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New article by Dr. Shannon Scott
Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings.
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Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice. METHODS: A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables. RESULTS: Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention. CONCLUSIONS: This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.
New articles by Dr. Greta Cummings
Performance management in healthcare: a critical analysis.
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Purpose – The purpose of this paper is to explore the underlying theoretical assumptions and implications of current micro-level performance management and evaluation (PME) practices, specifically within health-care organizations. PME encompasses all activities that are designed and conducted to align employee outputs with organizational goals. Design/methodology/approach – PME, in the context of healthcare, is analyzed through the lens of critical theory. Specifically, Habermas’ theory of communicative action is used to highlight some of the questions that arise in looking critically at PME. To provide a richer definition of key theoretical concepts, the authors conducted a preliminary, exploratory hermeneutic semantic analysis of the key words “performance” and “management” and of the term “performance management”. Findings – Analysis reveals that existing micro-level PME systems in health-care organizations have the potential to create a workforce that is compliant, dependent, technically oriented and passive, and to support health-care systems in which inequalities and power imbalances are perpetually reinforced. Practical implications – At a time when the health-care system is under increasing pressure to provide high-quality, affordable services with fewer resources, it may be wise to investigate new sector-specific ways of evaluating and managing performance. Originality/value – In this paper, written for health-care leaders and health human resource specialists, the theoretical assumptions and implications of current PME practices within health-care organizations are explored. It is hoped that readers will be inspired to support innovative PME practices within their organizations that encourage peak performance among health-care professionals.
Quality-based procedures in Ontario: exploring health-care leaders’ responses.
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AIM: To examine health-care leaders’ initial response to the implementation of orthopaedic quality based procedures (QBPs) in hospitals across Ontario, Canada. BACKGROUND: In 2012, Ontario, Canada shifted 91 hospitals to a patient-based funding (PBF) approach. This approach funds health-care organisations based on the number of patients treated with select procedures known as QBPs. METHODS: An exploratory descriptive design was employed to better understand health-care leaders’ early implementation experiences. Seventy organisational leaders from 20 hospitals participated in six focus groups and four interviews to discuss their initial responses to the implementation of two QBPs (primary unilateral hip replacement and primary unilateral knee replacement). Qualitative data underwent content analysis. FINDINGS: Three key major themes emerged; (1) responding to change, (2) leading the change and (3) managing the change. Within each of these themes, barriers and benefits were identified. CONCLUSION: Leaders are accepting of PBF and QBPs. However, challenges exist that require further exploration including the need for a strong infrastructure, accurate and timely clinical and financial data, and policies to prevent unintended consequences. IMPLICATIONS FOR NURSING MANAGEMENT: Implementing QBPs requires careful planning, adequate and appropriate resources, vertical and horizontal communication strategies, and policies to ensure that unintended consequences are avoided and positive outcomes achieved.
Grants & Awards
Alberta Innovates – Health Solutions (AIHS) Health Research New Investigator award
Alberta Innovates – Health Solutions (AIHS) has developed this program in collaboration with our university partners to support the recruitment of outstanding junior researchers in key priority areas of health research. Funding for this award was transitioned from the already successful Translational Health Chairs program.
TVN announces 2016 Summer Student Awards Program
TVN is providing up to ten awards of up to $4,500 each. Student’s supervisor must guarantee the student will receive 100% matching funds for salary and benefits only. Each student award covers 14 weeks of full-time participation from May 09 to August 12, 2016.
Following the successful first Data Impact Challenge, the ImagineNation team wants another set of important health and health care questions to be answered to inform health care decision-making, but with a new twist … We want to hear from you! All Canadians were invited to submit, then vote on, the health care questions that they would like to see in the Challenge. The chosen list of Challenge questions are now available. Authorized users of health data sets are invited to answer them for the potential to earn part of the more than $95,000 in awards available.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology
Aging
KT
The Case for Conceptual and Computable Cross-Fertilization Between Audit and Feedback and Clinical Decision Support.
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Many patients do not receive care consistent with best practice. Health informatics interventions often attempt to address this problem by comparing care provided to patients (e.g., from electronic health record data) to quality standards (e.g., described in clinical guidelines) and feeding this information back to clinicians. Traditionally these interventions are delivered at the patient-level as computerized clinical decision support (CDS) or at the population level as audit and feedback (A&F). Both CDS and A&F can improve care for patients but are variably effective; the challenge is to understand how the efficacy can be maximized. Although CDS and A&F are traditionally considered separate approaches, we argue that the systems share common mechanisms, and efficacy may be improved by cross-fertilizing relevant features and concepts. We draw on the Health Informatics and Implementation Science literature to argue that common mechanisms include functions typically associated with the other system, in addition to other features that may prove fruitful for further research.
The problem with Plan-Do-Study-Act cycles
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This article presents our reflections on the full potential of using PDSA in healthcare, but in doing so we explore the inherent complexity and multiple challenges of executing PDSA well. Ultimately, we argue that the problem with PDSA is the oversimplification of the method as it has been translated into healthcare and the failure to invest in a rigorous and tailored application of the approach.
Barriers and facilitators to uptake of systematic reviews by policy makers and health care managers: a scoping review 
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BACKGROUND: We completed a scoping review on the barriers and facilitators to use of systematic reviews by health care managers and policy makers, including consideration of format and content, to develop recommendations for systematic review authors and to inform research efforts to develop and test formats for systematic reviews that may optimise their uptake. METHODS: We used the Arksey and O’Malley approach for our scoping review. Electronic databases (e.g., MEDLINE, EMBASE, PsycInfo) were searched from inception until September 2014. Any study that identified barriers or facilitators (including format and content features) to uptake of systematic reviews by health care managers and policy makers/analysts was eligible for inclusion. Two reviewers independently screened the literature results and abstracted data from the relevant studies. The identified barriers and facilitators were charted using a barriers and facilitators taxonomy for implementing clinical practice guidelines by clinicians. RESULTS: We identified useful information for authors of systematic reviews to inform their preparation of reviews including providing one-page summaries with key messages, tailored to the relevant audience. Moreover, partnerships between researchers and policy makers/managers to facilitate the conduct and use of systematic reviews should be considered to enhance relevance of reviews and thereby influence uptake. CONCLUSIONS: Systematic review authors can consider our results when publishing their systematic reviews. These strategies should be rigorously evaluated to determine impact on use of reviews in decision-making.
The Influence of Organizational Systems on Information Exchange in Long-Term Care Facilities: An Institutional Ethnography.
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Person-centered care is heavily dependent on effective information exchange among health care team members. We explored the organizational systems that influence resident care attendants’ (RCAs) access to care information in long-term care (LTC) settings. We conducted an institutional ethnography in three LTC facilities. Investigative methods included naturalistic observations, in-depth interviews, and textual analysis. Practical access to texts containing individualized care-related information (e.g., care plans) was dependent on job classification. Regulated health care professionals accessed these texts daily. RCAs lacked practical access to these texts and primarily received and shared information orally. Microsystems of care, based on information exchange formats, emerged. Organizational systems mandated written exchange of information and did not formally support an oral exchange. Thus, oral information exchanges were largely dependent on the quality of workplace relationships. Formal systems are needed to support structured oral information exchange within and between the microsystems of care found in LTC.
Using diffusion of innovation theory to describe perceptions of a passive positioning alarm among persons with mild dementia: a repeated interview study
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BACKGROUND: Problems with memory and decline in cognitive abilities are common during development of dementia. Different kinds of technologies may be useful in supporting persons with dementia and their relatives in daily life. Tracking technologies have the potential to improve independence among persons with dementia. Consequently, the aim of the present study was to describe perceptions of a passive positioning alarm (PPA) among persons with mild dementia. METHODS: A repeated interview study was conducted in Sweden with a strategic sample of 11 persons with mild dementia. Roger’s Diffusion of Innovation Theory was used to deductively analyse the data. RESULTS: Regarding the advantages of the PPA, participants described perceived safety and security for, both themselves, and their relatives, as well as freedom and independence. However, they also expressed concern about the cost of the PPA, reflected on who might be the receiver of the alarm from the PPA, emphasized the importance of opportunities to test the device before becoming a user and early introduction before their problems start, thus allowing them to decide for themselves. CONCLUSIONS: Supporting persons with dementia in their own homes using, e.g., a PPA may enable them and their relatives to remain longer in their own homes and be safer in their own neighbourhoods.
Nursing culture: An enemy of evidence-based practice? A focus group exploration
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Evidence-based practice (EBP) is challenging for most nurses due to the time constraints of caring for patients and the emerging pressures of a changing health service. To explore these challenges, and thus to establish possible means of overcoming them, three focus groups (n = 17) with children’s nurses were conducted. Participants were asked how they would define EBP, what the barriers to EBP were, what skills they needed to help access evidence and how they could integrate evidence into everyday practice. Data were analysed thematically and the anticipated themes of definitions of EBP, barriers, education and nursing culture were determined. Important subthemes were personal and employer disengagement, passivity and lack of resource utilisation. Passive use of evidence readily available in patient folders and on the wards was common. It seemed that little consideration was given to how often this evidence was updated. Nurses define their access to evidence as primarily passive in nature. This is reinforced by a lack of ready access to ongoing education and a perceived lack of investment at institutional level in their continued engagement with evidence. Promoting EBP needs to engage more with those ritual and traditional aspects of nursing culture to challenge these perceptions.
Psychometric Testing of the Health Care Evidence-Based Practice Assessment Tool.
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BACKGROUND AND PURPOSE: Evidence-based practice (EBP) is essential to optimal health care outcomes. Interventions to improve use of evidence depend on accurate assessments from reliable, valid, and user-friendly tools. This study reports psychometric analyses from a modified version of a widely used EBP questionnaire, the information literacy for nursing practice (ILNP). METHODS: After content validity assessments by nurse researchers, a convenience sample of 2,439 nurses completed the revised 23-item questionnaire. We examined internal consistency and used factor analyses to assess the factor structure. RESULTS: A modified 4-factor model demonstrated adequate fit to the data. Cronbach’s alpha was .80-.92 for the subscales. CONCLUSIONS: The shortened ILNP (renamed Healthcare EBP Assessment Tool or HEAT) demonstrated adequate content validity, construct validity, and reliability.
