administration Long-Term Care Facilities.
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OBJECTIVE A nationwide initiative was implemented in February 2014 to decrease Clostridium difficile infections (CDI) in Veterans Affairs (VA) long-term care facilities. We report a baseline of national CDI data collected during the 2 years before the Initiative. METHODS Personnel at each of 122 reporting sites entered monthly retrospective CDI case data from February 2012 through January 2014 into a national database using case definitions similar to those used in the National Healthcare Safety Network Multidrug-Resistant Organism/CDI module. The data were evaluated using Poisson regression models to examine infection occurrences over time while accounting for admission prevalence and type of diagnostic test. RESULTS During the 24-month analysis period, there were 100,800 admissions, 6,976,121 resident days, and 1,558 CDI cases. The pooled CDI admission prevalence rate (including recurrent cases) was 0.38 per 100 admissions, and the pooled nonduplicate/nonrecurrent community-onset rate was 0.17 per 100 admissions. The pooled long-term care facility-onset rate and the clinically confirmed (ie, diarrhea or evidence of pseudomembranous colitis) long-term care facility-onset rate were 1.98 and 1.78 per 10,000 resident days, respectively. Accounting for diagnostic test type, the long-term care facility-onset rate declined significantly (P=.05), but the clinically confirmed long-term care facility-onset rate did not. CONCLUSIONS VA long-term care facility CDI rates were comparable to those in recent reports from other long-term care facilities. The significant decline in the long-term care facility-onset rate but not in the clinically confirmed long-term care facility-onset rate may have been due to less testing of asymptomatic patients. Efforts to decrease CDI rates in long-term care facilities are necessary as part of a coordinated approach to decrease healthcare-associated infections.
Reducing dehydration in residents of care homes.
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Dehydration can have serious consequences for older people and is a particular problem for residents of nursing and care homes. This article, the second in a two-part series, describes how a specialist care home for people with dementia in Great Yarmouth introduced high-quality hydration care to frail residents. By involving all staff and ensuring residents take a litre of fluid by the end of a relaxed and extended breakfast, staff have reduced anxiety and aggression and created a calmer and more sociable atmosphere. This has benefitted residents, visitors and staff, and is reflected in low levels of unplanned hospital admissions and paramedic call-outs.
A Japanese booklet about palliative care for advanced dementia in nursing homes.
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BACKGROUND: A Canadian guide for nursing home staff on comfort care for dementia has been translated and adapted for use in Japan. The present study piloted educational intervention for nursing home staff using the Japanese comfort care booklet. METHOD: Some 61 nursing home staff (nurses and other care workers) completed a session that included pre-assessment, a 30-minute seminar using the comfort care booklet, post-assessment, and a one-hour debriefing meeting. A Japanese version of the questionnaire on palliative care for advanced dementia (qPAD) scale was used to assess knowledge and attitudes toward palliative care for advanced dementia. RESULTS: The participants demonstrated a significant increase in knowledge (mean score, 14.3 to 15.1/23, t (60) = 2.35, p=0.011) and attitudes (43.8 to 45.2/60, t (60) = 2.51, p = 0.015) toward palliative care for advanced dementia from pre-assessment to post-assessment. CONCLUSION: The educational intervention using the Japanese comfort care booklet may have improved nursing home staff’s perspectives on palliative care for advanced dementia.
Public policy response, aging in place, and big data platforms: Creating an effective collaborative system to cope with aging of the population.
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The unprecedented rapid aging of the population is poised to become the next global public health challenge, as is apparent by the fact that 23.1% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Aging of the population is the biggest driver of substantial increases in the prevalence of chronic conditions, and the prevalence of multi-morbidity is much higher in older age groups. This places a large burden on countries’ health and long-term care systems. Many behavioral changes and public policy responses to aging of the population have been implemented to cope with these challenges. A system of “aging in place” has been implemented in some high-income countries in order to better provide coordinated and cost-effective health services for the elderly. This approach reduces institutional care while supporting home- or community-based care and other services. Advances in information and communications technology (ICT), assistive devices, medical diagnostics, and interventions offer many ways of more efficiently providing long-term care as part of aging in place. The use of big data on a web services platform in an effective collaborative system should promote systematic data gathering to integrate clinical and public health information systems to provide support across the continuum of care. However, the use of big data in collaborative system is a double-edged sword, as it also bring challenges for information sharing, standardized data gathering, and the security of personal information, that warrant full attention.
