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New article by Dr. Jo Rycroft-Malone & Dr. Ali Hutchinson
Collaboration and Co-Production of Knowledge in Healthcare: Opportunities and Challenges.
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Over time there has been a shift, at least in the rhetoric, from a pipeline conceptualisation of knowledge implementation, to one that recognises the potential of more collaboration, co-productive approaches to knowledge production and use. In this editorial, which is grounded in our research and collective experience, we highlight both the potential and challenge with collaboration and co-production. This includes issues about stakeholder engagement, governance arrangements, and capacity and capability for working in a coproductive way. Finally, we reflect on the fact that this approach is not a panacea, but is accompanied by some philosophical and practical challenges.
New article by Dr. Jo Rycroft-Malone & Dr. Lars Wallin
A Bridge Over Turbulent Waters: Illustrating the Interaction Between Managerial Leaders and Facilitators When Implementing Research Evidence
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BACKGROUND: Emerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process. AIMS: To describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people. METHODS: Semistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs. RESULTS: This study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: “realising commitment”; “negotiating conditions”; and “encouragement to keep momentum going.” The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the “building of a bridge” emerged as one way of understanding the findings. LINKING EVIDENCE TO ACTION: Our findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved.
New article by Dr. Greta Cummings
Starting Out: A time-lagged study of new graduate nurses’ transition to practice
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Background As the nursing profession ages, new graduate nurses are an invaluable health human resource. Objectives The purpose of this study was to investigate factors influencing new graduate nurses’ successful transition to their full professional role in Canadian hospital settings and to determine predictors of job and career satisfaction and turnover intentions over a one-year time period in their early employment. Design A national two-wave survey of new graduate nurses across Canada. Participants A random sample of 3,906 Registered Nurses with less than 3 years of experience currently working in direct patient care was obtained from the provincial registry databases across Canada. At Time 1, 1,020 of 3743 eligible nurses returned completed questionnaires (usable response rate = 27.3%). One year later, Time 1 respondents were mailed a follow-up survey; 406 returned a completed questionnaire (response rate = 39.8%). Methods Surveys containing standardized questionnaires were mailed to participants’ home address. Descriptive statistics, correlations, and hierarchical linear regression analyses were conducted using \{SPSS\} software. Results Overall, new graduate nurses were positive about their experiences and committed to nursing. However, over half of new nurses in the first year of practice reported high levels of emotional exhaustion and many witnessed or experienced incivility (24-42%) at work. Findings from hierarchical linear regression analyses revealed that situational and personal factors explained significant amounts of variance in new graduate nurses’ job and career satisfaction and turnover intentions. Cynicism was a significant predictor of all four outcomes one year later, while Psycap predicted job and career satisfaction and career turnover intentions. Conclusions Results provide a look into the worklife experiences of Canadian new graduate nurses over a one-year time period and identify factors that influence their job-related outcomes. These findings show that working conditions for new graduate nurses are generally positive and stable over time, although workplace mistreatment is an issue to be addressed.
Calls for Abstracts
CALL FOR ABSTRACTS:
Gerontological Society of America’s Annual Scientific Meeting: New Lens on Aging: Changing Attitudes, Expanding Possibilities
Discover what’s new in aging. GSA’s Annual Scientific Meeting brings together 4,000 international experts and partners from academia, industry, government, and beyond to exchange information and to discuss the broader role of aging science. This meeting is the premier gathering of gerontologists from both the United States and around the world. They participate in over 450 scientific sessions including symposia, paper, and poster presentations. – See more at: https://www.geron.org/meetings-events/2016-gsa-annual-scientific-meeting/#sthash.chbJ7ZhW.dpuf
CALL FOR ABSTRACTS:
CAG 2016
CAG2016 is your opportunity to share your research and other work in the field of aging with your national and international colleagues from a diverse spectrum of disciplines. Abstracts are welcomed from all disciplines and all interests in aging, including research, practice, policy and related areas. International submissions are encouraged.
CALL FOR ABSTRACTS:
Patient-Oriented Research Summer Institute
Whether you are a researcher, patient, student, trainee, clinician or policy maker, the institute is a great opportunity to meet with others interested in patient-oriented research (POR). We aim to celebrate early successes, provide updates on SPOR activities, showcase exceptional researcher and student POR work, provide workshops on key POR topics, and continue building relationships to promote the growth of POR in the Alberta research community.
CALL FOR ABSTRACTS:
KT Canada Annual Scientific Meeting
Speakers include:
-Dr. France Légaré, Chairholder, Canada Research Chair in Implementation of Shared Decision Making in Primary Care, Full Professor, Department of Family Medicine, Université Laval
-Prof. Sandy Middleton, Director, Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University (ACU)
-Dr. Enola Proctor, Shanti K. Khinduka Distinguished Professor, Washington University in St. Louis
-KT Consultation sessions (proposal submission required) with Ian Graham, Jeremy Grimshaw, Brian Haynes, David Johnson, France Légaré, Sumit (Me2) Majumdar, Enola Proctor, Sharon Straus, Cynthia Vinson
-Panel discussion on challenges in scale and spread of complex interventions with Lee Fairclough (HQO), Michael Hilmer (MOHLTC), and Cynthia Vinson (NCI)
Grants & Awards
The Alberta Innovates Health Solutions (AIHS) Summer Studentship program provides funding to support students engaging in health sciences research during the summer months (May-August). The intent of the program is to encourage such students to consider careers in medical/health research.
Faculty of Nursing Undergraduate Student Summer Research Award
The Faculty of Nursing offers a summer research program for undergraduate nursing students, providing them with an opportunity to experience the research environment first-hand. Students will be involved in a research project under the supervision of a Faculty of Nursing tenure track member. Students will engage in activities that develop their research skills and experience. The award is meant to encourage students to pursue graduate education and possibly a research career. The overall purpose of this program is to strengthen nursing-related research and talent development by providing research training support to students. The goal is to lead to the development of the next generation of nursing researchers.
Paula Goering Collaborative Research and Knowledge Translation Award
This award recognizes an innovative researcher-knowledge user collaborative project for integrated knowledge translation in the area of mental health and addictions. The $2000 award is named in recognition of Dr. Paula Goering’s wide-ranging and significant contributions to the field of mental health services research in Canada and internationally, including advancements in the field of knowledge translation. The Award Committee is inviting applicants for partnership projects that specifically demonstrate use of an integrated knowledge translation approach.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice and Methodology
Bibliometrics
Aging
KT
Management Involvement-A Decisive Condition When Implementing Evidence-Based Practice.
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BACKGROUND: Even though health professionals have a positive attitude toward evidence-based practice (EBP), they have limited skills when it comes to implementation of EBP. A postprofessional program in EPB has been offered at Bergen University College since 2004. To date, there is limited knowledge of how the graduates of the program implement and make use of the EBP principles in their working environment in different healthcare settings. AIM: The aim of the study was to explore the facilitators and strategies to successful implementation of the steps of EBP as experienced by health professionals who had completed a postgraduate program in EBP. METHODS: Grounded theory was used in gathering and analyzing data from single and focus group interviews of 20 health professionals who had attended a postprofessional program in EBP. Inclusion criteria also required current clinical practice. RESULTS: This study identified a specific set of activities used by health professionals when implementing EBP within their service organization. Creating an interest and understanding of EBP amongst their colleagues appeared to be a challenge, which they addressed by using the generated grounded theory of “tailoring principles.” The dominant condition of this theory was management involvement. LINKING EVIDENCE TO ACTION: This study highlighted the importance of middle-range managers’ coordinating and supporting role as a decisive component in the process of implementing EBP to clinical settings in Norway. Moreover, the dynamic complex process of “tailoring principles” also showed how the production of a clinical protocol became an outcome of implementation effectiveness as well as input for further intervention effectiveness. Tailoring the principle of EBP to the organizational and cultural context facilitated the implementation of EBP.
An Overview of Discourses on Knowledge in Policy: Thinking Knowledge, Policy and Conflict Together
Around the world, there is a growing interest among policy scholars and practitioners in the role of knowledge in relation to public policy. These debates are accompanied by some confusion about what is meant by knowledge or evidence, as well as controversies around the role of scientists and suspicions of increasingly technocratic decision making. Our aim is to provide a useful overview of the major debates in this paper, and to trace six dominant discourses in current research that address the role of scientific knowledge or expertise in the policy process. We distinguish evidence-based policy making, knowledge utilisation, policy learning, knowledge transfer, social construction of knowledge and boundaries, and knowing in practice as separate discourses. We show how they differ in their understanding of knowledge, of the problem to solve in terms of the role of knowledge in policy, of practical implications, as well as in their understanding of public policy and in their ontologies and epistemologies. A condensed and structured representation serves as a basis for conducting comparisons across discourses as well as to open ways for analysis of strategic associations between the discourses. We hope to contribute to extending the discussion of knowledge in policy into the realm of epistemic politics and we suggest several avenues for future research that can draw on a range of concepts from across all of the discourses.
Implementation Science: A Potential Catalyst for Delivery System Reform.
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Understanding which of the multitude of technological, policy, and organizational changes under way are most effective at improving care will be critical if the nation is to achieve the goals of better, less-expensive care and greater population health. In this Viewpoint, we describe 3 ideas that could be helpful: application of a well-grounded conceptual framework; distinguishing 3 distinct types of innovations that health systems are using to improve care; and a focus on building the information systems needed to accelerate timely learning.
Reporting and design elements of audit and feedback interventions: a secondary review. 
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BACKGROUND: Audit and feedback (A&F) is a frequently used intervention aiming to support implementation of research evidence into clinical practice with positive, yet variable, effects. Our understanding of effective A&F has been limited by poor reporting and intervention heterogeneity. Our objective was to describe the extent of these issues. METHODS: Using a secondary review of A&F interventions and a consensus-based process to identify modifiable A&F elements, we examined intervention descriptions in 140 trials of A&F to quantify reporting limitations and describe the interventions. RESULTS: We identified 17 modifiable A&F intervention elements; 14 were examined to quantify reporting limitations and all 17 were used to describe the interventions. Clear reporting of the elements ranged from 56% to 97% with a median of 89%. There was considerable variation in A&F interventions with 51% for individual providers only, 92% targeting behaviour change and 79% targeting processes of care, 64% performed by the provider group and 81% reporting aggregate patient data. CONCLUSIONS: Our process identified 17 A&F design elements, demonstrated gaps in reporting and helped understand the degree of variation in A&F interventions.