The development of ORACLe: a measure of an organisation’s capacity to engage in evidence-informed health policy
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BACKGROUND: Evidence-informed policymaking is more likely if organisations have cultures that promote research use and invest in resources that facilitate staff engagement with research. Measures of organisations’ research use culture and capacity are needed to assess current capacity, identify opportunities for improvement, and examine the impact of capacity-building interventions. The aim of the current study was to develop a comprehensive system to measure and score organisations’ capacity to engage with and use research in policymaking, which we entitled ORACLe (Organisational Research Access, Culture, and Leadership). METHOD: We used a multifaceted approach to develop ORACLe. Firstly, we reviewed the available literature to identify key domains of organisational tools and systems that may facilitate research use by staff. We interviewed senior health policymakers to verify the relevance and applicability of these domains. This information was used to generate an interview schedule that focused on seven key domains of organisational capacity. The interview was pilot-tested within four Australian policy agencies. A discrete choice experiment (DCE) was then undertaken using an expert sample to establish the relative importance of these domains. This data was used to produce a scoring system for ORACLe. RESULTS: The ORACLe interview was developed, comprised of 23 questions addressing seven domains of organisational capacity and tools that support research use, including (1) documented processes for policymaking; (2) leadership training; (3) staff training; (4) research resources (e.g. database access); and systems to (5) generate new research, (6) undertake evaluations, and (7) strengthen relationships with researchers. From the DCE data, a conditional logit model was estimated to calculate total scores that took into account the relative importance of the seven domains. The model indicated that our expert sample placed the greatest importance on domains (2), (3) and (4). CONCLUSION: We utilised qualitative and quantitative methods to develop a system to assess and score organisations’ capacity to engage with and apply research to policy. Our measure assesses a broad range of capacity domains and identifies the relative importance of these capacities. ORACLe data can be used by organisations keen to increase their use of evidence to identify areas for further development.
An evaluation of orthopaedic nurses’ participation in an educational intervention promoting research usage – a triangulation convergence model.
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AIMS AND OBJECTIVES: To describe the orthopaedic nurses’ experiences regarding the relevance of an educational intervention and their personal and contextual barriers to participation in the intervention. BACKGROUND: One of the largest barriers against nurses’ research usage in clinical practice is the lack of participation. A previous survey identified 32 orthopaedic nurses as interested in participating in nursing research. An educational intervention was conducted to increase the orthopaedic nurses’ research knowledge and competencies. However, only an average of six nurses participated. DESIGN: A triangulation convergence model was applied through a mixed methods design to combine quantitative results and qualitative findings for evaluation. METHODS: Data were collected from 2013-2014 from 32 orthopaedic nurses in a Danish regional hospital through a newly developed 21-item questionnaire and two focus group sessions. Data were first analysed using descriptive statistics (stata 12.0) and qualitative manifest content analysis. Second, the results were compared, contrasted and interpreted using international literature. RESULTS: The nurses experienced the intervention as a new way to focus on nursing research in practice. However, some nurses were not able to see the relevance of research usage in clinical practice. Nursing research was not a top priority for the nurses and their personal barriers for research usage during their working day were prioritising patients’ and colleagues’ well-being. Their colleagues’ and head section nurses’ lack of acceptance regarding participation in the teaching session was a contextual barrier for the nurses. CONCLUSION: The nurses were interested in participating in the intervention. However, some felt restricted by the research-practice gap and by diverse personal and contextual barriers. RELEVANCE TO CLINICAL PRACTICE: The knowledge derived from this study has high clinical and practical relevance and is currently used to facilitate the nurses’ research usage in the orthopaedic department setting, by working around the perceived barriers.
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Health Care Administration and Organization
Complexity in the new NHS: longitudinal case studies of CCGs in England.
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OBJECTIVE: The reform in the English National Health Services (NHS) under the Health and Social Care Act 2012 is unlike previous NHS reorganisations. The establishment of clinical commissioning groups (CCGs) was intended to be ‘bottom up’ with no central blueprint. This paper sets out to offer evidence about how this process has played out in practice and examines the implications of the complexity and variation which emerged. DESIGN: Detailed case studies in CCGs across England, using interviews, observation and documentary analysis. Using realist framework, we unpacked the complexity of CCG structures. SETTING/PARTICIPANTS: In phase 1 of the study (January 2011 to September 2012), we conducted 96 interviews, 439 h of observation in a wide variety of meetings, 2 online surveys and 38 follow-up telephone interviews. In phase 2 (April 2013 to March 2015), we conducted 42 interviews with general practitioners (GPs) and managers and observation of 48 different types of meetings. RESULTS: Our study has highlighted the complexity inherent in CCGs, arising out of the relatively permissive environment in which they developed. Not only are they very different from one another in size, but also in structure, functions between different bodies and the roles played by GPs. CONCLUSIONS: The complexity and lack of uniformity of CCGs is important as it makes it difficult for those who must engage with CCGs to know who to approach at what level. This is of increasing importance as CCGs are moving towards greater integration across health and social care. Our study also suggests that there is little consensus as to what being a ‘membership’ organisation means and how it should operate. The lack of uniformity in CCG structure and lack of clarity over the meaning of ‘membership’ raises questions over accountability, which becomes of greater importance as CCG is taking over responsibility for primary care co-commissioning.
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.
Advanced nurse practitioners in the care of frail older people: a challenge for geriatricians?
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There may be no single national specialist qualification for nursing care for older adults, but there are opportunities for nurses to become an advanced nurse practitioner, a role recognised and validated by the RCN.
The facilitators of communication with people with dementia in a care setting: an interview study with healthcare workers.
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OBJECTIVES: to describe the views of healthcare workers on the facilitators of communication with people with dementia in a care setting. DESIGN: thematic analysis of semi-structured interviews. SETTING: all participants were interviewed in their place of work. PARTICIPANTS: sixteen healthcare workers whose daily work involves interacting with people with dementia. RESULTS: four overarching categories of themes were identified from the interviews that impact on communication: the attributes of a care worker, communication strategies used, organisational factors and the physical characteristics of the care environment. CONCLUSION: many strategies used by healthcare workers to facilitate communication have not yet been studied in the research literature. Participants’ views on training should be incorporated into future dementia training programmes.
Stress, Social Support, and Burnout Among Long-Term Care Nursing Staff.
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Long-term care nursing staff are subject to considerable occupational stress and report high levels of burnout, yet little is known about how stress and social support are associated with burnout in this population. The present study utilized the job demands-resources model of burnout to examine relations between job demands (occupational and personal stress), job resources (sources and functions of social support), and burnout in a sample of nursing staff at a long-term care facility (N = 250). Hierarchical linear regression analyses revealed that job demands (greater occupational stress) were associated with more emotional exhaustion, more depersonalization, and less personal accomplishment. Job resources (support from supervisors and friends or family members, reassurance of worth, opportunity for nurturing) were associated with less emotional exhaustion and higher levels of personal accomplishment. Interventions to reduce burnout that include a focus on stress and social support outside of work may be particularly beneficial for long-term care staff.
How the perspectives of nursing assistants and frail elderly residents on their daily interaction in nursing homes affect their interaction: a qualitative study
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BACKGROUND: Good support from and positive relations with institutional staff can enhance the psychosocial wellbeing of residents admitted to a nursing home. Nursing assistants (NAs) interact most frequently with residents and play an important role in developing good rapport with them. Most studies have described the daily interactions between NAs and residents as task oriented. Only few have attempted to explore the perspectives of NAs and residents on their daily interactions. Therefore, the aim of this study was to identify the types of daily interactions perceived by NAs and residents. We also investigated those intentions / beliefs held by NAs and residents that might direct their interactive behaviors. METHODS: A descriptive, exploratory, qualitative approach was used to explore the perspectives of 18 NAs (mean age: 51) and 15 residents (mean age: 84.4) on their daily interactions. Unstructured in-depth interviews were used to collect data. All of the interviews were conducted from July to December 2013. The collected data were transcribed verbatim and analyzed by content analysis. RESULTS: Three types of interactions were found that described the NAs’ and residents’ perspectives on their daily interactions: (1) physiologically-oriented daily interactions; (2) cordial interactions intended to maintain a harmonious atmosphere; and (3) reciprocal social interactions intended to develop closer rapport. One or more themes reflecting the participants’ intentions or beliefs were identified from each group to support each type of interaction. CONCLUSIONS: An over-emphasis on the formal caring relationship and over-concern about maintaining a harmonious atmosphere contributed to a superficial and distant relationship between the two parties. Building close rapport takes time and involves repeated reciprocal social interactions. The findings showed that with good intentions to establish closer rapport, both NAs and residents did favors for each other. All of those favors were easily integrated in the care provided to the residents without increasing the workload of the NAs. Modifying the training given to NAs and adjusting institutional policies are crucial to raising the competence of the NAs in building good relationships with residents. Positive interactions improve the psychosocial wellbeing of the residents and encourage them to cooperate during the delivery of care, thereby improving their overall health and contributing to the NAs’ job satisfaction.
Assessment of immigrant certified nursing assistants’ communication when responding to standardized care challenges.
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OBJECTIVE: Certified nursing assistants (CNAs) provide 80% of the hands-on care in US nursing homes; a significant portion of this work is performed by immigrants with limited English fluency. This study is designed to assess immigrant CNA’s communication behavior in response to a series of virtual simulated care challenges. METHODS: A convenience sample of 31 immigrant CNAs verbally responded to 9 care challenges embedded in an interactive computer platform. The responses were coded with the Roter Interaction Analysis System (RIAS), CNA instructors rated response quality and spoken English was rated. RESULTS: CNA communication behaviors varied across care challenges and a broad repertoire of communication was used; 69% of response content was characterized as psychosocial. Communication elements (both instrumental and psychosocial) were significant predictors of response quality for 5 of 9 scenarios. Overall these variables explained between 13% and 36% of the adjusted variance in quality ratings. CONCLUSION: Immigrant CNAs responded to common care challenges using a variety of communication strategies despite fluency deficits. PRACTICE IMPLICATIONS: Virtual simulation-based observation is a feasible, acceptable and low cost method of communication assessment with implications for supervision, training and evaluation of a para-professional workforce.
Investigating staff knowledge of safeguarding and pressure ulcers in care homes.