Trends in prevalence, incidence and pharmacologic management of diabetes mellitus among seniors newly admitted to long-term care facilities in Saskatchewan between 2003 and 2011.
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OBJECTIVE: We aimed to describe trends in the prevalence and incidence of diabetes mellitus and also report the overall use of diabetes medications among patients newly admitted to a long-term care facility (LTCF). METHODS: A retrospective cohort study was done using health administrative databases in Saskatchewan. Eligible patients were newly admitted to LTCF in Saskatchewan between 2003 and 2011 and maintained LTCF residency for at least 6 months. Prevalence of diabetes was defined with physician or hospital claims in the 2 years preceding admission. Antihyperglycemic medication use was estimated from prescription claims data during the first 6 months after LTCF admission. All data were descriptively analyzed. RESULTS: The validated case definition for diabetes (>/=2 diagnostic claims) in the 2 years before or 6 months after admission was met by 16.9% of patients (2471 of 14,624). An additional 965 patients (6.6%) had a single diabetes diagnostic claim or antihyperglycemic prescriptions only. Among patients receiving antihyperglycemic therapies, 64.9% (1518 of 2338) were exclusively managed with oral medications, and metformin was the most commonly used medication. Glyburide was commonly withdrawn after LTCF admission. Insulin use was observed in 23.9% of diabetes patients, with a mean daily average consumption of 54.7 units per day. CONCLUSIONS: Use of diabetes medications appear to generally align with Canadian practice recommendations as evidenced by declining use of glyburide and frequent use of metformin. Future studies should examine clinical benefits and safety of hypoglycemic agent use in LTCFs.
Variables associated with change in quality of life among persons with dementia in nursing homes: a 10 months follow-up study.
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AIM: To investigate variables associated with change in quality of life (QOL), measured by QUALID scale and three subscales; tension, sadness and wellbeing, among dementia patients in nursing homes. METHOD: A 10 months follow-up study including 198 (female 156, 79%) nursing home patients, mean age 87 (s.d 7.7) years. Scales applied; quality of life in late stage dementia (QUALID) scale and three subscales (wellbeing, sadness and tension), neuropsychiatric inventory questionnaire 10 items (NPI-10-Q), clinical dementia rating (CDR) scale, physical self-maintenance (PSMS) scale and a scale of general medical health. Use of psychotropic medication, gender and age was collected from the patient’s records. RESULTS: Mean baseline QUALID score: 20.6 (s.d.7.0), follow-up score: 22.9 (s.d.7.4), mean change 2.8 (s.d.7.4). QOL improved in 30.8%, were unchanged in 14.7%, deteriorated in 54.6% of patients. A regression analysis revealed that change in QUALID score was significantly associated with: QUALID baseline score (beta -.381, p-value.000), change in NPI score (beta.421, p-value.000), explained variance 38.1%. Change in score on wellbeing subscale associated with: change in PSMS score (beta.185, p-value.019), wellbeing baseline score (beta -.370, p-value.000), change in NPI score (beta.186, p-value.017), explained variance 25.3%. Change in score on tension subscale associated with: change in CDR sum-of-boxes (beta.214, p-value.003), change in NPI score (beta.270, p-value.000), tension baseline score (beta -.423, p-value.000), explained variance 34.6%. Change in score on sadness subscale associated with: change in NPI score (beta.404, p-value.000), sadness baseline score (beta -.438, p-value.000), explained variance 38.8%. CONCLUSION: The results imply that a lower baseline score (better QOL) results in a larger change in QOL (towards worse QOL). Change in QOL is mostly associated with change in neuropsychiatric symptoms. In almost 50% of patients QOL did not deteriorate.
The meaning of slow nursing in dementia care.
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Research literature in the dementia field lacks examples of ‘best-practices’ demonstrating concretely how it is possible to support the sense of coherence in people with dementia. The purpose of this study was to elucidate the nurses’ views concerning a caring approach that may support the sense of coherence in people with dementia. The data were collected through participant observation and focus group interviews during a four-month period in 2011. Sixteen registered nurses recruited from two Norwegian nursing homes participated in this study. The data were interpreted using a phenomenological-hermeneutical method. Three themes were identified: ‘being in the moment’, ‘doing one thing at a time’, and ‘creating joy and contentment’. An overall interpretation of these themes is described by the metaphor ‘slow nursing’, a caring approach that may lead to supporting the sense of coherence in people with dementia.