Evidence-informed health policy making in Canada:
past, present, and future.
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Evidence-informed health policy making (EIHP) is becoming a necessary means to achieving health system reform. Although Canada has a rich and well documented history in the field of evidence-based medicine, a concerted effort to capture Canada’s efforts to support EIHP in particular has yet to be realized. This paper reports on the development of EIHP in Canada, including promising approaches being used to support the use of evidence in policy making about complex health systems issues. In light of Canada’s contributions, this paper suggests that scholars in Canada will continue engaging in the field of EIHP through further study of interventions underway, as well as by sharing knowledge within and beyond Canada’s borders about approaches that support EIHP.
Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners: a theory-informed interview study
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BACKGROUND: General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections. METHODS: Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: >/=50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto ‘intervention functions’ of the Behaviour Change Wheel system. RESULTS: Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs’ antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation). CONCLUSIONS: This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists’ inappropriate prescribing behaviour.
Implementing evidence-based practices in an emergency department: contradictions exposed when prioritising a flow culture
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BACKGROUND: An emergency department is typically a place of high activity where practitioners care for unanticipated presentations, which yields a flow culture so that actions that secure available beds are prioritised by the practitioners. OBJECTIVES: How does the flow culture in an emergency department influence nurses’ use of a research-based clinical guideline and a nutrition screening routine. METHODS: Ethnographic fieldwork was carried out over three months. The first author followed nurses, medical secretaries and doctors in the emergency department. Data were also collected by means of semi-structured interviews. An activity system analysis, as described in the Cultural Historical Activity Theory, was conducted to identify various contradictions that could exist between different parts of the activity system. RESULTS: The main contradiction identified was that guidelines and screening routines provided a flow stop. Four associated contradictions were identified: insufficient time to implement guidelines; guilty conscience due to perceived nonadherence to evidence-based practices; newcomers having different priorities; and conflicting views of what constituted being a professional. CONCLUSION: We found that research-supported guidelines and screening routines were not used if they were perceived to stop the patient flow, suggesting that the practice was not fully evidence based.
How do nurses and ward managers perceive that evidence-based sources are obtained to inform relevant nursing interventions? – an exploratory study
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AIMS AND OBJECTIVES: To explore how nurses and managers perceive that evidence-based sources are obtained to inform relevant nursing interventions. BACKGROUND: Implementation of evidence-based practice requires a systematic search and evaluation of research, clinical expertise and consideration of the patients’ preferences and values. Much has been written over the past decade about how this should be done and nurses’ mandatory education has provided them with the necessary tools to work in this way. In spite of this, nurses do not provide evidence-based practice on a regular basis. Many of the barriers against evidence-based practice are dependent on contextual factors. Therefore, it can be of interest to study both managers and nurses. DESIGN: This qualitative study has an explorative and retrospective design. METHOD: Interviews were conducted with 15 participants, including eight nurses, four ward managers, two operation managers and one care developer. Directed content analysis was used. RESULT: Nurses and managers had different approaches towards the use of scientific knowledge. Nurses’ use of clinical experience and learning from each other was common. Nurses’ work as facilitators was structured by managers. Not involving the patient in the care was common among the nurses. CONCLUSION: The parts of evidence-based practice that are supported by the managers are also used by the nurses. When use of research is not controlled by the managers, the nurses do not search for scientific research. Neither is the patients’ involvement in decision-making obvious. RELEVANCE TO CLINICAL PRACTICE: A change in nurses’ attitudes to scientific knowledge and perception of patient participation is needed. For this to happen, nurses need managers with a strong interest in evidence-based practice that support successful implementation of research in everyday clinical practise.
The use of evidenced-based information by nurses and midwives to inform practice
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AIMS AND OBJECTIVES: To examine the implementation of evidence-based information by nurses and midwives to inform their practice. BACKGROUND: It is widely recognised that the main benefits of using evidence-based information are to improve and update clinical practice and to enhance the quality of care and outcomes for patients. However, despite a large body of research showing that nurses and midwives have positive attitudes towards evidence-based practice , its implementation remains a considerable and significant challenge. DESIGN: This was a cross-sectional on-line survey. METHODS: A self-completed questionnaire was used to collect data from a convenience sample of 386 nursing and midwifery diplomates and graduates from June-December 2013. One hundred and seventy-two participants completed the questionnaire, giving a response rate of 44.6%. RESULTS/FINDINGS: The majority of respondents expressed very positive attitude towards evidence-based practice and nearly everyone felt that this should become an important part of daily practice. A significant number stated that they have regular access to research through a number of relevant databases and the Internet at their place of work and evidence-based guidelines relevant to their speciality were also available. The two top barriers perceived by respondents were lack of time to search for relevant evidence-based information and being able to make time during working hours to look for new information. The most popular strategy suggested was to ensure evidence-based information is readily available in a form which nurses and midwives can easily understand the implications for their practice. CONCLUSION: Health services and government agencies should make a concerted effort to make time for nurses and midwives to access, appraise and use evidence-based information to inform practice. RELEVANCE TO CLINICAL PRACTICE: More resources including protected time should be made available to support nurses and midwives to use evidence-based information to improve the quality of care provided.
Systems consultation: protocol for a novel implementation strategy designed to promote evidence-based practice in primary care.
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BACKGROUND: Adoption of evidence-based practices takes place at a glacial place in healthcare. This research will pilot test an innovative implementation strategy – systems consultation -intended to speed the adoption of evidence-based practice in primary care. The strategy is based on tenets of systems engineering and has been extensively tested in addiction treatment. Three innovations have been included in the strategy – translation of a clinical practice guideline into a checklist-based implementation guide, the use of physician peer coaches (‘systems consultants’) to help clinics implement the guide, and a focus on reducing variation in practices across prescribers and clinics. The implementation strategy will be applied to improving opioid prescribing practices in primary care, which may help ultimately mitigate the increasing prevalence of opioid abuse and addiction. METHODS/DESIGN: The pilot test will compare four intervention clinics to four control clinics in a matched-pairs design. A leading clinical guideline for opioid prescribing has been translated into a checklist-based implementation guide in a systematic process that involved experts who wrote the guideline in consultation with implementation experts and primary care physicians. Two physicians with expertise in family and addiction medicine are serving as the systems consultants. Each systems consultant will guide two intervention clinics, using two site visits and follow-up communication by phone and email, to implement the translated guideline. Mixed methods will be used to test the feasibility, acceptability, and preliminary effectiveness of the implementation strategy in an evaluation that meets standards for ‘fully developed use’ of the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). The clinic will be the primary unit of analysis. DISCUSSION: The systems consultation implementation strategy is intended to generalize to the adoption of other clinical guidelines. This pilot test is intended to prepare for a large randomized clinical trial that will test the strategy against other implementation strategies, such as audit/feedback and academic detailing, used to close the gap between knowledge and practice. The systems consultation approach has the potential to shorten the famously long time it takes to implement evidence-based practices and clinical guidelines in healthcare.
Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement “Sepsis Six”.
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BACKGROUND: Sepsis has a mortality rate of 40 %, which can be halved if the evidence-based “Sepsis Six” care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital. METHODS: Factors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity. RESULTS: Five themes were identified as influencing implementation and guided intervention modification. These were:(1) “knowing what to do and why” (TDF domains knowledge, social/professional role and identity); (2) “risks and benefits” (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle’s effectiveness acting as a lever to implementation; (3) “working together” (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier; (4) “empowerment and support” (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues’ decisions not to implement acting as a barrier; (5) “staffing levels” (environmental context and resources), e.g. shortages of doctors at night preventing implementation. The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions; documents and materials). CONCLUSIONS: This work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.
A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study.
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BACKGROUND: Best practice guidelines are a tool for narrowing research-to-practice gaps and improving care outcomes. There is some empirical understanding of guideline implementation in nursing settings, yet there has been almost no consideration of the longer-term sustainability of guideline-based practice improvements. Many healthcare innovations are not sustained, underscoring the need for knowledge about how to promote their survival. PURPOSE: To understand how a nursing best practice guidelines program was sustained on acute healthcare center nursing units. METHODS: We undertook a qualitative descriptive case study of an organization-wide nursing best practice guidelines program with four embedded nursing unit subcases. The setting was a large, tertiary/quaternary urban health center in Canada. The nursing department initiated a program to enhance patient safety through the implementation of three guidelines: falls prevention, pressure ulcer prevention, and pain management. We selected four inpatient unit subcases that had differing levels of program sustainability at an average of almost seven years post initial program implementation. Data sources included 39 key informant interviews with nursing leaders/administrators and frontline nurses; site visits; and program-related documents. Data collection and content analysis were guided by a framework for the sustainability of healthcare innovations. RESULTS: Program sustainability was characterized by three elements: benefits, routinization, and development. Seven key factors most accounted for the differences in the level of program sustainability between subcases. These factors were: perceptions of advantages, collaboration, accountability, staffing, linked levels of leadership, attributes of formal unit leadership, and leaders’ use of sustainability activities. Some prominent relationships between characteristics and factors explained long-term program sustainability. Of primary importance was the extent to which unit leaders used sustainability-oriented activities in both regular and responsive ways to attend to the relationships between sustainability characteristics and factors. CONCLUSIONS: Continued efforts are required to ensure long-term program sustainability on nursing units. Persistent and adaptive orchestration of sustainability-oriented activities by formal unit leadership teams is necessary for maintaining best practice guidelines over the long term. Leaders should consider a broad conceptualization of sustainability, beyond guideline-based benefits and routinization, because the development of unit capacity in response to changing circumstances appears essential.
Successful knowledge translation intervention in long-term care: final results from the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial.