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OBJECTIVE: To investigate whether nursing/care home staff regard pressure ulceration as a safeguarding issue; and to explore reporting mechanisms for pressure ulcers (PUs) in nursing/care homes. METHOD: Within one clinical commissioning group, 65 staff members from 50 homes completed a questionnaire assessing their experiences of avoidable and unavoidable PUs, grading systems, and systems in place for referral to safeguarding teams. Understanding of safeguarding was assessed in depth by interviews with 11 staff members. RESULTS: Staff observed an average of 2.72 PUs in their workplaces over the previous 12 months, judging 45.6% to be avoidable. Only a minority of respondents reported knowledge of a grading system (mostly the EPUAP/NPUAP system). Most respondents would refer PUs to the safeguarding team: the existence of a grading system, or guidance, appeared to increase that likelihood. Safeguarding was considered a priority in most homes; interviewees were familiar with the term safeguarding, but some confusion over its meaning was apparent. Quality of written documentation and verbal communication received before residents returned from hospital was highlighted. However, respondents expressed concern over lack of information regarding skin integrity. Most staff had received education regarding ulcer prevention or wound management during training, but none reported post-registration training or formal education programmes; reliance was placed on advice of district nurses or tissue viability specialists. CONCLUSION: Staff within nursing/care homes understand the fundamentals of managing skin integrity and the importance of reporting skin damage; however, national education programmes are needed to develop knowledge and skills to promote patient health-related quality of life, and to reduce the health-care costs of pressure damage. Further research to investigate understanding, knowledge and skills of nursing/care home staff concerning pressure ulcer development and safeguarding will become increasingly necessary, as levels of the older population who may require assisted living continue to rise.
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Health Care Innovation and Quality Assurance
Implementing Montessori Methods for Dementia™ in Ontario long-term care homes: Recreation staff and multidisciplinary consultants’ perceptions of policy and practice issues
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Montessori-based activities use a person-centred approach to benefit persons living with dementia by increasing their participation in, and enjoyment of, daily life. This study investigated recreation staff and multidisciplinary consultants’ perceptions of factors that affected implementing Montessori Methods for Dementia in long-term care homes in Ontario, Canada. Qualitative data were obtained during semi-structured telephone interviews with 17 participants who worked in these homes. A political economy of aging perspective guided thematic data analysis. Barriers such as insufficient funding and negative attitudes towards activities reinforced a task-oriented biomedical model of care. Various forms of support and understanding helped put Montessori Methods for Dementia into practice as a person-centred care program, thus reportedly improving the quality of life of residents living with dementia, staff and family members. These results demonstrate that when Montessori Methods for Dementia approaches are learned and understood by staff they can be used as practical interventions for long-term care residents living with dementia.
Social-Professional Networks in Long-Term Care Settings With People With Dementia: An Approach to Better Care? A Systematic Review
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Dementia is a syndrome associated with stigma and social isolation. Forty-two percent of people with dementia in the United States and almost 40% in the United Kingdom live in assisted living and residential care facilities. Up to 90% of residents with dementia experience behavioral and psychological symptoms of dementia (BPSD). Currently psychotropic drugs are often used to manage BPSD, despite the drugs’ limited efficacy and adverse effects. Even though psychosocial approaches are as effective as medical ones without side effects, their uptake has been slow. Social networks that investigate the structure of relationships among residents and staff may represent an important resource to increase the uptake of psychosocial approaches and facilitate improvements in care.; BackgroundDementia is a syndrome associated with stigma and social isolation. Forty-two percent of people with dementia in the United States and almost 40% in the United Kingdom live in assisted living and residential care facilities. Up to 90% of residents with dementia experience behavioral and psychological symptoms of dementia (BPSD). Currently psychotropic drugs are often used to manage BPSD, despite the drugs’ limited efficacy and adverse effects. Even though psychosocial approaches are as effective as medical ones without side effects, their uptake has been slow. Social networks that investigate the structure of relationships among residents and staff may represent an important resource to increase the uptake of psychosocial approaches and facilitate improvements in care.
Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections.
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OBJECTIVES: The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member. DESIGN: Indepth interviews were conducted with GPs, and focus groups were held with community members. SETTING: General practice and community setting. PARTICIPANTS: 15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken. RESULTS: The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available. CONCLUSIONS: Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing. TRIAL REGISTRATION NUMBER: NCT01913860; Pre-results.
Quality in residential care from the perspective of people living with dementia: The importance of personhood
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Background Providing quality care for people with dementia to meet the growing demand for services is a significant challenge to Australia and globally. When it comes to planning for current and future care needs, limited information is available on what people living with dementia and their family members consider the meaning of “quality: in residential care services. Objective To describe the meaning of quality residential care from the perspective of people with cognitive impairment and their family members. Design Qualitative data collection via in-depth interviews and focus groups was undertaken with people with dementia or cognitive impairment living in residential care or the community (n = 15), and family members of people with dementia (n = 26). Thematic analysis was undertaken to identify key themes. Results The theme of supporting personhood was identified as the overarching concept of importance to both people with dementia and their family members and as the foundation for quality care. There were subtle differences in how this concept was expressed by people with dementia themselves and their family members. However, for both groups, access to meaningful activities and opportunities to feel useful and valued were identified as important ways to support personhood in residential care. Separate to this theme of personhood, family members also talked about the importance of a supportive physical environment in the care home, while for the people with dementia themselves maintaining a connection with family was an important contributor to their experience of good quality residential care. Conclusions Supporting personhood was identified as a critical key concept underpinning quality residential aged care, from the perspective of both people with cognitive impairment and their family members. This highlights the important contribution that the psychological and social characteristics of care make to providing a good quality residential care experience from the perspective of consumers with dementia.
Perceived and observed quality of long-term care for residents – Does functional ability account?
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BACKGROUND: Measuring quality in long-term residential care involves challenges concerning both the measurement method and the impaired functional ability of many older people. Ensuring quality in care is even more important for people with functional impairments, as this is a vulnerable group who may be unable to report poor quality of care for themselves. AIMS AND OBJECTIVES: The aim of this study was to analyse how perceived and observed assessments of the quality of care varied according to the residents’ functional ability. DESIGN: The data (n = 278) used in the analyses included residents’, family members’ and staff assessments of perceived and observed quality of care combined with the Resident Assessment Instrument (RAI) scales measuring the same residents’ functional abilities (physical, psychological, cognitive and social). Observations were included in the data if all four assessment types (by residents, family members, staff and the RAI) were available. The dimensions of quality of care emerging from the factor analysis were used. METHODS: Linear regression was used to explore the association between resident’s functional abilities and assessed quality of care. RESULTS: Higher level of depression symptoms and higher level of dependency in activities of daily living (ADL) were significantly associated with lower level of perceived and observed quality of care. By contrast, the level of residents’ cognitive functioning was not significantly associated with any quality dimensions. The social aspect was the only dimension of functional ability on which better functional ability indicated better quality of care, although differences between respondent groups were also observed. CONCLUSIONS: These analyses emphasize the importance of taking residents’ functional ability into account when collecting information on and interpreting the results of perceived and observed quality of care reported separately by residents, family members and staff. IMPLICATIONS FOR PRACTICE: The information obtained can inform care professionals of how dimensions of residents’ functional impairments are associated with perceived and observed quality of care and the quality of older people’s care can thereby be improved.
Green House Adoption and Nursing Home Quality.
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OBJECTIVE: To evaluate the impact of the Green House (GH) model on nursing home resident-level quality of care measures. DATA SOURCES/STUDY SETTING: Resident-level minimum data set (MDS) assessments merged with Medicare inpatient claims for the period 2005 through 2010. STUDY DESIGN: Using a difference-in-differences framework, we compared changes in care quality and outcomes in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nursing homes that had not adopted the GH model. PRINCIPAL FINDINGS: For individuals residing in GH homes, adoption of the model lowered readmissions and several MDS measures of poor quality, including bedfast residents, catheter use, and pressure ulcers, but these results were not present across the entire GH organization, suggesting possible offsetting effects for residents of non-GH “legacy” units within the GH organization. CONCLUSIONS: GH adoption led to improvement in rehospitalizations and certain nursing home quality measures for individuals residing in a GH home. The absence of evidence of a decline in other clinical quality measures in GH nursing homes should reassure anyone concerned that GH might have sacrificed clinical quality for improved quality of life.
Scale-up of routine viral load testing in resource-poor settings: current and future implementation challenges.
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Despite immense progress in ART scale-up, many people still lack access to basic standards of care, with our ability to meet UNITAIDS 90-90-90 treatment targets for HIV/AIDS dependent on dramatic improvements in diagnostics. WHO recommends routine monitoring of ART effectiveness using viral load (VL) testing at 6 months and every 12 months, to monitor treatment adherence and minimise failure and will publish its VL toolkit later this year. However, the cost and complexity of VL is preventing scale-up beyond developed countries and there is a lack of awareness among clinicians as to the long-term patient benefits and its role in prolonging the longevity of treatment programmes. With developments in this diagnostic field rapidly evolving – including the recent improvements for accurately using Dried Blood Spot (DBS) and the imminent appearance to the market of point-of-care (POC) technologies offering decentralised diagnosis – we describe current barriers to VL testing in resource-limited settings. Effective scale-up can be achieved through health- and laboratory-system strengthening and test price reductions, as well as tackling multiple programmatic and funding challenges.
Expert views on the factors enabling good end of life care for people with dementia: a qualitative study.
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BACKGROUND: Dementia, of all long term illnesses, accounts for the greatest chronic disease burden, and the number of people with age-related diseases like dementia is predicted to double by 2040. People with advanced dementia experience similar symptoms to those dying with cancer yet professional carers find prognostication difficult and struggle to meet palliative care needs, with physical symptoms undetected and untreated. While elements of good practice in this area have been identified in theory, the factors which enable such good practice to be implemented in real world practice need to be better understood. The aim of this study was to determine expert views on the key factors influencing good practice in end of life care for people with dementia. METHODS: Semi-structured telephone and face-to-face interviews with topic guide, verbatim transcription and thematic analysis. Interviews were conducted with experts in dementia care and/or palliative care in England (n = 30). RESULTS: Four key factors influencing good practice in end of life care for people with dementia were identified from the expert interviews: leadership and management of care, integrating clinical expertise, continuity of care, and use of guidelines. CONCLUSIONS: The relationships between the four key factors are important. Leadership and management of care have implications for the successful implementation of guidelines, while the appropriate and timely use of clinical expertise could prevent hospitalisation and ensure continuity of care. A lack of integration across health and social care can undermine continuity of care. Further work is needed to understand how existing guidelines and tools contribute to good practice. DISCLAIMER: This article presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Grant Reference Number RP-PG-0611-20005). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Person-centered Climate Questionnaire-Patient in English: A psychometric evaluation study in long-term care settings.