The characteristics of diabetic residents in European nursing homes: results from the SHELTER study.
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OBJECTIVES: The objectives of this study were to describe the prevalence of diabetes mellitus (DM) in European nursing homes (NHs), and the health and functional characteristics of diabetic residents (DMR) aged 60 years and older. DESIGN: Between 2009 and 2011, the Services and Health for Elderly in Long TERm care (SHELTER) project, a 12-month prospective cohort study, was conducted to assess NH residents across different health care systems in 7 European countries and Israel. METHODS: The study included 59 NHs in 8 countries with a total of 4037 residents living in or admitted to a NH during the 3-month enrollment period. The multidimensional InterRAI instrument for Long-Term Care Facilities (InterRAI-LTCF) was used to assess health and functional status among residents. Descriptive statistics and linear, ordinal, and logistic regression were used to perform the analyses. RESULTS: We found a 21.8% prevalence of DM among NH residents. Residents with DM (DMRs) were significantly younger compared with non-DMRs (82.3, SD +/- 7.7; 84.6, SD +/- 8.4; P < .001). DMRs were more frequently overweight or obese, and presented more often with ischemic heart disease, congestive heart failure, hypertension, and stroke than residents without DM. DMRs also took more drugs, had pressure ulcers (PU) or other wounds more often, and more frequently had urinary incontinence (UI); they also reported worse self-perceived health. DM independently of other factors increased risk of PU occurrence (odds ratio 1.38; 95% confidence interval [CI] 1.02-1.86; P = .036) and decreased probability of higher pain scores (B = -0.28; 95% CI -0.41 to -0.14; P < .001). DM was not associated with ADL dependency, cognitive impairment, and depression in NH residents. CONCLUSION: Prevalence of DM in European NH residents is comparable to US national NH surveys, and to UK and German NH data based on glucose-level testing. DMRs compared with non-DMRs have more comorbid conditions, and a particularly higher incidence of cardiovascular diseases and obesity, PU, and severe UI. DMRs should be regarded as a specific group of residents who require an interdisciplinary approach in medical and nursing care.
Resident Reactions to Person-Centered Communication by Long-Term Care Staff
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Long-term care staff caregivers who are person centered incorporate the life history, preferences, and feelings of residents with dementia during care interactions. Communication is essential for person-centered care. However, little is known about residents’ verbal reactions when staff use person-centered communication. Accordingly, this study investigated the impact of person-centered communication and missed opportunities for such communication by staff on resident reactions. Conversations (N = 46) between staff–resident dyads were audio-recorded during routine care tasks over 12 weeks. Staff utterances were coded for person-centered communication and missed opportunities. Resident utterances were coded for positive reactions, such as cooperation, and negative reactions, such as distress. Linear regression analyses revealed that the more staff used person-centered communication, the more likely that residents reacted positively. Additionally, the more missed opportunities in a conversation, the more likely that the residents reacted negatively. Conversation illustrations elaborate on the quantitative findings and implications for staff training are discussed.