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BACKGROUND: Few studies have systematically examined whether knowledge translation (KT) strategies can be successfully implemented within the long-term care (LTC) setting. In this study, we examined the effectiveness of a multifaceted, interdisciplinary KT intervention for improving the prescribing of vitamin D, calcium and osteoporosis medications over 12-months. METHODS: We conducted a pilot, cluster randomized controlled trial in 40 LTC homes (21 control; 19 intervention) in Ontario, Canada. LTC homes were eligible if they had more than one prescribing physician and received services from a large pharmacy provider. Participants were interdisciplinary care teams (physicians, nurses, consultant pharmacists, and other staff) who met quarterly. Intervention homes participated in three educational meetings over 12 months, including a standardized presentation led by expert opinion leaders, action planning for quality improvement, and audit and feedback review. Control homes did not receive any additional intervention. Resident-level prescribing and clinical outcomes were collected from the pharmacy database; data collectors and analysts were blinded. In addition to feasibility measures, study outcomes were the proportion of residents taking vitamin D (>/=800 IU/daily; primary), calcium >/=500 mg/day and osteoporosis medications (high-risk residents) over 12 months. Data were analyzed using the generalized estimating equations technique accounting for clustering within the LTC homes. RESULTS: At baseline, 5,478 residents, mean age 84.4 (standard deviation (SD) 10.9), 71% female, resided in 40 LTC homes, mean size = 137 beds (SD 76.7). In the intention-to-treat analysis (21 control; 19 intervention clusters), the intervention resulted in a significantly greater increase in prescribing from baseline to 12 months between intervention versus control arms for vitamin D (odds ratio (OR) 1.82, 95% confidence interval (CI): 1.12, 2.96) and calcium (OR 1.33, 95% CI: 1.01, 1.74), but not for osteoporosis medications (OR 1.17, 95% CI: 0.91, 1.51). In secondary analyses, excluding seven nonparticipating intervention homes, ORs were 3.06 (95% CI: 2.18, 4.29), 1.57 (95% CI: 1.12, 2.21), 1.20 (95% CI: 0.90, 1.60) for vitamin D, calcium and osteoporosis medications, respectively. CONCLUSIONS: Our KT intervention significantly improved the prescribing of vitamin D and calcium and is a model that could potentially be applied to other areas requiring quality improvement. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01398527
BACKGROUND:Bridging the gap between science and policy is an important task in evidence-informed policy making. The objective of this study is to prioritize ways to bridge the gap.METHODS:The study was based on an online survey of high-ranking scientists and policy makers who have a senior position in universities and governments in the health sector in China and Canada. The sampling frame comprised of universities with schools of public health and medicine and various levels of government in health and public health. Participants included university presidents and professors, and government deputy ministers, directors general and directors working in the health field. Fourteen strategies were presented to the participants for ranking as current ways and ideal ways in the future to bridge the gap between science and policy.RESULTS:Over a 3-month survey period, there were 121 participants in China and 86 in Canada with response rates of 30.0 and 15.9%, respectively. The top strategies selected by respondents included focus on policy (conducting research that focuses on policy questions), science-policy forums, and policy briefs, both as current ways and ideal ways to bridge the gap between science and policy. Conferences were considered a priority strategy as a current way, but not an ideal way in the future. Canadian participants were more in favor of using information technology (web-based portals and email updates) than their Chinese counterparts. Among Canadian participants, two strategies that were ranked low as current ways (collaboration in study design and collaboration in analysis) became a priority as ideal ways. This could signal a change in thinking in shifting the focus from the “back end” or “downstream” (knowledge dissemination) of the knowledge transfer process to the “front end” or “upstream” (knowledge generation).CONCLUSIONS:Our international study has confirmed a number of previously reported priority strategies to bridge the gap between science and policy. More importantly, our study has contributed to the future work on evidence-based policy making by comparing the responses from China and Canada and the current and ideal way for the future. Our study shows that the concept and strategies of bridging the gap between science and policy are not static but varying in space and evolving over time.
Policy claims and problem frames: a cross-case comparison of evidence-based policy in an Australian context
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This paper explores the signification of evidence-based policy as a new policy-making paradigm in Australia through a cross-case comparison of the role of evidence in two key areas: child protection and illicit drug policy. Although evidence makes certain courses of action appear valid and credible, quality evidence is not necessarily the critical factor in driving or explaining policy outcomes. Policy solutions are perceived more favourably and driven forward when the initial problem is viewed by actors through a common frame. Rather than a policy input or driver, evidence operates as a discursive tool for consolidation of particular frames and problem representations.
Evidence, fidelity, and organisational rationales: multiple uses of Motivational Interviewing in a social services agency
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In discussions and empirical investigations of the implementation of evidence-based interventions there is often a narrow focus on treatment fidelity. Studying a social services agency trying to incorporate Motivational Interviewing (MI), commonly regarded as evidence-based, this paper problematises a one-sided attention to treatment fidelity by showing how non-fidelity can be constructive from an organisational perspective. While treatment fidelity is one important aspect, it is argued that there might be other rationales to take into account when implementing evidencebased interventions in professional practices.
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Health Care Administration and Organization
A cost-benefit analysis of peer coaching for overhead lift use in the long-term care sector in Canada.
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OBJECTIVES: To evaluate whether a peer-coaching programme for patient lift use in British Columbia, Canada, was effective and cost-beneficial. METHODS: We used monthly panel data from 15 long-term care facilities from 2004 to 2011 to estimate the number of patient-handling injuries averted by the peer-coaching programme using a generalised estimating equation model. Facilities that had not yet introduced the programme served as concurrent controls. Accepted lost-time claim counts related to patient handling were the outcome of interest with a denominator of full-time equivalents of nursing staff. A cost-benefit approach was used to estimate the net monetary gains at the system level. RESULTS: The coaching programme was found to be associated with a reduction in the injury rate of 34% during the programme and 56% after the programme concluded with an estimated 62 lost-time injury claims averted. 2 other factors were associated with changes in injury rates: larger facilities had a lower injury rate, and the more care hours per bed the lower the injury rate. We calculated monetary benefits to the system of $748 431 and costs of $894 000 (both in 2006 Canadian dollars) with a benefit-to-cost ratio of 0.84. The benefit-to-cost ratio was -0.05 in the worst case scenario and 2.31 in the best case scenario. The largest cost item was peer coaches’ time. A simulation of the programme continuing for 5 years with the same coaching intensity would result in a benefit-to-cost ratio of 0.63. CONCLUSIONS: A peer-coaching programme to increase effective use of overhead lifts prevented additional patient-handling injuries but added modest incremental cost to the system.
Ethical and cultural striving: Lived experiences of minority nurses in dementia care.
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BACKGROUND: Nursing workforce in Western European health institutions has become more diverse because of immigration and recruitment from Asian, African, and East-European countries. Minority healthcare providers may experience communication problems in interaction with patients and coworkers, and they are likely to experience conflict or uncertainty when confronted with different cultural traditions and values. Persons with dementia are a vulnerable group, and the consequences of their illness challenge the ability to understand and express oneself verbally. The large number of minority healthcare providers in nursing homes underlines the importance to obtain better knowledge about this group’s experiences with the care challenges in dementia care units. RESEARCH QUESTION: Can you tell about any challenges in the experiences in the encounter with persons suffering from dementia? PARTICIPANTS AND RESEARCH CONTEXT: Five minority healthcare providers in a nursing home, in a dementia unit. All guidelines for research ethic were followed. ETHICAL CONSIDERATION: The participants were informed that participation was voluntary, and they were guarantied anonymity. METHOD: We used a qualitative method, conducting individual interviews, using a narrative approach. In the analysis, we applied a phenomenological-hermeneutical method, developed for researching life experiences. FINDINGS: One theme and four subthemes: striving to understand the quality of care for persons with dementia. The subthemes: sensitivity to understand the patients’ verbal and nonverbal expressions. To understand gratefulness, understand the patient as an adult and autonomous person, and understand the patient as a patient in a nursing home. Challenges comprise both ethical and cultural striving to understand persons with dementia. CONCLUSION: To care for persons with dementia in an unfamiliar context may be understood as a striving for acting ethically, when at the same time striving to adapt and acculturate to new cultural norms, in order to practice good dementia care.
Views from health professionals on accessing rehabilitation for people with dementia following a hip fracture.
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The literature reports that rehabilitation for elderly patients with mild-to-moderate dementia who have a hip fracture improves functional outcomes. However, access to rehabilitation may be difficult due to misconceptions about the ability of these patients to engage in and benefit from rehabilitation. Additionally, people who are admitted from residential care may not have the same options for rehabilitation as those admitted from home. This study sought to understand from expert clinicians how and why decisions are made to accept a person with dementia post-fracture for rehabilitation. In this Australian-based qualitative study, 12 health professionals across a state and territory were interviewed. These clinicians were the primary decision makers in accepting or rejecting elderly patients with dementia post-fracture into rehabilitation. Three key themes emerged from the data: criteria for accessing rehabilitation, what works well and challenges to rehabilitation. The participants were unanimous in the view that access to rehabilitation should be based on the ability of the patient to engage in a rehabilitation programme and not assessed solely on cognition. In terms of clinical care, a coherent rehabilitation pathway with integration of geriatric and ortho-geriatric services was reported as ideal. Challenges remain, importantly, the perception of some health care staff that people with dementia have limited capability to benefit from rehabilitation. Rehabilitation for this growing group of patients requires multiple resources, including skilled practitioners, integrated clinical systems and staff education regarding the capabilities of people with dementia. Future research in this area with patients with moderate-to-severe dementia in residential care is warranted.
Comparison of the Value of Nursing Work Environments in Hospitals Across Different Levels of Patient Risk.
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Importance: The literature suggests that hospitals with better nursing work environments provide better quality of care. Less is known about value (cost vs quality). Objectives: To test whether hospitals with better nursing work environments displayed better value than those with worse nursing environments and to determine patient risk groups associated with the greatest value. Design, Setting, and Participants: A retrospective matched-cohort design, comparing the outcomes and cost of patients at focal hospitals recognized nationally as having good nurse working environments and nurse-to-bed ratios of 1 or greater with patients at control group hospitals without such recognition and with nurse-to-bed ratios less than 1. This study included 25752 elderly Medicare general surgery patients treated at focal hospitals and 62882 patients treated at control hospitals during 2004-2006 in Illinois, New York, and Texas. The study was conducted between January 1, 2004, and November 30, 2006; this analysis was conducted from April to August 2015. Exposures: Focal vs control hospitals (better vs worse nursing environment). Main Outcomes and Measures: Thirty-day mortality and costs reflecting resource utilization. Results: This study was conducted at 35 focal hospitals (mean nurse-to-bed ratio, 1.51) and 293 control hospitals (mean nurse-to-bed ratio, 0.69). Focal hospitals were larger and more teaching and technology intensive than control hospitals. Thirty-day mortality in focal hospitals was 4.8% vs 5.8% in control hospitals (P < .001), while the cost per patient was similar: the focal-control was -$163 (95% CI = -$542 to $215; P = .40), suggesting better value in the focal group. For the focal vs control hospitals, the greatest mortality benefit (17.3% vs 19.9%; P < .001) occurred in patients in the highest risk quintile, with a nonsignificant cost difference of $941 per patient ($53701 vs $52760; P = .25). The greatest difference in value between focal and control hospitals appeared in patients in the second-highest risk quintile, with mortality of 4.2% vs 5.8% (P < .001), with a nonsignificant cost difference of -$862 ($33513 vs $34375; P = .12). Conclusions and Relevance: Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing, especially for higher-risk patients. These results do not suggest that improving any specific hospital’s nursing environment will necessarily improve its value, but they do show that patients undergoing general surgery at hospitals with better nursing environments generally receive care of higher value.