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BACKGROUND: There is increasing evidence that person-centered care improves nursing home residents’ quality of life. Despite the clear focus of person-centered care on enhancing care for residents and engaging residents in care, there are few options available for measuring person-centered care from the perspective of the elder residents. OBJECTIVE: The aim of this study was to assess the psychometric properties of the English version of the Person-centered Climate Questionnaire-Patient (PCQ-P) in U.S. long-term care settings. METHODS: A total of 189 older adults from six nursing homes in the Midwestern United States were included. Convergent validity and known-group comparison were examined for construct validity. Exploratory factor analysis and second-order confirmatory factor analysis were utilized to examine the factor structure. Reliability was tested using Cronbach’s alpha values for internal consistency. RESULTS: This study demonstrated a substantial convergent validity of the PCQ-P in English as higher scores correlated significantly with higher resident life satisfaction (r=0.459), and the satisfactory construct validity as evidenced by a significantly higher mean PCQ-P score from residents in higher quality nursing homes. Factor analysis demonstrated that the PCQ-P had three factors (hospitality, safety, and everydayness) in U.S. nursing home residents. The PCQ-P showed satisfactory internal consistency reliability (alpha=0.89). CONCLUSION: The English version of the PCQ-P is a valid and reliable tool to directly measure the perceptions of the person-centered climate in the U.S nursing homes. The simple and straightforward PCQ-P items are easy to administer to nursing home residents. Consequently, clinical staff can utilize the PCQ-P to assess the unit climate, and evaluate outcomes of person-centered interventions.
Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa: Review of Randomised Clinical Trials.
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BACKGROUND: Africa bears 24% of the global burden of disease but has only 3% of the world’s health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness. METHODS AND FINDINGS: A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions’ components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover. CONCLUSIONS: Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.
A Quality Improvement Project to Improve and Reduce the Use of Hand Mitt Restraints in Nursing Home Residents.
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Physical restraints can be harmful and abusive. Improper use of physical restraints has negative consequences on physical, functional, and psychological aspects and can even cause death. The main indication for physical restraint is a safety measure intended to protect individuals or others from disruptive behavior or for therapy maintenance. However, there is almost nonexistent evidence that physical restraints can prevent harm. Restraint-related injury is also underreported.1–3 On the contrary, restraint removal was found to reduce fall injuries in nursing home residents4 and reduce lengths of stay in hospital patients.
Improving the Quality of Care of Long-Stay Nursing Home Residents in France.
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The aim of the Impact d’une demarche QUAlite sur l’evolution des pratiques et le declin fonctionnel des Residents en Etablissement d’hebergement pour personnes agees dependantes (IQUARE) study was to examine the effects of a global intervention comprising professional support and education for nursing home (NH) staff on quality indicators (QIs) and functional decline and emergency department (ED) transfers of residents. One hundred seventy-five NHs in France (a total of 6,275 residents randomly selected from NHs) volunteered and were enrolled in a nonrandomized controlled multicenter individually customize trial with 18-month follow-up. NHs were allocated to a quality audit and feedback intervention (control group: 90 NHs, 3,258 residents) or to the quality audit and feedback intervention plus collaborative work meetings between a hospital geriatrician and NH staff (experimental group: 85 NHs, 3,017 residents). At the NH level, prevalence of assessment of kidney function, cognitive function, risk of pressure ulcers, behavioral disturbances, depression, pain, weight measurement, and transfer to the ED were recorded. Ability to perform basic activities of daily living was assessed at the resident level. At baseline, NH QIs were generally low (with large standard deviations), and annual rate of transfer to the ED was high (~20%) and similar in both groups. The intervention had a significant positive effect on the prevalence of assessment of pressure ulcer risk, depression, pain, and prevalence of ED transfers. It had no significant effect on functional decline. Large-scale efforts to improve QIs involving collaboration between hospital and NH providers and based on audit and collaborative discussion are feasible and improve some aspects of quality of care in NHs.
Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes.
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OBJECTIVES: To examine facility-level pressure ulcer (PrU) development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes. DESIGN: Four-year retrospective longitudinal design. SETTING: VHA facilities (N = 109) representing 132 nursing homes known as community living centers (CLCs). PARTICIPANTS: VHA nursing home residents. MEASUREMENTS: PrUs were identified using fiscal year (FY) 2008-11 Minimum Data Set (MDS) data. PrU development was defined as a Stage 2 or larger PrU on an MDS assessment with no PrU on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of PrUs (c-statistic = 0.72). A Bayesian hierarchical model that adjusted for differences in the precision of PrU rates from different-size facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope. RESULTS: Over the 4-year period, the beginning of which coincided with the VHA’s system-wide adoption of culture change as a performance measure, median SRA facility PrU development rates were fairly consistent at approximately 4%. The range in SRA rates declined over the years, from a 14.8-percentage point spread to 10.1-percentage point spread. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (P < .001) that were below the median across all 4 years. CONCLUSION: A system-wide culture change implementation did not affect CLC PrU development rates, but there was significant variation in facility rates, and some facilities had sustained high performance.
Study protocol of a cluster randomized controlled trial evaluating the efficacy of a comprehensive pressure ulcer prevention programme for private for-profit nursing homes.
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BACKGROUND: Because the demand for government-subsidized nursing homes in Hong Kong outstrips the supply, the number of for-profit private nursing homes has been increasing rapidly. However, the standard of care in such homes is always criticized. Pressure ulcers are a major long-term care issue that is closely associated with the quality of care delivered in nursing home settings. The aim of this study is to evaluate the effectiveness of a pressure ulcer prevention programme for residents in private for-profit nursing homes. METHODS/DESIGN: This is a two-arm cluster randomized controlled trial with an estimated sample size of 1088 residents and 74 care staff from eight for-profit private nursing homes. Eligible nursing homes will be those classified as category A2 homes in the Enhanced Bought Place Scheme (EBPS), having a capacity of around 130-150 beds, and no structured PU prevention protocol and/or programmes in place. Care staff will be health workers, personal care workers, and nurses who are front-line staff providing direct care to residents. Eight nursing homes will be randomly assigned to either an experimental or control group. The experimental group will be provided with an intensive training programme and will be involved in the implementation of a 16-week pressure ulcer prevention protocol, while the control group will deliver the usual pressure ulcer prevention care. The study outcomes are the pressure ulcer prevention knowledge and skills of the care staff and the prevalence and incidence of pressure ulcers. Data on the knowledge and skills of care staff, and prevalence of pressure ulcer will be collected at the base line, and then at the 8(th) week and at completion of the implementation of the protocol. The assessment of the incidence of pressures will start from before the commencement of the intensive training course to the end of the implementation of the protocol. DISCUSSION: In view of the negative impact of pressure ulcers, it is important to have an effective and evidence-based pressure ulcer prevention programme to improve preventive care in private for-profit nursing homes. The programme will potentially improve the knowledge and skills of care staff on the prevention of pressure ulcers and also lead to a reduction in the development of pressure ulcers in nursing homes. TRIAL REGISTRATION: The Current Controlled Trial is NCT02270385 , 18 October 2014.
Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations.
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BACKGROUND: Performing root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions. OBJECTIVES: To describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers. DESIGN: SNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period. SETTING: SNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial. PARTICIPANTS: Sixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers. INTERVENTIONS: SNFs received education and technical assistance in INTERACT implementation. MEASURES: Data were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. RESULTS: A total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers. CONCLUSION: Summarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.
Ontario’s emergency department process improvement program: the experience of implementation.
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OBJECTIVES: In recent years, Lean manufacturing principles have been applied to health care quality improvement efforts to improve wait times. In Ontario, an emergency department (ED) process improvement program based on Lean principles was introduced by the Ministry of Health and Long-Term Care as part of a strategy to reduce ED length of stay (LOS) and to improve patient flow. This article aims to describe the hospital-based teams’ experiences during the ED process improvement program implementation and the teams’ perceptions of the key factors that influenced the program’s success or failure. METHODS: A qualitative evaluation was conducted based on semistructured interviews with hospital implementation team members, such as team leads, medical leads, and executive sponsors, at 10 purposively selected hospitals in Ontario, Canada. Sites were selected based, in part, on their changes in median ED LOS following the implementation period. A thematic framework approach as used for interviews, and a standard thematic coding framework was developed. RESULTS: Twenty-four interviews were coded and analyzed. The results are organized according to participants’ experience and are grouped into four themes that were identified as significantly affecting the implementation experience: local contextual factors, relationship between improvement team and support players, staff engagement, and success and sustainability. The results demonstrate the importance of the context of implementation, establishing strong relationships and communication strategies, and preparing for implementation and sustainability prior to the start of the project. CONCLUSIONS: Several key factors were identified as important to the success of the program, such as preparing for implementation, ensuring strong executive support, creation of implementation teams based on the tasks and outcomes of the initiative, and using multiple communication strategies throughout the implementation process. Explicit incorporation of these factors into the development and implementation of future similar interventions in health care settings could be useful.
A review of the implementation and research strategies of advance care planning in nursing homes.
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BACKGROUND: Nursing home (NH) patients have complex health problems, disabilities and needs for Advance Care Planning (ACP). The implementation of ACP in NHs is a neglected research topic, yet it may optimize the intervention efficacy, or provide explanations for low efficacy. This scoping review investigates methods, design and outcomes and the implementation of ACP (i.e., themes and guiding questions, setting, facilitators, implementers, and promoters/barriers). METHODS: A systematic search using ACP MESH terms and keywords was conducted in CINAHL, Medline, PsychINFO, Embase and Cochrane libraries. We excluded studies on home-dwelling and hospital patients, including only specific diagnoses and/or chart-based interventions without conversations. RESULTS: Sixteen papers were included. There were large variations in definitions and content of ACP, study design, implementation strategies and outcomes. Often, the ACP intervention or implementation processes were not described in detail. Few studies included patients lacking decision-making capacity, despite the fact that this group is significantly present in most NHs. The chief ACP implementation strategy was education of staff. Among others, ACP improved documentation of and adherence to preferences. Important implementation barriers were non-attending NH physicians, legal challenges and reluctance to participate among personnel and relatives. CONCLUSION: ACP intervention studies in NHs are few and heterogeneous. Variation in ACP definitions may be related to cultural and legal differences. This variation, along with sparse information about procedures, makes it difficult to collate and compare research results. Essential implementation considerations relate to the involvement and education of nurses, physicians and leaders.