Caregiving for Older Adults with Disabilities: Present Costs, Future Challenges
Being an unpaid caregiver for one’s adult family members is increasingly common in Canada as growing numbers of disabled individuals need help with tasks such as housekeeping, meal preparation and transportation. Although the amount of care most caregivers provide to adult family members and friends is modest, the responsibilities can be demanding and can present financial risks. The number of people requiring care is forecast to rise dramatically in coming years, while families’ capacity to meet those demands will decrease as a result of demographic and socio-economic factors. In this study, Janet Fast assesses the financial and other challenges faced by caregivers and their employers. She also examines what employers and governments are currently doing, as well as what they should do, to mitigate the negative effects of caregiving. The vast majority of working-age caregivers are employed and work full time. Many experience conflicting demands between paid work and caregiving and have to miss days at work or reduce their paid work hours. Those who provide many hours of care, who reside with the care recipient or care for someone with a cognitive disability are more likely to quit their jobs, and they may even be fired. As such, they are at greater risk of experiencing poor social, economic, physical and mental health outcomes. Clearly, caregivers bear a disproportionate share of the costs of caring for those with long-term health problems and disabilities. The issue also presents challenges for employers, for example, increased turnover, absenteeism, reduced productivity and more demands on employee benefit programs. Some employers offer supports such as flexible work hours, direct compensation and information for caregiver employees. However, there is a marked discrepancy between the way employers treat new parents and how they treat people with care responsibilities. Although over the past decade governments have introduced new policies to enhance work-care reconciliation, there is no comprehensive public policy strategy to support caregivers and to mitigate the negative consequences of caregiving. We need to correct this urgently, Fast argues. Canada should follow the example of the United Kingdom and Australia, which have recognized caregivers’ contributions, introduced an allowance or wage to help cover caregivers’ income security needs, and explicitly codified caregivers’ rights in legislation. Policy-makers should also extend care service providers’ mandates to include caregivers as clients, introduce compulsory assessment of caregivers’ needs and recognize caregivers’ right to have those needs met. She calls for a comprehensive caregiver policy strategy based on four pillars: (1) recognizing caregivers and their rights; (2) adequate, accessible and affordable services for care receivers and caregivers; (3) work-care reconciliation measures; and (4) measures to protect caregivers’ income security.
OECD Insights: Ageing: Debate the Issues
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Ageing has a wide range of impacts on individuals and society as a whole. But the consequences for health care, working life, income and well-being in general are not always what many people imagine. OECD Insights: Ageing: Debate the Issues discusses the problems, challenges, and opportunities that ageing brings to citizens and governments in developed and developing countries. Experts on demography, medical research, pensions, employment and other domains from inside and outside the OECD present their latest analyses and views on one of the most important trends shaping our societies.
Dementia in the Family: The impact on carers (UK)
Alzheimer’s Research UK commissioned Opinion Leader to investigate all aspects of the impact of caring for a relative with dementia. Topics covered include changing family relationships, increased social isolation, coping with behaviour change, the influence on carers’ psychological and physical health, and the many hidden financial costs involved.
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Events
UofA
SSHRC IDG Writing Retreat – Expression of Interest
Are you intending to submit an Insight Development Grant in February 2016? If interest is sufficient, the Grant Assist Program will sponsor a special retreat in January 2016, dedicated to polishing up the proposal just in time for submission. This retreat will likely appeal to applicants who will not be ready for the internal Peer Review.
Ethical issues in inner city health
Presented by Dr. Kathryn Dong.
Online
Webinar: Evaluating Research Impact:From the General to Specific
This webinar will provide an overview of research impact evaluation, from planning, to implementing, to understanding and using the results.
Aging is a lifelong and socially patterned process: Insights from a life course approach using a maturing British birth cohort study, presented by Dr. Diana Kuh, professor of Life Course Epidemiology and director of the Medical Research Council Unit for Lifelong Health and Ageing at University College London.
Rural emergency Care in Canada: Should you be concerned?
Learning Objectives:
-Better understand the concerning inequities in rural emergency care in Canada
-Appreciate how an entire research program can be inspired by a rural Community (Nelson, BC)
-Understand what a team of Canadian researchers plan to do to improve standards of rural emergency care.
Courses
Online
Making Your Good Stuff Better: Course on Facilitation
Are you called on to lead meetings or workshops? Do you often wonder if the sessions could be more productive? Do you sense that there must be better ways to use your time? If these questions resonate for you, (whether you consider yourself a facilitator or not) then this practical, four-week online course will help. It will equip you to run meetings that are more effective and engaging. Dr. Rebecca Sutherns, Certified Professional Facilitator and Guelph-based consultant, has over 20 years of facilitation experience and is known for designing outstanding learning experiences. She will join you and other Danby learners on this customized journey to “make your good stuff better.”
News
Essential Guide: Eight ways research gets into Parliament (UK)
Discussions about research and policy have a tendency to be more reflective about policy-making in general, rather than focusing on the more practical aspects of how research filters through a variety of networks and into policy discussions. Sarah Foxen looks at eight specific ways research currently gets into Parliament and provides some helpful links on where to start to get more involved.
Alberta’s research ethics boards exist to ensure that health research follows strict guidelines
Alberta’s research ethics boards exist to ensure that health research follows strict guidelines based on the commitment to protect and advance human welfare, knowledge and understanding. They are based on the principles of respect for persons, concern for welfare and justice, among others.