Dementia-related work activities of home care nurses and aides: Frequency, perceived competence, and continuing education priorities
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An understanding of the specific dementia learning needs of home care staff is needed to plan relevant continuing education (CE) programs and supports. The study’s objective was to examine frequency and perceived competence in performing 20 dementia-related work activities, and identify CE priorities among home care staff. A cross-sectional survey of all home care staff in a primarily rural health region was used to gather data. Of 111 eligible staff, 82 participated (41 nursing aides, 41 nurses/case managers). To explore the relationship between activity frequency (F) and competence (C), the proportion of nurses and aides in four quadrants for each activity was examined: (1) low F-low C, (2) low F-high C, (3) high F-low C, and (4) high F-high C. Nurses/case managers were significantly more likely than aides to regularly perform 11 activities and to report high competence in 9 activities (p < .05); aides were more likely to assist with two activities (personal care and daily living activities). Thus, nurses/case managers performed a broader range of activities and reported higher competence overall. The top CE topic for both groups was recognizing differences between dementia subtypes, but rankings for most activities varied by group. Aides’ CE priorities indicated a desire to develop competence in low frequency-low competence activities, suggesting an expanded role in supporting dementia patients and their families. Nurses’ CE priority topics were in the high F-high C quadrant, indicating a need to further develop competence in these activities. Findings have implications for planning CE programming for home care providers.
Implications of the Patient-Centered Medical Home for Nursing Practice.
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OBJECTIVE: The experiences of RNs and licensed practical nurses (LPNs) implementing a patient-centered medical home (PCMH) in the Department of Veterans Affairs (VA) primary care clinics were examined to understand model implications for nursing practice and professional identity. BACKGROUND: National implementation of the PCMH model, called patient-aligned care teams (PACTs) in VA, emphasizes areas of nursing expertise, yet little is known about the effect of medical homes on the day-to-day work of nurses. METHODS: As part of a formative evaluation to identify barriers and facilitators to PACT implementation, we interviewed 18 nurses implementing PACT. RESULTS: Challenges to nurse’s organizational and professional roles were experienced differently by RNs and LPNs in the following areas: (1) diversified modes of care and expanded clinical duties, (2) division of labor among PACT nurses, and (3) interprofessional status in the team. CONCLUSIONS: Healthcare managers implementing PCMH should consider its inherent cultural and practice transformations.
Applying a palliative care approach in residential care: effects on nurse assistants’ work situation.
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OBJECTIVES: The aim was to investigate the effects of an intervention that applies a palliative care approach in residential care upon nurse assistants’ level of strain, job satisfaction, and view of leadership. METHOD: A quasi-experimental, pretest and posttest design was used. Study circles with workshops involving nurse assistants (n = 75) and their superiors (n = 9) focusing on emotional and existential issues in palliative care were evaluated using a questionnaire answered by the nurse assistants at baseline (November 2009), post-intervention (May 2010), and six-month follow-up (November 2010) in comparison with controls (n = 110). RESULTS: Directly after the intervention, the job satisfaction of the nurse assistants decreased and they perceived the leadership more negatively than before the intervention. Six months later, strain as a result of criticism from residents and their superiors and having difficulty in balancing emotional involvement had decreased. SIGNIFICANCE OF RESULTS: The intervention initially seemed to decrease the well-being of the nurse assistants, which could be the result of their increased awareness of the residents’ and relatives’ needs, in combination with limited support. More emphasis should be placed on the role of leadership when implementing changes in practice.
Is an unhealthy work environment in nursing home care for people with dementia associated with the prescription of psychotropic drugs and physical restraints?
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BACKGROUND: Research showed that long-term care facilities differ widely in the use of psychotropic drugs and physical restraints. The aim of this study is to investigate whether characteristics of an unhealthy work environment in facilities for people with dementia are associated with more prescription of psychotropic drugs and physical restraints. METHODS: Data were derived from the first wave (2008-2009) of a national monitoring study in the Netherlands. This paper used data on prescription of psychotropic drugs and physical restraints from 111 long-term care facilities, residing 4,796 residents. Survey data of a sample of 996 staff and 1,138 residents were considered. The number of residents with prescribed benzodiazepines and anti-psychotic drugs, and physical restraints were registered. Work environment was assessed using the Leiden Quality of Work Questionnaire (LQWQ). RESULTS: Logistic regression analyses showed that more supervisor support was associated with less prescription of benzodiazepines. Coworker support was found to be related to less prescription of deep chairs. Job demands and decision authority were not found to be predictors of psychotropic drugs and physical restraints. CONCLUSIONS: Staff’s job characteristics were scarcely related to the prescription of psychotropic drugs and physical restraints. This finding indicates that in facilities with an unhealthy work environment for nursing staff, one is not more likely to prescribe drugs or restraints. Further longitudinal research is needed with special attention for multidisciplinary decision making – especially role of physician, staff’s knowledge, philosophy of care and institutional policy to gain further insight into factors influencing the use of psychotropic drugs and restraints.
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Organizational Change
Exploring senior nurses’ experiences of leading organizational change.
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Purpose – The aim of this paper is to explore Senior nurses’ experiences of leading organizational change. There is a substantial literature reporting middle-level nurse managers’ experiences of change; however, there is less evidence concerning senior nurses’ perspectives. In view of this, interview data collected from senior nurses, as part of a study of major organizational change, were analysed to redress this imbalance. Design/methodology/approach – In-depth semi-structured interviews (n = 14) were conducted with senior nurses (between 2009 and 2012). Findings – Senior nurses’ activity centred on leadership and workforce issues, internal influences and external pressures. In periods of change, appropriate leadership was vital, and “weak” leaders were considered to have an adverse effect on teams. Concerns were expressed about financial strictures and their impact on patient care and service provision. The senior nurses were striving to provide the best quality of service delivery with the limited resources available. Concentration on operational matters was necessary to maintain stability in periods of change. However, this prevented senior nurses from influencing strategic decision-making in their organizations. Practical implications – If senior nurses are to realise their potential to operate at a strategic level, they need to be given time and support to lead, rather than just react to change. This research emphasises the importance of a “nursing voice” to inform board-level decisions and maintain a focus on patient care. Originality/value – This research sheds light on the work of a key group of staff in health-care organizations. Understanding senior nurses’ experience of and contribution to change is a useful contribution to health services research.
Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions.
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BACKGROUND: This paper argues that the global health agenda tends to privilege short-term global interests at the expense of long-term capacity building within national and community health systems. The Health Systems Strengthening (HSS) movement needs to focus on developing the capacity of local organizations and the institutions that influence how such organizations interact with local and international stakeholders. DISCUSSION: While institutions can enable organizations, they too often apply requirements to follow paths that can stifle learning and development. Global health actors have recognized the importance of supporting local organizations in HSS activities. However, this recognition has yet to translate adequately into actual policies to influence funding and practice. While there is not a single approach to HSS that can be uniformly applied to all contexts, several messages emerge from the experience of successful health systems presented in this paper using case studies through a complex adaptive systems lens. Two key messages deserve special attention: the need for donors and recipient organizations to work as equal partners, and the need for strong and diffuse leadership in low-income countries. An increasingly dynamic and interdependent post-Millennium Development Goals (post-MDG) world requires new ways of working to improve global health, underpinned by a complex adaptive systems lens and approaches that build local organizational capacity.
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Health Care Innovation and Quality Assurance
Harnessing Protocolized Adaptation in Dissemination: Successful Implementation and Sustainment of the Veterans Affairs Coordinated-Transitional Care Program in a Non-Veterans Affairs Hospital.
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The Department of Veterans Affairs (VA) Coordinated-Transitional Care (C-TraC) program is a low-cost transitional care program that uses hospital-based nurse case managers, inpatient team integration, and in-depth posthospital telephone contacts to support high-risk patients and their caregivers as they transition from hospital to community. The low-cost, primarily telephone-based C-TraC program reduced 30-day rehospitalizations by one-third, leading to significant cost savings at one VA hospital. Non-VA hospitals have expressed interest in launching C-TraC, but non-VA hospitals differ in important ways from VA hospitals, particularly in terms of context, culture, and resources. The objective of this project was to adapt C-TraC to the specific context of one non-VA setting using a modified Replicating Effective Programs (REP) implementation theory model and to test the feasibility of this protocolized implementation approach. The modified REP model uses a mentored phased-based implementation with intensive preimplementation activities and harnesses key local stakeholders to adapt processes and goals to local context. Using this protocolized implementation approach, an adapted C-TraC protocol was created and launched at the non-VA hospital in July 2013. In its first 16 months, C-TraC successfully enrolled 1,247 individuals with 3.2 full-time nurse case managers, achieving good fidelity for core protocol steps. C-TraC participants experienced a 30-day rehospitalization rate of 10.8%, compared with 16.6% for a contemporary comparison group of similar individuals for whom C-TraC was not available (n = 1,307) (P < .001). The new C-TraC program continues in operation. Use of a modified REP model to guide protocolized adaptation to local context resulted in a C-TraC program that was feasible and sustained in a real-world non-VA setting. A modified REP implementation framework may be an appropriate foundational step for other clinical programs seeking to harness protocolized adaptation in mentored dissemination activities.
Reverse innovation: an opportunity for strengthening health systems.
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BACKGROUND: Canada, when compared to other OECD countries, ranks poorly with respect to innovation and innovation adoption while struggling with increasing health system costs. As a result of its failure to innovate, the Canadian health system will struggle to meet the needs and demands of both current and future populations. The purpose of this initiative was to explore if a competition-based reverse innovation challenge could mobilize and stimulate current and future leaders to identify and lead potential reverse innovation projects that address health system challenges in Canada. METHODS: An open call for applications took place over a 4-month period. Applicants were enticed to submit to the competition with a $50,000 prize for the top submission to finance their project. Leaders from a wide cross-section of sectors collectively developed evaluation criteria and graded the submissions. The criteria evaluated: proof of concept, potential value, financial impact, feasibility, and scalability as well as the use of prize money and innovation team. RESULTS: The competition received 12 submissions from across Canada that identified potential reverse innovations from 18 unique geographical locations that were considered developing and/or emerging markets. The various submissions addressed health system challenges relating to education, mobile health, aboriginal health, immigrant health, seniors health and women’s health and wellness. Of the original 12 submissions, 5 finalists were chosen and publically profiled, and 1 was chosen to receive the top prize. CONCLUSIONS: The results of this initiative demonstrate that a competition that is targeted to reverse innovation does have the potential to mobilize and stimulate leaders to identify reverse innovations that have the potential for system level impact. The competition also provided important insights into the capacity of Canadian students, health care providers, entrepreneurs, and innovators to propose and implement reverse innovation in the context of the Canadian health system.