Physical Restraint and Antipsychotic Medication Use Among Nursing Home Residents With Dementia.
Health systems guidance appraisal—a critical interpretive synthesis
BACKGROUND:Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process.METHODS:We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed.RESULTS:We identified 43 papers that met eligibility criteria. No existing review was found on this topic, and no HSG appraisal tool was identified. Over one third of the authors implicitly or explicitly identified the need for a high-quality tool aimed to systematically evaluate HSG and contribute to its development/reporting. We identified 30 concepts that may be relevant to the appraisal of HSG and were able to cluster them into three meaningful domains: process principles, content, and context principles.CONCLUSIONS:Our study showed the role that the quality criteria play in the development, appraisal, and reporting of HSG and demonstrated the link and resonance within and between the various concepts in the three domains.
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Research Practice and Methodology
Development and implementation of a peer mentoring program for early career gerontological faculty.
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PURPOSE: The Hartford Gerontological Nursing Leaders (HGNL) formerly known as the Building Academic Geriatric Nursing Capacity Initiative (BAGNC), in conjunction with the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE), developed and executed a peer mentoring program beginning in 2011 to enhance both (a) the experience of newly selected scholars and fellows to the NHCGNE and (b) the ongoing professional development of HGNL members. The purpose of this article is to describe key strategies used to develop and execute the peer mentoring program and to present formative program evaluation. DESIGN: The program was launched in January 2011 with seven peer mentor and mentee matches. In June 2012, the peer mentoring committee solicited feedback on the development of the peer mentoring program and changes were made for the subsequent cohorts. FINDINGS: An additional 12 matches were made in the following 2 years (2012 and 2013), for a total of 31 matches to date. We have learned several key lessons from our three cohorts regarding how to structure, implement, and carefully evaluate a peer mentoring program. CONCLUSIONS: Informal evaluation of our peer mentoring program noted several challenges for both peer mentors and mentees. Having knowledge of and addressing those challenges may increase the overall quality and effectiveness of peer mentoring programs and, in turn, benefit academic nursing by strengthening the faculty workforce. CLINICAL RELEVANCE: Findings from development and implementation of a peer mentoring program for gerontological faculty could lead to new and adaptable programs in a variety of clinical and education settings.
The Future of Theory-Generating Meta-Synthesis Research.
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Nearly 30 years have passed since Noblit and Hare (1988) published their seminal monograph relating to meta-ethnography (i.e., meta-synthesis) research. During that time, scholars have used meta-synthesis methods to summarize and synthesize findings from across countless primary qualitative investigations. In addition, they have used these same methods to adapt and develop novel concepts and theoretical frameworks. Currently, findings from meta-synthesis investigations range from simple re-categorizations of primary qualitative research findings to newly synthesized theoretical frameworks.
Meta-Study as Diagnostic: Toward Content Over Form in Qualitative Synthesis
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Having previously conducted qualitative syntheses of the diabetes literature, we wanted to explore the changes in theoretical approaches, methodological practices, and the construction of substantive knowledge which have recently been presented in the qualitative diabetes literature. The aim of this research was to explore the feasibility of synthesizing existing qualitative syntheses of patient perspectives of diabetes using meta-study methodology. A systematic review of qualitative literature, published between 2000 and 2013, was conducted. Six articles were identified as qualitative syntheses. The meta-study methodology was used to compare the theoretical, methodological, analytic, and synthetic processes across the six studies, exploring the potential for an overarching synthesis. We identified that while research questions have increasingly concentrated on specific aspects of diabetes, the focus on systematic review processes has led to the neglect of qualitative theory and methods. This can inhibit the production of compelling results with meaningful clinical applications. Although unable to produce a synthesis of syntheses, we recommend that researchers who conduct qualitative syntheses pay equal attention to qualitative traditions and systematic review processes, to produce research products that are both credible and applicable.
Using Sandelowski and Barroso’s Meta-Synthesis Method in Advancing Qualitative Evidence
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The purpose of this article was to iteratively account for and discuss the handling of methodological challenges in two qualitative research syntheses concerning patients’ experiences of hospital transition. We applied Sandelowski and Barroso’s guidelines for synthesizing qualitative research, and to our knowledge, this is the first time researchers discuss their methodological steps. In the process, we identified a need for prolonged discussions to determine mutual understandings of the methodology. We discussed how to identify the appropriate qualitative research literature and how to best conduct exhaustive literature searches on our target phenomena. Another finding concerned our status as third-order interpreters of participants’ experiences and what this meant for synthesizing the primary findings. Finally, we discussed whether our studies could be classified as metasummaries or metasyntheses. Although we have some concerns regarding the applicability of the methodology, we conclude that following Sandelowski and Barroso’s guidelines contributed to valid syntheses of our studies.
Reporting standards for guideline-based performance measures
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BACKGROUND: The Guidelines International Network (G-I-N) aims to promote high quality clinical guideline development and implementation. Guideline-based performance measures are a key implementation tool and are widely used internationally for quality improvement, quality assurance, and pay for performance in health care. There is, however, no international consensus on best methods for guideline-based performance measures. In order to address this issue, the G-I-N Performance Measures Working Group aimed to develop a set of consensus-based reporting standards for guideline-based performance measure development and re-evaluation. METHODS: Methodology publications on guideline-based performance measures were identified from a systematic literature review and analyzed. Core criteria for the development and evaluation process of guideline-based performance measures were determined and refined into draft standards with an associated rationale and description of the evidence base. In a two-round Delphi-process, the group members appraised and approved the draft standards. After the first round, the group met to discuss comments and revised the drafts accordingly. RESULTS: Twenty-one methodology publications were reviewed. The group reached strong consensus on nine reporting standards concerning: (1) selection of clinical guidelines, (2) extraction of clinical guideline recommendations, (3) description of the measure development process, (4) measure appraisal, (5) measure specification, (6) description of the intended use of the measure, (7) measure testing/validating, (8) measure review/re-evaluation, and (9) composition of the measure development panel. CONCLUSIONS: These proposed international reporting standards address core components of guideline-based performance measure development and re-evaluation. They are intended to contribute to international reporting harmonization and improvement of methods for performance measures. Further research is required regarding validity, acceptability, and practicality.
Use of network meta-analysis in systematic reviews: a survey of authors
The reporting of network meta-analysis in systematic reviews has increased rapidly since 2009. This qualitative study was undertaken to identify authors’ perceptions of the use of these methods and of what standards for conduct and reporting should apply. Methods This is a survey of authors of systematic reviews reporting network meta-analysis. Results The response rate was 32 % of the authors contacted, with these authors responsible for 34 % of the fully published systematic reviews identified within the period searched. Almost all authors would use the method again. Elements of reporting standards were proposed. Responses revealed some tensions between the view that use of network meta-analysis should be more easily accessible, particularly in the form of software tools, and concern that there is some inappropriate use of the methods, which wider use and greater accessibility could exacerbate. Conclusions Authors demonstrated strong support for adoption of standards for conduct and reporting. The elements of reporting standards proposed are consistent with those included in the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement. Adoption of standards for conduct and reporting will be a significant step towards clarifying what is appropriate use of the methods and what is not. This should be followed by the development of a critical appraisal tool to support end users of systematic reviews reporting network meta-analysis.
Core outcome sets and systematic reviews.
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Systematic reviews seek to bring together research evidence to answer the question for the review. The reviewers usually wish to compare, contrast and, if appropriate, combine the findings of the existing research studies. However, these intentions are often thwarted by inconsistencies in the outcomes that were measured and reported in the individual studies. This, in turn, makes it difficult for readers of the review to use it to make informed decisions and choices about health and social care. One solution is for trials in a particular topic area to measure and report a standardised set of outcomes, which would then be used in the review. Core outcome sets are a means of doing this, providing an agreed standardised collection of outcomes for measuring and reporting for a specific area of health. In this commentary, we argue for greater involvement of systematic reviewers in the development and implementation of core outcome sets. This might help with, for example, the selection of outcomes to include in the Summary of findings tables that provide users of the review with the key quantitative findings. Consideration of core outcome sets when reviewers register their topics with Cochrane Review Groups or in PROSPERO would also help reviewers to plan their reviews. A greater uptake of core outcome sets across research, including systematic reviews, would help towards the ultimate aim of improving health and well-being through improving health and social care.
Objective The aim of this study is to review highly cited articles that focus on non-publication of studies, and to develop a consistent and comprehensive approach to defining (non-) dissemination of research findings.Setting We performed a scoping review of definitions of the term publication bias in highly cited publications.Participants Ideas and experiences of a core group of authors were collected in a draft document, which was complemented by the findings from our literature search.Interventions The draft document including findings from the literature search was circulated to an international group of experts and revised until no additional ideas emerged and consensus was reached.Primary outcomes We propose a new approach to the comprehensive conceptualisation of (non-) dissemination of research.Secondary outcomes Our What, Who and Why approach includes issues that need to be considered when disseminating research findings (What?), the different players who should assume responsibility during the various stages of conducting a clinical trial and disseminating clinical trial documents (Who?), and motivations that might lead the various players to disseminate findings selectively, thereby introducing bias in the dissemination process (Why?).Conclusions Our comprehensive framework of (non-) dissemination of research findings, based on the results of a scoping literature search and expert consensus will facilitate the development of future policies and guidelines regarding the multifaceted issue of selective publication, historically referred to as publication bias.
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Aging
Barricades and brickwalls – a qualitative study exploring perceptions of medication use and deprescribing in long-term care.