Saskatchewan to track, report on safety incidents involving patients and employees
Saskatchewan’s health system leaders are committed to making health care environments safer for everyone and have set a target to eliminate preventable harm to patients and employees province-wide by March 31, 2020.
One advantage to taking a real break over the holidays is that it allows you to return to your work life with new eyes. We all develop habits. Some of them are good habits that allow you to get things done efficiently and effectively. Others are not as helpful and might be contributing to your frustration and stress.
Baby Boomers Set Another Trend: More Golden Years In Poorer Health
After the last of the baby boomers become fully eligible for Medicare, the federal health program can expect significantly higher costs in 2030 both because of the high number of beneficiaries and because many are expected to be significantly less healthy than previous generations.
Seniors in long-term care getting antipsychotic drugs they don’t need: CIHI
Almost one-third of long-term care residents in Saskatchewan with no documented diagnosis of psychosis have received an antipsychotic medication. According to a report from the Canadian Institute for Health Information (CIHI) released Wednesday, 31.1 per cent of Saskatchewan LTC residents in 2014-15 potentially received antipsychotics that weren’t required. The national average was 27.5 per cent in the same time period.
This infographic helps explain the economic implications of a growing aging population in the United States for older Americans and their families.
The Agency for Healthcare Research and Quality (AHRQ) is recruiting 50 nursing homes to participate in a facilitated quality improvement opportunity using the On-Time Pressure Ulcer Prevention Program.
Depression in the Elderly: A Common Condition That’s Often Overlooked (US)
Depression is frequently overlooked in older individuals, in part because their condition is often expressed in physical symptoms like fatigue, insomnia or loss of appetite, as opposed to overt sadness. Another reason is that the elderly are often dealing with other serious health conditions, with the result that signs of depression may be ignored or written off as a “natural” response to these other medical issues. Depression can also cause transient cognitive problems, leading people to mistake it for dementia.
Some people can thrive with dementia but the disease is often shrouded in misconceptions, which the Alzheimer Society seeks to dispel in a new campaign.
Five-minute survey to advance implementation science
Dear colleagues,
We need your help. The use of frameworks and theories in implementation research guide evidence translation, identify implementation determinants, and evaluate implementation. Selecting an appropriate framework or theory is made challenging by the lack of clear guidance for selecting from amongst the increasing number of frameworks and theories in the field. These challenges may contribute to the default use, underuse or misuse of frameworks and theories.
The objective of our study is to understand criteria for selecting appropriate frameworks and theories for implementation research.
Please help us by completing a brief survey in which you tell us about the criteria that you use to select a framework or theory for your implementation research. The survey takes about 5 minutes to complete. If you have already completed this survey, please feel free to disregard this message.
Feel free to contact me (birken@unc.edu) with any questions or concerns about the study.
If the link is not working copy and paste the following URL into your browser address bar: http://tinyurl.com/theorycriteria
Sarah A. Birken, PhD University of North Carolina at Chapel Hill
Byron J. Powell, PhD University of North Carolina at Chapel Hill
Justin Presseau, PhD Ottawa Hospital Research Institute
Resources
Lakeview Ranch, Inc., a long-term residential care facility, provides a person-centered approach to caring for persons with dementia who exhibit challenging, aggressive behavior. Using many highly trained staff, this care model includes comprehensive screening and evaluation, careful management of the initial transition to the facility, daily dementia-specific activities and therapies (including animal, music, and spiritual therapy), extensive medication reviews, and ongoing monitoring of needs. The program reduced psychiatric hospitalizations and the use of behavior-related medications.
Dementia And Staff Grief: A Resource For Healthcare Providers
This resource is meant to help you and your organization gain a better understanding of the multiple losses experienced by staff caring for people with dementia across the continuum of care, and how staff members can be effectively supported in managing their loss and grief when clients are dying and after their deaths, transitioning out of a program or to another level of care.
Opportunities
Three funded PhD studentships on ‘Living With Feeling’ project
The Centre for the History of the Emotions at Queen Mary University of London invites applications from outstanding post-graduate students wishing to pursue doctoral research into aspects of the histories of emotions and health. These studentships are offered as a core element of a Collaborative Humanities and Social Science research project funded by the Wellcome Trust. This interdisciplinary project is entitled ‘Living With Feeling: Emotional Health in History, Philosophy, and Experience’.