Nursing Assistant Perceptions of Their Role in Quality Improvement Processes in Nursing Homes.
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Nursing assistants provide the majority of direct resident care in nursing homes and are centrally involved in implementing quality improvement (QI), yet little is known about their experiences in QI. Interviews with nursing assistants found that respondents perceive themselves as having a unique and important role in QI. They described key outcomes of QI as positive gains in the daily lives of residents, improved work processes, and increased time between staff and residents.
Quality of in-home care, long-term care placement, and the survival of persons with dementia.
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PURPOSE OF THE STUDY: Caregivers of persons with dementia living at home adopt a variety of caregiving styles that vary in quality. Three styles of high-quality care and poor-quality care have been identified. The outcomes, however, of varying styles of caregiving are unknown. Our purpose was to investigate the linkage of quality of care to long-term care placement and survival. DESIGN AND METHODS: We used a sample of 148 primary caregivers of a relative living at home and needing assistance due to memory or thinking problems. We used items from four existing scales and five new items to construct measures of high-quality and poor-quality care. Long-term care and survival were determined from two follow-ups. Cox proportional hazards regression was used to estimate the relationship of quality of care to long-term care placement and survival. RESULTS: Poor quality of care increased the risk of long-term care placement, as expected, but high-quality care was not related to placement. Surprisingly, high-quality care increased the risk of death while poor-quality care decreased the risk. Secondary results were: wishful/intrapsychic coping (a dysfunctional type of emotion-focused coping) and long-term care placement shortened the survival; and caregiver personality traits of neuroticism and agreeableness lengthened the survival. IMPLICATIONS: It is premature to recommend caregiver interventions based on our unexpected findings. Further studies are vital and should include care-recipient impairments and the quality of life of the person with dementia as additional outcomes.
Lean interventions in healthcare-do they actually work? A systematic literature review.
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PURPOSE: Lean is a widely used quality improvement methodology initially developed and used in the automotive and manufacturing industries but recently expanded to the healthcare sector. This systematic literature review seeks to independently assess the effect of Lean or Lean interventions on worker and patient satisfaction, health and process outcomes, and financial costs. DATA SOURCES: We conducted a systematic literature review of Medline, PubMed, Cochrane Library, CINAHL, Web of Science, ABI/Inform, ERIC, EMBASE and SCOPUS. STUDY SELECTION: Peer reviewed articles were included if they examined a Lean intervention and included quantitative data. Methodological quality was assessed using validated critical appraisal checklists. Publically available data collected by the Saskatchewan Health Quality Council and the Saskatchewan Union of Nurses were also analysed and reported separately. DATA EXTRACTION: Data on design, methods, interventions and key outcomes were extracted and collated. RESULTS OF DATA SYNTHESIS: Our electronic search identified 22 articles that passed methodological quality review. Among the accepted studies, 4 were exclusively concerned with health outcomes, 3 included both health and process outcomes and 15 included process outcomes. Our study found that Lean interventions have: (i) no statistically significant association with patient satisfaction and health outcomes; (ii) a negative association with financial costs and worker satisfaction and (iii) potential, yet inconsistent, benefits on process outcomes like patient flow and safety. CONCLUSION: While some may strongly believe that Lean interventions lead to quality improvements in healthcare, the evidence to date simply does not support this claim. More rigorous, higher quality and better conducted scientific research is required to definitively ascertain the impact and effectiveness of Lean in healthcare settings.
A Multi-Method Study of the Geriatric Learning Needs of Acute Care Hospital Nurses in Ontario, Canada.
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Older people are at risk of experiencing functional decline and related complications during hospitalization. In countries with projected increases in age demographics, preventing these adverse consequences is a priority. Because most Canadian nurses have received little geriatrics content in their basic education, understanding their learning needs is fundamental to preparing them to respond to this priority. This two-phased multi-method study identified the geriatrics learning needs and strategies to address the learning needs of acute care registered nurses (RNs) and registered practical nurses (RPNs) in the province of Ontario, Canada. In Phase I, a survey that included a geriatric nursing knowledge scale was completed by a random sample of 2005 Ontario RNs and RPNs. Average scores on the geriatric nursing knowledge scale were in the “neither good nor bad” range, with RNs demonstrating slightly higher scores than RPNs. In Phase II, 33 RN and 24 RPN survey respondents participated in 13 focus group interviews to help confirm and expand survey findings. In thematic analysis, three major themes were identified that were the same in RNs and RPNs: (a) geriatric nursing is generally regarded as simple and custodial, (b) older people’s care is more complex than is generally appreciated, and (c) in the current context, older people’s care is best learned experientially and in brief on-site educational sessions. Healthcare providers, policy-makers, and educators can use the findings to develop educational initiatives to prepare RNs and RPNs to respond to the needs of an aging hospital population.
A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa.
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BACKGROUND: Scaling up complex health interventions to large populations is not a straightforward task. Without intentional, guided efforts to scale up, it can take many years for a new evidence-based intervention to be broadly implemented. For the past decade, researchers and implementers have developed models of scale-up that move beyond earlier paradigms that assumed ideas and practices would successfully spread through a combination of publication, policy, training, and example. Drawing from the previously reported frameworks for scaling up health interventions and our experience in the USA and abroad, we describe a framework for taking health interventions to full scale, and we use two large-scale improvement initiatives in Africa to illustrate the framework in action. We first identified other scale-up approaches for comparison and analysis of common constructs by searching for systematic reviews of scale-up in health care, reviewing those bibliographies, speaking with experts, and reviewing common research databases (PubMed, Google Scholar) for papers in English from peer-reviewed and “gray” sources that discussed models, frameworks, or theories for scale-up from 2000 to 2014. We then analyzed the results of this external review in the context of the models and frameworks developed over the past 20 years by Associates in Process Improvement (API) and the Institute for Healthcare improvement (IHI). Finally, we reflected on two national-scale improvement initiatives that IHI had undertaken in Ghana and South Africa that were testing grounds for early iterations of the framework presented in this paper. RESULTS: The framework describes three core components: a sequence of activities that are required to get a program of work to full scale, the mechanisms that are required to facilitate the adoption of interventions, and the underlying factors and support systems required for successful scale-up. The four steps in the sequence include (1) Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale; (2) Develop the Scalable Unit, which is an early testing phase; (3) Test of Scale-up, which then tests the intervention in a variety of settings that are likely to represent different contexts that will be encountered at full scale; and (4) Go to Full Scale, which unfolds rapidly to enable a larger number of sites or divisions to adopt and/or replicate the intervention. CONCLUSIONS: Our framework echoes, amplifies, and systematizes the three dominant themes that occur to varying extents in a number of existing scale-up frameworks. We call out the crucial importance of defining a scalable unit of organization. If a scalable unit can be defined, and successful results achieved by implementing an intervention in this unit without major addition of resources, it is more likely that the intervention can be fully and rapidly scaled. When tying this framework to quality improvement (QI) methods, we describe a range of methodological options that can be applied to each of the four steps in the framework’s sequence.
Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review.
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BACKGROUND: While health care services are beginning to implement system-wide patient safety interventions, evidence on the efficacy of these interventions is sparse. We know that uptake can be variable, but we do not know the factors that affect uptake or how the interventions establish change and, in particular, whether they influence patient outcomes. We conducted a systematic review to identify how organisational and cultural factors mediate or are mediated by hospital-wide interventions, and to assess the effects of those factors on patient outcomes. METHODS: A systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Database searches were conducted using MEDLINE from 1946, CINAHL from 1991, EMBASE from 1947, Web of Science from 1934, PsycINFO from 1967, and Global Health from 1910 to September 2012. The Lancet, JAMA, BMJ, BMJ Quality and Safety, The New England Journal of Medicine and Implementation Science were also hand searched for relevant studies published over the last 5 years. Eligible studies were required to focus on organisational determinants of hospital- and system-wide interventions, and to provide patient outcome data before and after implementation of the intervention. Empirical, peer-reviewed studies reporting randomised and non-randomised controlled trials, observational, and controlled before and after studies were included in the review. RESULTS: Six studies met the inclusion criteria. Improved outcomes were observed for studies where outcomes were measured at least two years after the intervention. Associations between organisational factors, intervention success and patient outcomes were undetermined: organisational culture and patient outcomes were rarely measured together, and measures for culture and outcome were not standardised. CONCLUSIONS: Common findings show the difficulty of introducing large-scale interventions, and that effective leadership and clinical champions, adequate financial and educational resources, and dedicated promotional activities appear to be common factors in successful system-wide change.The protocol has been registered in the international prospective register of systematic reviews, PROSPERO (Registration No. CRD42103003050).
A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes.
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BACKGROUND: We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes. METHODS: Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure. RESULTS: Sixty-three unique studies were broadly grouped according to clinical domain-oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics). CONCLUSION: Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.
Care by design: New model of coordinated on-site primary and acute care in long-term care facilities.
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PROBLEM ADDRESSED: A recently implemented model of care in long-term care facilities (LTCFs) called Care by Design addresses concerns about a previously uncoordinated care system, a reduction in family physician services, and high rates of ambulance transports to emergency departments. OBJECTIVE OF PROGRAM: Care by Design is designed to increase access to care and continuity and quality of care by family physicians, reduce unwanted and unnecessary transfers to the emergency department, and lessen the burden on care teams including physicians and nurses in LTCFs. PROGRAM DESCRIPTION: The core of Care by Design is a dedicated family physician for each LTCF floor, with regular on-site visits; physician on-call coverage, 24 hours a day, 7 days a week; and standing orders and protocols. Care by Design also includes a comprehensive geriatric assessment tool, an interdisciplinary team approach, access to a dedicated extended care paramedic program to respond to urgent care needs, and ongoing performance measurement. CONCLUSION: Care by Design aims to improve on-site care for LTCF residents and family physicians’ experiences with providing care in several ways, including increased clinical efficiency, communication, and continuity, and appropriate support within the interdisciplinary team model.