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BACKGROUND: The co-administration of multiple drugs (polypharmacy) is the single most common cause of adverse drug events in the older population, and residents of long-term care facilities (LTCFs) are at particularly high risk of medication harm. ‘Deprescribing’ – the withdrawal of an inappropriate medication with goal of managing polypharmacy and improving outcomes – may improve the quality of life of LTCF residents. The RELEASE study sought to explore perceptions of medication use and the concept of deprescribing in LTCFs. METHODS: Focus groups and interviews were conducted with General Practitioners (GPs), pharmacists, nursing staff, residents and their relatives within three LTCFs in the Illawarra-Shoalhaven region of NSW, Australia. Audiotapes were transcribed verbatim and, using the Integrative Model of Behaviour Prediction as a framework, thematic analysis of transcripts was conducted using QSR NVivo 10. RESULTS: Participants acknowledged the burden of too many medications (time to administer, physical discomfort, cost), yet displayed passivity towards medication reduction. Residents and relatives lacked understanding of medicine indications or potential harms. Willingness to initiate and accept medication change was dependent on the GP, who emerged as a central trusted figure. GPs preferred ‘the path of least resistance’, signalling systems barriers (poor uniformity of LTCF medical records, limited trained LTCF personnel); time constraints (resident consultations, follow-up with specialists and family); and the organisation of care (collaborating with LTCF staff, pharmacists and prescribing specialists) as obstacles to deprescribing. CONCLUSIONS: Targeted engagement is required to raise awareness of the risks of polypharmacy in LTCFs and encourage acceptance of deprescribing amongst residents and their relatives. GPs are integral to the success of deprescribing initiatives within this sector.
Physical Restraint and Antipsychotic Medication Use Among Nursing Home Residents With Dementia
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Purpose To explore antipsychotic (AP) medications and physical restraint use and their effects on physical function and cognition in older nursing home residents.; PurposeTo explore antipsychotic (AP) medications and physical restraint use and their effects on physical function and cognition in older nursing home residents.
General practitioners’ perceptions of the stigma of dementia and the role of reciprocity
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A qualitative exploration of the stigma of dementia reported that general practitioners described lack of reciprocity as one way in which people with dementia are perceived within society. This was closely linked to their perception of dementia as a stigma. In this article, we explore whether general practitioners perceive people with dementia as lacking reciprocity and, if so, if this is linked with societal opinions about dementia as a stigma. The implications of both perceptions of people with dementia failing to reciprocate and of stigma for timely diagnosis are explored. Our approach is to follow the thread of reciprocity in the data from our initial study. In this follow-up study, general practitioners’ perceptions of societal views of people with dementia included a perception of a lack of reciprocity specifically linked with; failing to respond to human contact, the absence of an appropriate return on social investment and failing to contribute to, or being a burden on, society. General practitioners reported a link between societal perceptions of lack of reciprocity and stereotypes about advanced dementia, difficulties communicating with people with dementia, and lack of opportunities for people with dementia to reciprocate. General practitioners occupy a key position, they can challenge stereotypes and, with support and targeted training about communicating with people living with dementia, can emphasize the ways in which people with dementia can communicate, thereby enhancing their potential to reciprocate. Such changes have implications for improved care and quality of life through the continued maintenance of social inclusion and perceptions of personhood.
Do physical environmental changes make a difference? Supporting person-centered care at mealtimes in nursing homes
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PURPOSE: Drawing on therapeutic physical environmental design principles and Kitwood’s theoretical view of person-centered care, this study examined the impact of environmental renovations in dining spaces of a long-term care facility on residents’ mealtime experience and staff practice in two care units. METHOD: The research design involved pre- and post-renovation ethnographic observations in the dining spaces of the care units and a post-renovation staff survey. The objective physical environmental features pre- and post-renovations were assessed with a newly developed tool titled Dining Environment Audit Protocol. We collected observational data from 10 residents and survey responses from 17 care aides and nurses. FINDINGS: Based on a systematic analysis of observational data and staff survey responses, five themes were identified: (a) autonomy and personal control, (b) comfort of homelike environment, (c) conducive to social interaction, (d) increased personal support, and (e) effective teamwork. IMPLICATIONS: Although the physical environment can play an influential role in enhancing the dining experience of residents, the variability in staff practices reveals the complexity of mealtime environment and points to the necessity of a systemic approach to foster meaningful culture change.
Incidence of Tube Feeding in 7174 Newly Admitted Nursing Home Residents With and Without Dementia
Non UofA Access
BACKGROUND: Tube feeding is a common form of long-term nutritional support, especially for nursing home residents, of whom many have dementia. OBJECTIVE: Estimating the incidence of feeding tube placement in nursing home residents with and without dementia. METHODS: Using claims data, we studied a cohort of newly admitted nursing home residents aged 65 years and older between 2004 and 2009. Analyses were stratified by dementia. We estimated incidence rates and performed multivariate Cox regression analyses. RESULTS: The study cohort included 7174 nursing home residents. Over a mean follow-up of 1.3 years, 273 people received a feeding tube. The incidence per 1000 person-years was 28.4, with higher estimates for patients with dementia. When adjusting for age, sex, and level of care as a time-dependent covariate, influence of dementia decreased to a nonsignificant hazard ratio. CONCLUSION: It seems that not dementia itself but the overall clinical condition might be a predictor of tube feeding placement.
Severe Impairment Rating Scale: A Useful and Brief Cognitive Assessment Tool for Advanced Dementia for Nursing Home Residents
Non UofA Access
To investigate the utility of the Severe Impairment Rating Scale (SIRS) as a cognitive assessment tool among nursing home residents with advanced dementia, we conducted a cross-sectional study of 96 residents in 3 nursing homes with Functional Assessment Staging Test (FAST) stage 6a and above. We compared the discriminatory ability of SIRS with the Chinese version of Mini-Mental State Examination, Abbreviated Mental Test, and Clock Drawing Test. Among the cognitive tests, SIRS showed the least “floor” effect and had the best capacity to distinguish very severe (FAST stages 7d-f) dementia (area under the curve 0.80 vs 0.46-0.76 for the other tools). The SIRS had the best correlation with FAST staging (r = -.59, P < .01) and, unlike the other 3 tools, exhibited only minimal change in correlation when adjusted for education and ethnicity. Our results support the utility of SIRS as a brief cognitive assessment tool for advanced dementia in the nursing home setting.
Continuous monitoring of emergency admissions of older care home residents to hospital.
Non UofA Access
BACKGROUND: evidence from inspection programmes suggest that the quality of care provided by individual care homes for older people is very variable. Aside from periodic inspection, there is limited information that is routinely collected and can be used to monitor quality. OBJECTIVES: to describe a method for using routine hospital data on admissions of older people as means for monitoring quality of care within a care home. To explore how this might be applied and used. METHODS: we linked hospital admissions to care homes using postcode matching and analysed hospital admission data as a time series, using the Cumulative Sum (CUSUM) technique to detect unusually high rates of admission. RESULTS: if we develop the CUSUM so that the number of times it falsely signals a high rate of admissions is limited to a rate of 0.1% per year, the chances of successfully detecting a doubling of the admission rate within 2 years will range from 48% for the smaller homes to 96% for the larger homes. CONCLUSION: monitoring tools using data on admissions to hospital are both possible and feasible, particularly for the larger homes. However, due to data limitations, users need to be careful about how they interpret triggers and thus ensure follow-up is appropriate. Some of the problems caused by using routine national data can be overcome if care homes used their own information for local monitoring.
Predicting Functional Decline and Recovery for Residents in Veterans Affairs Nursing Homes.
Non UofA Access
PURPOSE OF THE STUDY: This article describes methods and accuracy of predicting change in activities of daily living (ADLs) for nursing home patients following hospitalization. DESIGN AND METHODS: Electronic Health Record data for 5,595 residents of Veterans Affairs’ (VAs’) Community Living Centers (CLCs) aged 70 years and older were analyzed within the VA Informatics and Computing Infrastructure. Data included diagnoses from 7,106 inpatient records, 21,318 functional status evaluations, and 69,140 inpatient diagnoses. The Barthel Index extracted from CLC’s Minimum Data Set was used to assess ADLs loss and recovery. Patients’ diagnoses on hospital admission, ADL status prior to hospitalization, age, and gender were used alone or in combination to predict ADL loss/gain following hospitalization. Area under the Receiver-Operator Curve (AUC) was used to report accuracy of predictions in short (14 days) and long-term (15-365 days) follow-up post-hospitalization. RESULTS: Admissions fell into 7 distinct patterns of recovery and loss: early recovery 19%, delayed recovery 9%, delayed recovery after temporary decline 9%, early decline 29%, delayed decline 10%, delayed decline after temporary recovery 6%, and no change 18%. Models accurately predicted ADL’s 14-day post-hospitalization (AUC for bathing 0.917, bladder 0.842, bowels 0.875, dressing 0.871, eating 0.867, grooming 0.902, toileting 0.882, transfer 0.852, and walking deficits was 0.882). Accuracy declined but remained relatively high when predicting 14-365 days post-hospitalization (AUC ranging from 0.798 to 0.875). IMPLICATIONS: Predictive modeling may allow development of more personalized predictions of functional loss and recovery after hospitalization among nursing home patients.
Sequence of Functional Loss and Recovery in Nursing Homes.
Non UofA Access
PURPOSE OF THE STUDY: This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery. DESIGN AND METHODS: We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits. RESULTS: The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments. IMPLICATIONS: Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.
Effectiveness of Expanded Implementation of STAR-VA for Managing Dementia-Related Behaviors Among Veterans.
Non UofA Access
PURPOSE OF THE STUDY: Nonpharmacological, psychosocial approaches are first-line treatments for managing behavioral symptoms in dementia, but they can be challenging to implement in long-term care settings. The Veterans Health Administration implemented STAR-VA, an interdisciplinary behavioral approach for managing challenging dementia-related behaviors in its Community Living Center (CLCs, nursing home care) settings. This study describes how the program was implemented and provides an evaluation of Veteran clinical outcomes and staff feedback on the intervention. DESIGN AND METHODS: One mental health professional and registered nurse team from 17 CLCs completed STAR-VA training, which entailed an experiential workshop followed by 6 months of expert consultation as they worked with their teams to implement STAR-VA with Veterans identified to have challenging dementia-related behaviors. The frequency and severity of target behaviors and symptoms of depression, anxiety, and agitation were evaluated at baseline and at intervention completion. Staff provided feedback regarding STAR-VA feasibility and impact. RESULTS: Seventy-one Veterans completed the intervention. Behaviors clustered into 6 types: care refusal or resistance, agitation, aggression, vocalization, wandering, and other. Frequency and severity of target behaviors and symptoms of depression, anxiety, and agitation all significantly decreased, with overall effect sizes of 1 or greater. Staff rated both benefits for Veterans and program feasibility favorably. IMPLICATIONS: This evaluation supports the feasibility and effectiveness of STAR-VA, an interdisciplinary, behavioral intervention for managing challenging behaviors among residents with dementia in CLCs.