Cost efficiency of nursing homes: do five-star quality ratings matter?
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Nursing homes may respond to the pressure to reduce costs by reducing quality of care, so the two are related. This study examines the determinants of nursing home costs and cost efficiency, and investigates how various measures of nursing home care quality influence both of these. It applies a one-step stochastic frontier approach to a large panel of California nursing homes surveyed between 2009 and 2013. Quality is measured by three different ratings available on the Nursing Home Compare website: rating on quality measures, rating on the health inspection, and rating on staffing levels. Results show that the rating on quality measures, an outcome-based measure of quality, is inversely related to costs but unrelated to mean cost efficiency. In other words, a better rating on quality measures is associated with lower nursing home costs. The health inspection rating is not associated with either costs or mean cost efficiency. The rating for staffing levels, a structural measure of quality, is negatively associated with cost efficiency. These findings reveal that different measures of quality have different relationships with costs and cost efficiency. The findings suggest that better quality outcomes in nursing homes may be achievable with fewer resources and/or improved care procedures, which in turn should reduce nursing home costs.
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Research Practice and Methodology
Systematic review finds major deficiencies in sample size methodology and reporting for stepped-wedge cluster randomised trials
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BACKGROUND: Stepped-wedge cluster randomised trials (SW-CRT) are increasingly being used in health policy and services research, but unless they are conducted and reported to the highest methodological standards, they are unlikely to be useful to decision-makers. Sample size calculations for these designs require allowance for clustering, time effects and repeated measures. METHODS: We carried out a methodological review of SW-CRTs up to October 2014. We assessed adherence to reporting each of the 9 sample size calculation items recommended in the 2012 extension of the CONSORT statement to cluster trials. RESULTS: We identified 32 completed trials and 28 independent protocols published between 1987 and 2014. Of these, 45 (75%) reported a sample size calculation, with a median of 5.0 (IQR 2.5-6.0) of the 9 CONSORT items reported. Of those that reported a sample size calculation, the majority, 33 (73%), allowed for clustering, but just 15 (33%) allowed for time effects. There was a small increase in the proportions reporting a sample size calculation (from 64% before to 84% after publication of the CONSORT extension, p=0.07). The type of design (cohort or cross-sectional) was not reported clearly in the majority of studies, but cohort designs seemed to be most prevalent. Sample size calculations in cohort designs were particularly poor with only 3 out of 24 (13%) of these studies allowing for repeated measures. DISCUSSION: The quality of reporting of sample size items in stepped-wedge trials is suboptimal. There is an urgent need for dissemination of the appropriate guidelines for reporting and methodological development to match the proliferation of the use of this design in practice. Time effects and repeated measures should be considered in all SW-CRT power calculations, and there should be clarity in reporting trials as cohort or cross-sectional designs.
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Bibliometrics
The emerging dynamic structure of national innovation studies: a bibliometric analysis
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The state is still the significant unit for innovative studies during the age of R&D globalization and innovation regionalization. Using the bibliometric method, this paper attempts to provide a comprehensive picture of national innovation studies based on data derived from the Web of Knowledge. In particular, we identify the most significant countries and institutions, major journals, seminal contributions and contributors, and clusters in the network of citations in the field of national innovation studies. The results are useful for understanding and promoting the field of national innovation.
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Aging
Factors related to falls, weight-loss and pressure ulcers – more insight in risk assessment among nursing home residents.
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AIMS AND OBJECTIVES: To describe how the included items in three different scales, Downton Fall Risk Index, the short form of Mini Nutritional Assessment and the Modified Norton Scale are associated to severe outcomes as falls, weight loss and pressure ulcers. BACKGROUND: Falls, malnutrition and pressure ulcers are common adverse events among nursing home residents and risk scoring are common preventive activities, mainly focusing on single risks. In Sweden the three scales are routinely used together with the purpose to improve the quality of prevention. DESIGN: Longitudinal quantitative study. METHODS: Descriptive analyses and Cox regression analyses. RESULTS: Only 4% scored no risk for any of these serious events. Longitudinal risk scoring showed significant impaired mean scores indicating increased risks. This confirms the complexity of this population’s status of general condition. There were no statistical significant differences between residents categorised at risk or not regarding events. Physical activity increased falls, but decreased pressure ulcers. For weight loss, cognitive decline and the status of general health were most important. CONCLUSIONS: Risk tendencies for falls, malnutrition and pressure ulcers are high in nursing homes, and when measure them at the same time the majority will have several of these risks. Items assessing mobility or items affecting mobility were of most importance. Care processes can always be improved and this study can add to the topic. RELEVANCE TO CLINICAL PRACTICE: A more comprehensive view is needed and prevention can not only be based on total scores. Mobility is an important factor for falls and pressure ulcers, both as a risk factor and a protective factor. This involves a challenge for care – to keep the inmates physical active and at the same time prevent falls.
Burden of Potentially Harmful Medications and the Association With Quality of Life and Mortality Among Institutionalized Older People.
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OBJECTIVES: This study investigated the overlap among 3 different definitions of potentially harmful medication (PHM) use and the corresponding associations with resident quality of life and mortality. DESIGN: Cross-sectional study with 3-year follow-up for mortality. SETTING: Assisted living facilities and nursing homes in Helsinki and Kouvola, Finland. PARTICIPANTS: A total of 326 residents. MEASUREMENTS: PHM use was defined as (1) use of medications with anticholinergic properties, (2) use of Beers Criteria medications, and (3) concomitant use 3 or more psychotropic medications. Health-related quality of life (HRQoL) was assessed using the 15D and psychological well-being (PWB) scale. Residents self-rated their own health using a 4-point scale. Mortality data were obtained from central registers. RESULTS: There were 38.0%, 28.2%, and 12.6% of residents who used PHMs according to 1 (G1), 2 (G2), and 3 definitions (G3), respectively. Overall, 21.2% of residents did not use PHMs according to any of the 3 definitions (G0). There were no significant differences in comorbidity, cognition, or functioning among groups. In adjusted analyses, there was a stepwise association between use of multiple PHMs and poorer self-rated health, poorer PWB, and poorer HRQoL. There was no association in adjusted analyses between PHM use and 3-year mortality (47.8%-63.8%). CONCLUSION: PHM use is highly prevalent in institutional settings, regardless of the definition of inappropriateness. Residents who used multiple categories of PHMs were at greatest risk of poor HRQoL, poor PWB, and poor self-rated health. However, there was no apparent association with increased mortality. Given the importance of quality of life as an outcome to older people, further efforts are needed to minimize PHM use in this setting.
Effects of a Stepwise Multidisciplinary Intervention for Challenging Behavior in Advanced Dementia: A Cluster Randomized Controlled Trial.
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OBJECTIVES: To assess whether implementation of a stepwise multicomponent intervention (STA OP!) is effective in reducing challenging behavior and depression in nursing home residents with advanced dementia. DESIGN: Cluster randomized controlled trial. SETTING: Twenty-one clusters (single independent nursing home units) in 12 nursing homes within the Netherlands. PARTICIPANTS: Residents with advanced dementia (N = 288). INTERVENTION: Staff working on intervention units received comprehensive stepwise multidisciplinary training; the control condition received training on general nursing skills, dementia management and pain without the stepwise component. MEASUREMENTS: The primary outcome was agitation (Cohen-Mansfield Agitation Inventory (CMAI)). Secondary outcomes included psychotropic medication use, neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and symptoms of depression (Cornell Scale for Depression in Dementia (CSDD), Minimum Dataset Depression Rating Scale (MDS-DRS)). Measurements were made at baseline and 3 and 6 months after the intervention. Multilevel analysis and logistical generalized estimating equations were used to test treatment and time effects. Analysis was on an intention-to-treat basis. RESULTS: Multilevel modeling revealed an overall effect of the intervention on challenging behavior and depression; CMAI (mean difference -4.07 points, 95% confidence interval = (CI) = -7.90 to -0.24, P = .02), NPI-NH (mean difference -3.57 points, 95% CI = -6.30 to -0.84, P = .005), CSDD (mean difference -1.59 points, 95% CI = -2.49 to -0.69, P < .001), and MDS-DRS (mean difference -0.96 points, 95% CI = -1.40 to -0.52, P < .001) scores were significantly lower in the intervention condition than the control condition. There was a significant reduction of antidepressants (N06A) (OR = 0.32); nonsignificant reductions of antipsychotics (N05A), anxiolytics (N05B), and hypnotic-sedatives (N05C) (odds ratios = 0.69 to 0.90). CONCLUSION: For nursing home residents with advanced dementia and challenging behavior, providing staff with comprehensive training in behavioral management, resulted in improved behavior and less psychotropic medication use.
Achieving High-Quality Multicultural Geriatric Care.
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As the ethnic diversity of the U.S. population increases, there is a growing awareness of healthcare disparities and the need to address them. This position statement that the American Geriatrics Society (AGS) Ethnogeriatrics Committee developed outlines healthcare disparities in the United States and the minimum quality indicators that healthcare organizations and healthcare providers should adopt to ensure that all older adults receive care that is culturally appropriate and takes into account level of health literacy.
The efficacy of a volunteer-administered cognitive stimulation program in long-term care homes.
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BACKGROUND: Cognitive impairment (CI) that arises in some older adults limits independence and decreases quality of life. Cognitive stimulation programs delivered by professional therapists have been shown to help maintain cognitive abilities, but the costs of such programming are prohibitive. The present study explored the feasibility and efficacy of using long-term care homes’ volunteers to administer a cognitive stimulation program to residents. METHODS: Thirty-six resident participants and 16 volunteers were alternately assigned to one of two parallel groups: a control group (CG) or stimulation group (SG). For eight weeks, three times each week, CG participants met for standard “friendly visits” (casual conversation between a resident and volunteer) and SG participants met to work through a variety of exercises to stimulate residents’ reasoning, attention, and memory abilities. Resident participants were pre- and post-tested using the Weschler Abbreviated Scale of Intelligence-Second Edition, Test of Memory, and Learning-Senior Edition, a modified Letter Sorting test (LS), Clock Drawing Test (CDT), and the Action Word Verbal Fluency Test. RESULTS: Two-way analyses of covariance (ANCOVA) controlling for dementia diagnosis indicated statistically greater improvements in the stimulation participants than in the control participants in Immediate Verbal Memory, p = 0.011; Non-Verbal Memory, p = 0.012; Learning, p = 0.016; and Verbal Fluency, p = 0.024. CONCLUSIONS: The feasibility and efficiency of a volunteer-administered cognitive stimulation program was demonstrated. Longitudinal studies with larger sample sizes are recommended in order to continue investigating the breadth and depth volunteer roles in the maintenance of the cognitive abilities of older adults.
The Current Landscape of Transitions of Care Practice Models: A Scoping Review.
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Transitions of care (TOC) are a set of actions to ensure patient coordination and continuity of care as patients transfer between different locations or levels. During transitions associated with chronic or acute illness, vulnerable patients may be placed at risk with fragmented systems compromising their health and safety. In addition, poor care transitions also have an enormous impact on health care spending. The primary objective of this scoping review is to summarize the current landscape of practice models that deliver TOC services in the United States. The secondary objective is to use the information to characterize the current state of best practice models. A search of the PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, International Pharmaceutical Abstracts, National Center for Biotechnology Information at the U.S. National Library of Medicine, and Cochrane Library databases (January 1, 2000-April 13, 2015) for articles pertaining to TOC models, limited to U.S. studies published in the English language with human subjects, gleaned 1362 articles. An additional 26 articles were added from the gray literature. Articles meeting inclusion criteria underwent a second review and were categorized into four groups: background information, original TOC research articles not evaluating practice model interventions, original TOC research articles describing practice models, and systematic or Cochrane reviews. The reviewers met weekly to discuss the challenges and resolve disagreements regarding literature reviews with consensus before progressing. A total of 188 articles describing TOC practice models met the inclusion criteria. Despite the strengths of several quality TOC models, none satisfied all the components recommended by leading experts. Multimodal interventions by multidisciplinary teams appear to represent a best practice model for TOC to improve patient outcomes and reduce readmissions, but one size does not fit all. Best model TOC services must include services along the TOC continuum: pretransition and posttransition, as well as at home and in outpatient health care settings. Studies clearly show that single-modal interventions are rarely successful in reducing readmissions and that successful TOC services must be multimodal and multidisciplinary, and continue throughout the care transition. Utilizing best practice TOC models described in this article as a starting point, practitioners interested in developing their own TOC program should test these tools in new practice environments and add to the body of literature by publishing their findings.
Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association.
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Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.
The determinants of home and nursing home death: a systematic review and meta-analysis.
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BACKGROUND: Most Canadians die in hospital, and yet, many express a preference to die at home. Place of death is the result of the interaction among sociodemographic, illness- and healthcare-related factors. Although home death is sometimes considered a potential indicator of end-of-life/palliative care quality, some determinants of place of death are more modifiable than others. The objective of this systematic review was to evaluate the determinants of home and nursing home death in adult patients diagnosed with an advanced, life-limiting illness. METHODS: A systematic literature search was performed for studies in English published from January 1, 2004 to September 24, 2013 that evaluated the determinants of home or nursing home death compared to hospital death in adult patients with an advanced, life-limiting condition. The adjusted odds ratios, relative risks, and 95 % confidence intervals of each determinant were extracted from the studies. Meta-analyses were performed if appropriate. The quality of individual studies was assessed using the Newcastle-Ottawa scale and the body of evidence was assessed according to the GRADE Working Group criteria. RESULTS: Of the 5,900 citations identified, 26 retrospective cohort studies were eligible. The risk of bias in the studies identified was considered low. Factors associated with an increased likelihood of home versus hospital death included multidisciplinary home palliative care, preference for home death, cancer as opposed to other diagnoses, early referral to palliative care, not living alone, having a caregiver, and the caregiver’s coping skills. CONCLUSIONS: Knowledge about the determinants of place of death can be used to inform care planning between healthcare providers, patients and family members regarding the feasibility of dying in the preferred location and may help explain the incongruence between preferred and actual place of death. Modifiable factors such as early referral to palliative care, presence of a multidisciplinary home palliative care team were identified, which may be amenable to interventions that improve the likelihood of a patient dying in the preferred location. Place of death may not be a very good indicator of the quality of end-of-life/palliative care since it is determined by multiple factors and is therefore dependent on individual circumstances.
Influencers on quality of life as reported by people living with dementia in long-term care: a descriptive exploratory approach.
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BACKGROUND: Over half of the residents in long-term care have a diagnosis of dementia. Maintaining quality of life is important, as there is no cure for dementia. Quality of life may be used as a benchmark for caregiving, and can help to enhance respect for the person with dementia and to improve care provision. The purpose of this study was to describe quality of life as reported by people living with dementia in long-term care in terms of the influencers of, as well as the strategies needed, to improve quality of life. METHODS: A descriptive exploratory approach. A subsample of twelve residents across two Australian states from a national quantitative study on quality of life was interviewed. Data were analysed thematically from a realist perspective. The approach to the thematic analysis was inductive and data-driven. RESULTS: Three themes emerged in relation to influencers and strategies related to quality of life: (a) maintaining independence, (b) having something to do, and (c) the importance of social interaction. CONCLUSIONS: The findings highlight the importance of understanding individual resident needs and consideration of the complexity of living in large group living situations, in particular in regard to resident decision-making.
Underreporting of nursing home utilization on the CMS-2728 in older incident dialysis patients and implications for assessing mortality risk.
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BACKGROUND: The usage of nursing home (NH) services is a marker of frailty among older adults. Although the Centers for Medicare & Medicaid Services (CMS) revised the Medical Evidence Report Form CMS-2728 in 2005 to include data collection on NH institutionalization, the validity of this item has not been reported. METHODS: There were 27,913 patients >/= 75 years of age with incident end-stage renal disease (ESRD) in 2006, which constituted our analysis cohort. We determined the accuracy of the CMS-2728 using a matched cohort that included the CMS Minimum Data Set (MDS) 2.0, often employed as a “gold standard” metric for identifying patients receiving NH care. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the CMS-2728 NH item. Next, we compared characteristics and mortality risk by CMS-2728 and MDS NH status agreement. RESULTS: The sensitivity, specificity, PPV and NPV of the CMS-2728 for NH status were 33%, 97%, 80% and 79%, respectively. Compared to those without the MDS or CMS-2728 NH indicator (No MDS/No 2728), multivariable adjusted hazard ratios (95% confidence interval) for mortality associated with NH status were 1.55 (1.46 – 1.64) for MDS/2728, 1.48 (1.42 – 1.54) for MDS/No 2728, and 1.38 (1.25 – 1.52) for No MDS/2728. NH utilization was more strongly associated with mortality than other CMS-2728 items in the model. CONCLUSIONS: The CMS-2728 underestimated NH utilization among older adults with incident ESRD. The potential for misclassification may have important ramifications for assessing prognosis, developing advanced care plans and providing coordinated care.
Effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review.
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AIM: The prevalence and severity of urinary incontinence (UI) increase with age and comorbidity. The benefits of pharmacotherapy for UI in the elderly are questionable. The aim of the present study was to systematically review the efficacy of pharmacological treatment for UI in the elderly and frail elderly. METHODS: We searched PubMed, EMBASE, Cochrane library and Cinahl databases through October 2013 to identify prospective controlled trials that evaluated pharmacological treatment for UI in persons aged >/=65 years. Elderly persons living in nursing homes were regarded as frail elderly. Outcomes were urinary leakage, quality of life and adverse events. RESULTS: We screened 1038 abstracts and assessed 309 full-text articles. We identified 13 trials of high or moderate quality; 11 evaluated anticholinergic drugs and two evaluated duloxetine. Oxybutynin, the only drug studied in the frail elderly population, had no effect on urinary leakage or quality of life in elderly with urgency UI (UUI). Seven trials evaluated the effects of darifenacin, fesoterodine, solifenacin, tolterodine or trospium. Urinary leakage decreased (standard mean difference: -0.24, 95% confidence interval -0.32-0.15), corresponding to a reduction of half a leakage per 24 h. Common side-effects of treatment were dry mouth and constipation. Data were insufficient for evaluation of the effect on quality of life or cognition. The evidence was insufficient to evaluate the effects of duloxetine. No eligible studies on mirabegron and estrogen were found. CONCLUSIONS: Anticholinergics have a small, but significant, effect on urinary leakage in older adults with UUI. Treatment with drugs for UUI in the frail elderly is not evidence based.
Despite the highly developed social services in Austria, the County of Upper Austria, one of the nine counties of Austria had only very limited specialized services for persons with dementia and their caregivers in 2001. Support groups existed in which the desire for more specialized services was voiced. In response to this situation, funding was received to develop a new structure for early disease detection and long term support for both the person with dementia and their caregivers. This article describes the development of the model of the Dementia Service Centres (DSCs) and the successes and difficulties encountered in the process of implementing the model in six different rural regions of Upper Austria. The DSC was described in the First Austrian Dementia Report as one of the potential service models for the future.
“Everyone else gets ice cream here more often than I do—It burns me up” – Perspectives on Diabetes Care from Nursing Home Residents and their Doctors
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BACKGROUND: To explore the perspectives of nursing home (NH) residents with diabetes and their doctors regarding the burdens of living with diabetes and diabetes treatments. METHODS: Qualitative study of nursing home residents aged 65 and older with diabetes (n = 14) and nursing home physicians (n = 9) at a Department of Veterans Affairs nursing home (known as the Community Living Center). A semi-structured interview was used to elicit nursing home residents’ and physicians’ perspectives on the burden of diabetes and diabetes treatments. Transcripts were analyzed using constant comparative methods. RESULTS: The mean age of the nursing home residents was 74; Most (93 %) were male and 50 % self-identified themselves as white. The mean age of nursing home physicians was 39 and 55 % were geriatricians. Dietary restrictions, loss of independence and fingersticks/insulin were noted to be the most burdensome aspects of diabetes. Nursing home residents with a more positive outlook were generally more engaged in their care, while nursing home residents with a more pessimistic outlook were less engaged, allowing their physicians to assume complete control of their care. While physicians noted the potential negative impact of dietary restrictions, nursing home residents’ comments suggest that physicians underestimate the burden of dietary restrictions. CONCLUSIONS: Veterans Affairs nursing home residents were substantially burdened by their diabetes treatments, especially dietary restrictions and fingerstick monitoring. Since there is little evidence that dietary restrictions improve outcomes, fewer dietary restrictions may be appropriate and lead to lower treatment burdens for nursing home residents with diabetes.