REACH VA: Moving from Translation to System Implementation.
Non UofA Access
PURPOSE OF THE STUDY: Resources for Enhancing All Caregivers Health in the Department of Veterans Affairs (REACH VA) has been implemented in the VA system as a national program for caregivers. DESIGN AND METHODS: We describe the trajectory of REACH VA from national randomized clinical trial through translation to national implementation. The implementation is examined through the six stages of the Fixsen and Blase implementation process model: exploration and adoption, program installation, initial implementation, full operation, innovation, and sustainability. Different drivers that move the implementation process forward are important at each stage, including staff selection, staff training, consultation and coaching, staff evaluation, administrative support, program evaluation/fidelity, and systems interventions. RESULTS: Caregivers in the REACH VA 4 session intervention currently implemented in the VA had similar outcomes to longer REACH interventions, including Resources for Enhancing Alzheimer’s Caregivers Health (REACH II). Caregivers experienced significant decreases in burden, depression, anxiety, number of troubling patient behaviors reported, caregiving frustrations, stress symptoms (feeling overwhelmed, feeling like crying, being frustrated as a result of caregiving, being lonely), and general stress. Effect sizes (Cohen’s d) for these significant variables were between small and medium ranging from .24 to .46. IMPLICATIONS: The implementation of REACH VA provides a road map for implementation of other behavioral interventions in health care delivery settings. Lessons learned include the importance of implementing a proven, needed intervention, support from both leadership and clinical staff, willingness to respond to staff and organization needs and modify the intervention while preserving its integrity, and fitting the intervention into ongoing routines and practices.
Quality of life in people with cognitive impairment: nursing homes versus home care.
Patient safety in domiciliary dental care for elderly nursing home residents in Sweden.
Non UofA Access
OBJECTIVE: To analyse patient safety in domiciliary dental care, with data from a quality registry. DESIGN: Retrospective analysis. CLINICAL SETTING: Domiciliary dental care, private caregiver, Sweden, 2012-2014. METHODS: All reported events in the quality registry at a provider of domiciliary dental care, (2012-05-01 to 2014-06-30) were categorized into 14 domains, and for severity as ‘minor’, ‘moderate’, or ‘serious’ events. The reported events were also independently assessed by an experienced reviewer for national requirements of reporting patient safety related events. RESULTS: The quality registry covered 724 (0.03%) reported events during 218,586 consecutive treatment sessions in domiciliary dental care, including 628,070 registered dental procedures. Fifty (6.9%) of the reported events were patient safety related, of which 11 (1.5%) events were reportedly of minor severity, 20 (2.8%) as moderate, and 19 (2.6%) as serious. For all degrees of severity, the most frequently reported events were related to problems with patient identity control (3.3%). None of the events required reporting to national authorities. CONCLUSIONS: Domiciliary dental care has a low frequency of patient safety related events (0.03% of all treatments). Identity controls need to be emphasised in nursing homes or where individuals are dependent on the care of others.
Psychometric Testing of the Health Care Evidence-Based Practice Assessment Tool.
‘I want to feel at home’: establishing what aspects of environmental design are important to people with dementia nearing the end of life.
Non UofA Access
BACKGROUND: The design of environments in which people with dementia live should be understandable, reinforce personal identity and maintain their abilities. The focus on supporting people with dementia to live well has omitted considering the needs or wishes for a supportive physical environment of those who are nearing the end of their lives. Using a combination of focus groups and a Delphi survey, this study explored the views of people with dementia, family carers and professionals on what aspects of the physical environment would be important to support a good quality of life to the very end. METHODS: Three focus groups were carried out in three cities along the East Coast of Australia using a discussion guide informed by a literature review. Focus groups comprised recently bereaved family carers of people with dementia (FG1), people with dementia and family carers of people with dementia (FG2) and practitioners caring for people with dementia nearing or at the end of their lives (FG3). Focus group conversations were audio-recorded with participants’ consent. Audio files were transcribed verbatim and analysed thematically to identify environmental features that could contribute to achieving the goal of providing a comfortable life to the end. A list of design features derived from analysis of focus group transcripts was distributed to a range of experts in the dementia field and a consensus sought on their appropriateness. From this, a set of features to inform the design of environments for people with dementia nearing the end of life was defined. RESULTS: Eighteen people took part in three focus groups: two with dementia, eleven current or recently bereaved family carers and five practitioners. There were differences in opinion on what were important environmental considerations. People with dementia and family carers identified comfort through engagement, feeling at home, a calm environment, privacy and dignity and use of technology to remain connected as important. For practitioners, design to facilitate duty of care and institutional influences on their practice were salient themes. Twenty one experts in the dementia field took part in the survey to agree a consensus on the desirable features derived from analysis of focus group transcripts, with fifteen features agreed. CONCLUSIONS: The fifteen features are compatible with the design principles for people with dementia who are mobile, but include a stronger focus on sensory engagement. We suggest that considering these features as part of a continuum of care will support good practice and offer those with dementia the opportunity to live well until the end and give their families a more positive experience in the last days of their lives together.
Rationale and study protocol for the Nursing Home Compare Plus (NHCPlus) randomized controlled trial: A personalized decision aid for patients transitioning from the hospital to a skilled-nursing facility.
Non UofA Access
BACKGROUND: Annually more than 3 million people are admitted to one of the 15,965 skilled nursing facilities (SNFs) in the United States with 90% of admissions occurring from a hospital. Although the Centers for Medicare and Medicaid Services (CMS) publishes several web-based report cards, including one for nursing homes (Nursing Home Compare, NHC), they are not widely used. This is due, in part, to the complexity of the information available and the fact that the choice of nursing homes is typically made while in the hospital without access to the web-based NHC. We developed Nursing Home Compare Plus (NHCPlus) to address these limitations and to improve the decision-making process. METHODS/DESIGN: This paper describes the design and rationale of a two-arm randomized controlled trial designed to test the effectiveness of NHCPlus compared to usual care only, in a sample of patients being discharged from the hospital to an SNF (N=229). Assessments were conducted within 24h prior to patient discharge and 30-days post discharge. Primary outcomes to be examined included the use of NHC, increased choice of nursing homes with better reported outcomes, and increased distance between patient/family residence and nursing home. Secondary outcomes included satisfaction with the decision to go to a nursing home, confidence in the choice of nursing home, and reduced hospital length of stay. DISCUSSION: NHCPlus is an innovative mobile application designed to allow patients to personalize their choice of nursing homes to meet their medical needs and preferences. The application to other quality report cards is discussed.
Quality of life in people with cognitive impairment: nursing homes versus home care.
Non UofA Access
BACKGROUND: The evaluation of quality of life (QoL) among older adults has become increasingly important, and living arrangements play a pivotal role in determining the QoL of people with cognitive impairment (PWCI). Although informal care (home-based) is favored, transition to formal care (residential care) often becomes necessary, especially in the later stages of cognitive impairment. The primary objective was to compare the QoL of PWCI in the community and nursing homes. Additionally, factors differentiate the QoL of PWCI in these two settings were identified. METHODS: This is a quasi-experimental study design involving 219 older adults with cognitive impairment, aged 60-89 years old from both nursing home and home care. Participants completed the EUROPE Health Interview Survey-QoL (WHO-8), the Short Mini-Mental State Examination (SMMSE), the Barthel Index (BI), the Geriatric Depression Scale (GDS-15), and the Friendship Scale (FS). RESULTS: There were significant differences in QoL, depression, social connectedness (p < 0.01) and cognitive functions (p = 0.01) between home care recipients and nursing home participants. No significant differences were observed with regards to health condition, co morbidities and physical functions between study cohorts. CONCLUSIONS: Older adults with cognitive impairment living at home experienced higher QoL, had better cognitive function, were less depressed and reported higher social connectedness compared to those living in institutional care. Therefore, support should be provided in enabling home care and empowering caregivers to provide better care for PWCI.
Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking.
Shifting Towards Autonomy: A Continuing Care Model for Canada
Canada’s provinces can learn important lessons from the debates and reforms in other developed countries. A number of them have faced the same challenges but have been much more proactive in establishing a framework for supporting greater independence among the elderly. In doing so, they have recognized that shifting more services to the home and community is a key goal. The experience abroad shows several countries, such as France, Germany and recently Australia, have implemented self-directed models of care delivery, boosting patient satisfaction by giving individuals and families a greater say in their care packages. Two of the biggest challenges for governments contemplating more cash-based, self-directed benefits for continuing-care services are impact on government budgets and quality assurance. All countries we studied have, however, managed to overcome these challenges, at least to some degree, through restrictions on the size of the subsidy to those with substantial means or available family help and by establishing oversight in the use of the cash subsidies. In the study, we sketch a provincial continuing care model that would draw on these countries’ experience. Establishing a new comprehensive self-directed model along the lines we propose will require:
-an assessment system;
-means testing;
-a funding mechanism that is based on need but controls government costs;
-an oversight system to ensure quality and enforce restrictions on use; and,
-establishing who will oversee, coordinate and be accountable for care.
The time to adopt new systems of supportive services for the elderly is now – before many more retiring
babyboomers start drawing heavily on them.
Right to Care: Palliative care for all Canadians
This report highlights major gaps in care and the barriers Canadians face when accessing quality palliative care at the time that they need it. It is informed by several reports, academic research articles, websites and discussions with palliative care experts.
Policy paper: Dementia: post-diagnostic care and support (UK)
Joint declaration across government, health, social care and the third sector to deliver better quality services to people with dementia.
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Events
UofA
Speed Networking: Find your ‘research on aging’ match!
Join us to celebrate International Week by discussing the topic of intercultural issues on January 29th with researchers, policy makers, employers, and community/continuing care providers. We will look at the perspectives of both caregivers (staff/providers) and care recipients (residents/family members) on this important issue.
Online
This webinar will describe the evolution of a collaboration between a professional college and a researcher that resulted development of a series KT tools aimed at improving community pharmacy practice. Since 2010, the Chat Check and Chart model has been widely used to help pharmacists implement the standards for practice and the model is currently recognized by more than 70% of Alberta community pharmacists. Plans for future implementation evaluation will be presented.
brainXchange Webinar: Get ready for an Emergency Department Visit: Older Adult Hospital Readiness
Whether it is a planned admission or an unexpected emergency visit, the unfamiliar noises and activities of a hospital can be especially upsetting for a person living with dementia. Preparation can improve a visit. The purpose of this webinar to present a series of communication tools: Be Ready for an Emergency Department Visit: A Toolkit. Developed from our research, the tools are intended to make the transition to the ED, the time in the ED and transition back home less distressing. The tools were developed with the support of the Alzheimer Society of Canada, and are available for download from their website.
When It Worked and When It Didn’t – Tales from a Pragmatic KT Scientist
The objectives of this session are for participants to learn about:
-Methods that can be used to create reliable and valid tools to support KT action.
-Factors of the research enterprise that might explain why some studies “succeed” and other studies “fail”
-What one might do when a study “fails”
Courses
This course is focused on achieving skills and culture change in care homes. Participants from other services are welcome and they will need to be able to transfer the course manual into their own work role.
Online
Gain a unique insight into dementia through stories, symptoms and science. In this free online course you’ll discover some of the key issues in dementia care and research by exploring four less common forms of dementia through the eyes of people affected by the condition, and world-leading experts at UCL. We’ll show how research into the signs, stages, symptoms and causes of less common forms can bring us closer to the aim of defeating dementia.
Dementia: Understanding and Managing Challenging Behaviour
If you are a carer looking after a family member with dementia in your own home or a professional working with people with dementia, this free online course will help you better understand the person and develop the skills needed to manage their challenging behaviour.
News
It’s Just a Job, Right? This is why professors who quit academe can’t stop talking about it
Scholars want to pursue their research, unencumbered by headaches and heartache, and they want to communicate the results of their scholarship to the brightest and most interested students around. Is that so much to ask?
Should You Speak Up or Shut Up?
Better to be the one who ignites the conversation than the one who dominates it.
The digital revolution: eight technologies that will change health and care
The past decade has seen rapid development and adoption of technologies that change the way we live. But which technologies will have a similarly transformative impact on health and care?
Special Report: Danger in the dementia care home
In B.C., thousands have been affected by senior-on-senior aggression; 16 have died in 4 years.
Writing the introduction to a journal article
So you want to write a journal article but are unsure about how to start it off? Well, here’s a few things to remember.
Palliative care in critical condition: Canadian Cancer Society
Inconsistent and inadequate patchwork of palliative care across Canada needs to be priority.
Preparing for the academic job interview
Most importantly: remember your audience.
Dr. John Lavis takes national prize for health policy impact
The annual CIHR Barer-Flood Prize in Health Services and Policy Research, is given to a Canadian researcher who has had a transformative impact through health services and policy research. Lavis is the 2015 co-winner along with Julio Montaner, a prominent AIDS researcher and professor of the University of British Columbia.
B.C. health minister pushing for age-based federal funding
Current system is a disadvantage to B.C. because province has lots of seniors, says Minister Terry Lake.
In nursing homes, deaths are shrouded in secrecy and silence
In many nursing homes run by the Department of Veterans Affairs, friends and acquaintances gather to honor residents after they have died, lining the halls as a body moves past, sometimes shrouded by an American flag. In other nursing homes and assisted-living facilities, bodies are often secreted out back passageways; friends who ask staff about missing residents are frequently told that information is private.
Ontario MPPs consult with the public as the province moves toward developing a strategy on dementia
Caregiver shares how her life has changed his her husband was diagnosed with Alzheimer’s
Using data to improve dementia care in England
A new Dementia Profile, developed by Public Health England’s (PHE’s) National Dementia Intelligence Network (DIN), presents a major change in the way dementia data will be used locally.
Long term care workers demand mandatory staff-to-patient ratios
Health care workers in long-term care homes are pushing the province to set mandatory staffing levels. The Ontario Council of Hospital Unions says 91 per cent of workers it surveyed feel they can’t provide quality care because they have too many residents to care for.
Top ten tips for getting your research the attention it deserves
Here are 10 simple steps for researchers looking to boost online engagement and wider attention of academic research.
Dementia diagnoses data for England
The Health and Social Care Information Centre has published quality and outcomes framework (QOF) recorded dementia diagnoses data for December 2015.
Alzheimer’s drugs prescriptions six times higher than a decade ago (UK)
The number of prescriptions dispensed in England for approved medicines to treat Alzheimer’s increased from 502,000 in 2004 to 3.0 million in 2014. The cost to the NHS of prescriptions for Alzheimer’s disease medicines dispensed in primary care stood at £45.7m in 2014. This was up from £42.8m in 2004, but down from the high point it reached in 2011 of £110.8m.
Dementia patients face ‘Russian roulette’ in hospital (UK)
Dementia patients admitted to hospital in England play “Russian roulette” with their health, a charity is warning. The Alzheimer’s Society said it had found “shocking” evidence of poor and variable care during its review.
What do reviewers want from peer review?
Time and again, journal authors tell us that the experience of peer review is the defining factor in their overall publishing experience. The quality of the peer review experience is crucial to an author’s decision of where to publish and the authors whoexpress the most satisfaction with their publishing experience are those whostate they have an easy time with the review process. But, as we know, it’s not all good news. Authors expressing lowest levels of satisfaction are those who experienced a difficult review process and struggled to communicate with the reviewers. For editors, recruiting reviewers can be a major pain point, and good reviewers can feel overloaded and under-rewarded.
It’s time to rethink academic conference funding
Grad students and early-career academics often can’t afford to go—but, for the sake of their careers, they also can’t afford not to go.
The Ontario Government has committed to developing and implementing an Ontario Dementia Strategy and has mandated Parliamentary Assistant to the Minister of Health and Long-Term Care MPP for Milton Indira Naidoo-Harris to lead this process.
Nursing homes ask province to help reduce violence among elderly
Facing a growing wave of dementia so violent it has led to 12 homicides in two years, Ontario nursing homes are pleading with the province to pay for a key prevention tool now available to fewer than one per cent of them.
Resources
Implementation Science Exchange: a one-stop resource for implementation science researchers
The Implementation Science Exchange is a free, online source for those interested in resources to help design, acquire funding for, execute and disseminate Implementation Science research projects. We find (or create) resources, tools, websites, guides, toolkits and sample grant applications to help support researchers in the field of Implementation Science, particularly those new to research or new to the field itself. The Implementation Science Exchange is a public service of the NC Translational and Clinical Sciences (NC TraCS) Institute at the University of North Carolina at Chapel Hill. It is developed and managed by the D&I Methods Unit, with support from NC TraCS Communications and Web Development team.
The Barrie Area Native Advisory Circle (BANAC), in association with community partners, developed a 4 part video series available on their website to increase cultural awareness of First Nations, Métis and Inuit worldviews for those working in social services, such as health care providers. One of BANAC’s goals is to assist long-term care facilities and home care health providers by promoting cultural sensitization to their organizations to improve the quality of care provided to Aboriginal clients. The videos consist of interviews with Elders and Senators from First Nations, Métis and Inuit communities sharing their experiences and wisdom in an oral tradition. Each video is accompanied by a viewing guide which outlines the overview and learning objectives of the video, profiles of the featured Elders and Senators, and features a “fill in the blanks” script for note taking.
Opportunities
Program Manager – Cochrane Child Health
The Department of Pediatrics within the University of Alberta is one of Canada’s leading academic pediatric institutions in medical education and pediatric research. The mission of the research portfolio is to conduct high-quality, clinically relevant research and translate knowledge to improve child health outcomes.
The Alberta Research Centre for Health Evidence (ARCHE) is located within the Department of Pediatrics at the University of Alberta. The mandate of ARCHE is to:
-Produce high-quality knowledge syntheses aimed at priority issues in health
-Educate health providers and assist them in producing knowledge syntheses
-Conduct knowledge translation activities to inform clinical and policy decisions
-Support and foster the development of evidence-based practice
We seek to recruit a researcher to work on knowledge translation applied to improving care of seniors. Specifically, the researcher will work on the development and evaluation of knowledge translation interventions. The work will be undertaken in close partnership with older patients, their caregivers, and healthcare and social services professionals. The researcher will collaborate to grant applications, writing of scientific articles, and will be supported in the development of his/her own research program. The selected candidate will work under the supervision of Anik Giguère and her co-researchers, and with the team responsible for pursuing research programs aimed at (1) meeting the training needs of primary care clinicians in caring for the seniors (2) promoting clinical decision making based on both scientific research and preferences of the patients and their caregivers.
Become a CIHR Institute Advisory Board member
The recruitment campaign to fill up to 75 positions within the five new Institutes Advisory Boards (IABs) has begun. Comprised of five (5) horizontal boards serving all 13 CIHR Institutes, this new advisory model will boost collaboration across Institutes and within our multitude of stakeholder communities by bringing together a wide range of perspectives within each IAB.
The five (5) new IABs are:
-IAB on Research Excellence, Policy and Ethics
-IAB on Health Innovation
-IAB on Indigenous Peoples’ Health
-IAB on Health Promotion and Prevention
-IAB on Chronic Conditions
Call for Editor – Pain Management Nursing Journal
The American Society for Pain Management Nursing is seeking an Editor for the Pain Management Nursing Journal.
Research Fellow Better Start Bradford Innovation Hub
Working under the supervision and mentorship of Dr Claudine Bowyer-Crane, and the Better Start management team, the Research Fellow will design and conduct research to evaluate interventions that aim to support early language development.
PenCLAHRC PhD Fellowship in Dementia Care
The successful applicant will join a thriving multi-disciplinary team delivering a coordinated and integrated research programme based on research priorities and uncertainties identified by the Alzheimer’s Society and others via the ‘James Lind Alliance’ process.
KT Methods Working Group
The KT Platform is convening a working group to identify areas in knowledge translation research (including knowledge synthesis and implementation science) where more work on methods would be valuable. If you are an Alberta-based faculty member or graduate student working in the areas of knowledge synthesis, knowledge translation or implementation science and would like to know more about this working group, please contact Denise Thomson denise.thomson@ualberta.ca, KT Platform Associate Director.