The Effect of Socioeconomic Status Across Adulthood on Trajectories of Frailty in Older Women
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BACKGROUND: To investigate whether distinct trajectories of frailty exist in older women and whether they are associated with measures of socioeconomic status (SES) across adulthood. METHODS: Participants were 7484 women born in 1921-1926 from the Australian Longitudinal Study on Women’s Health who were surveyed every 3 years from 1999 to 2011. Frailty was measured at each survey using the FRAIL scale. Group-based trajectory modeling was used to assess patterns of frailty. Multinomial logistic regression was used to examine associations of trajectories with SES (level of education, occupation, and ability to manage on income) across adulthood. RESULTS: Three trajectory groups were identified: low (19.5%), increasing (40.7%), and high (39.9%). Compared with women in the increasing frailty group, those who reported difficulty managing on their income in 1999 were less likely to be in the low frailty group (relative risk ratio 0.57, 95% confidence interval 0.39-0.84) and more likely to be in the high frailty group (relative risk ratio 2.65, 95% confidence interval 2.07-3.39), after adjusting for other SES variables, age, and social support. Occupation and education were not associated with trajectories of frailty. CONCLUSIONS: Some women remain frailty free until age 85-90 years. The strongest impact on frailty is late-life SES.
Gaps between the subjective needs of older facility residents and how care workers understand them: a pairwise cross-sectional study.
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BACKGROUND: To promote active daily living and improve the quality of life of older facility residents, it is important that care staff understand their day-to-day activities and needs. However, only a few studies have examined the needs of older residents and how care workers understand them. This study aimed to examine the subjective needs of older residents at aged care facilities, care workers’ understanding of these needs, and the gaps that exist between them. METHODS: Structured interviews with older residents with no severe cognitive impairment in ten Japanese aged care facilities and a questionnaire survey of care workers were conducted in 2008 regarding resident subjective needs. The questionnaire, which had satisfactory factorial validity, internal consistency, and reproducibility, consisted of seven items on basic activities of daily living (BADL), five items on instrumental ADL (IADL), eight items on environment and lifestyle (EL), and five items on emotion (EM). Pair-wise analyses were performed to compare responses. RESULTS: Responses of 115 pairs were analyzed (residents >/=75 years, 85 %; 21 men, 94 women). Median proportions of residents with IADL (66 %) and EL (69 %) needs were lower compared with those with BADL (83 %) and EM (91 %) needs. Median proportions of care workers understanding IADL (55 %) and EL (60 %) needs were lower compared with those understanding BADL (87 %) and EM (87 %) needs. Less than half of the care workers understood IADL needs for household chores (30 %) and money management (43 %), and an EL need for playing a role (41 %). CONCLUSIONS: Gaps were found between resident subjective needs and how care workers understood them. Specifically, care workers underestimated older residents’ IADL and EL needs, especially with regard to playing a role. These results highlight the need for care workers to set goals based on each resident’s subjective needs and plan strategies for care provision accordingly.
Capillary blood glucose measurements are regularly used for nursing home residents with diabetes. The usefulness of these measurements relies on clear indications for use, correct measurement techniques, proper documentation and clinical use of the resulting blood glucose values. The use of a regular, invasive procedure may also entail additional challenges in a population of older, multimorbid patients who often suffer from cognitive impairment or dementia. The aim of this study was to explore the perspectives of physicians, registered nurses and auxiliary nurses on the use, usefulness and potential challenges of using capillary blood glucose measurements in nursing homes, and the procedures for doing so.
Relationship between restraint use, engagement in social activity, and decline in cognitive status among residents newly admitted to long-term care facilities.
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AIM: Declining cognitive function can negatively affect residents’ quality of life (QOL) in long-term care facilities (LTCFs). The present study examined the role of physical restraint use, use of antipsychotic medications, and engagement in social activities to affect change in cognitive status and drive cognitive decline among residents newly admitted to a LTCF. METHODS: Secondary data analysis used interRAI Minimum Data Set 2.0 data gathered at admission and first follow-up assessment (n = 111,052). The interRAI Minimum Data Set 2.0 collects comprehensive information as part of regular clinical care, and is mandated for all LTCF in Ontario, Canada. Bivariate and logistic regression analyses investigated the roles of physical restraint use, antipsychotic medication use and social engagement affecting cognition, and were stratified based on the presence/absence of diagnosis of dementia. RESULTS: At follow up, 16.1% of residents (n = 16 414) showed decline in cognition. Residents with one or more physical restraints (chair, trunk and limb) were at increased risk for cognitive decline evidenced among residents with and without a diagnosis of dementia. Antipsychotic medication use did not emerge as a strong predictor of cognitive decline. Social engagement was protective against cognitive decline, and more pronounced for residents without a diagnosis of dementia. CONCLUSION: Physical restraint use should be avoided, or used as a last resort. LTCFs should prioritize resident engagement in social activities in either formal activities or ad hoc, as soon as possible on entry to the LTCFs. Prioritizing social networks and greater participation in activities might decrease the risk for cognitive decline, thereby improving or maintaining resident quality of life.
Antipsychotic Medication Use in Nursing Homes: Approaches to Reduce Use and National Trends.
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Consensus exists regarding the need to reduce antipsychotic medication use in nursing homes, multiple initiatives have been implemented with the intent to achieve this goal, and progress is being made. While limited high quality research is available documenting the impact of various approaches, resource tool kits and best practice descriptions can help guide efforts.
Quality standard for people with sight loss and dementia in an ophthalmology department (UK)
Many patients who attend ophthalmology departments also have dementia. This quality standard has been developed to help ophthalmology departments provide high quality care for these patients. It addresses staff training, support to participate in decisions about care, the design of clinical areas, waiting times and appointment durations, provision of information, assessment of vision and referral for support. The breadth of what should be considered in providing care to patients with dementia in an eye clinic requires liaison between all staff, managers, and commissioners of care within the care pathway.
Higher Quality Dementia Care (UK)
A key policy priority Dementia is a high-level government priority for action and the care of dementia patients in a hospital setting is a major policy focus.
Fix Dementia Care – Hospitals (UK)
Alzheimer’s Society wants to ensure that people with dementia receive the highest standards of care wherever they are: in hospital, in a care home, or in the home. Our latest report has uncovered some shocking examples of dangerous and inadequate care in hospitals throughout England. Hospitals have a duty to be transparent and accountable to their patients, and to continually monitor and improve dementia care. While there are notable examples of excellent care across the country, the difference from one hospital to the next is far too great and there is inconsistent understanding of the needs of people with dementia.
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Events
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Using performance feedback to improve healthcare delivery: An international symposium
Interactive symposium involving presentations on the state of the evidence on using audit and feedback to improve healthcare delivery, practical examples of audit and feedback in use in healthcare systems in Canada and internationally, discussion on next steps in audit and feedback and opportunities for fostering new collaborations between research and practice. To register your interest in attending, please email Véronique Perreault at vperreault@ohri.ca and include your name, affiliation and current e-mail address.
This half day course is designed to provide grant writers with the needed tools to write the KT portion of their grant applications. Course attendees will use their own grants to develop an end of grant KT plan.
Speakers include:
-Kim Barnhardt (Communications, Canadian Medical Association Journal)
-Jessie McGowan (Senior Information Scientist, Institute of Population Health, Ottawa)
-Dr. Sharon Straus (Scientist, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto)
Topics include:
-A framework for end of grant KT
-Assessing impact of research – how to use and interpret bibliometrics and altmetrics
-Approach to media and social media
Evidence-Informed Decision Making Workshop
Advance your skills in critical appraisal of research literature
Learn strategies for implementing evidence-informed decisions
Small and large group sessions led by faculty at McMaster
Tutorial groups for health professionals, administrators, managers, and policymakers
Online
Exercise programs for people with dementia: What’s the evidence?
Join Dorothy Forbes, Professor, Faculty of Nursing, University of Alberta, Edmonton, for an overview of findings from her latest Cochrane review examining the effectiveness of exercise programs for people with dementia.
Courses
Systematic Reviewing for Evidence-based Practice: An Introductory Workshop
This workshop provides NIDILRR grantees the opportunity to learn the basics of conducting a high-quality systematic review, using the “gold standard” methods of the Campbell Collaboration (C2). This 2-day workshop includes lectures and small group work, and covers the entire systematic review process. Upon completion of this workshop, participants should be able to:
-Identify and structure a systematic review topic
-Describe the steps for conducting a comprehensive literature search and gathering relevant studies
-Develop a coding protocol for extracting relevant information from included studies
-Describe basic meta-analysis techniques for synthesizing statistical findings from included studies
-Have a working knowledge of the tools and resources available for conducting a Campbell systematic review and meta-analysis
-Be informed consumers of systematic reviews and meta-analyses
News
I got my PhD by making YouTube videos – and so can you
But first, your university needs a policy on alternative-format dissertations.
Often, authors are the ones asserting that journal publishers do so little, which is understandable, as authors only experience a small part of the journal publishing process, and care about the editing and formatting bits the most, making those the most memorable. In fact, publishers’ service mentalities often include deliberately limiting the number of things authors have to worry about, which further limits their view of what it actually takes to publish a work and remain viable to publish the next one.
Care homes and the NHS: The silent scandal? (UK)
The plight of care home residents has pretty much slipped below the radar in recent years. While there is close scrutiny of everything from A&E waiting times to access to the latest cancer drugs, the support – or rather lack of it – care home residents receive from the NHS has gone almost unnoticed.
Journal Editors To Researchers: Show Everyone Your Clinical Data
The editors of the leading medical journals around the world have made a proposal that could change medical science forever. They said that researchers would have to publicly share the data gathered in their clinical studies as a condition of publishing the results in the journals. This idea is now out for public comment.
Vitamin B12 deficiency a concern in LTC
Low levels of the vitamin have been linked to a number of health conditions, including anemia, neurological issues, depression and dementia. The study found that 14% of study participants were deficient, and 38% had less then optimal levels.
CIHI: Development of new financial long-term care indicator is in the works
One of CIHI’s current projects is a great example of how feedback grows from an idea to an indicator. Given Canada’s aging population and the increasing importance of understanding seniors’ care, stakeholders across the country asked us to shift our focus and consider spending across the health care continuum. Our latest National Health Expenditure Database (NHEX) report shows that spending in “other institutions” — largely composed of long-term care services — represents 10.7% of annual health spending in Canada.
Things to do during the PhD – publish articles on the side
Marianne Hem Eriksen is an archaeologist at the University of Oslo, Norway. She recently won a mobility grant from the Research Council of Norway/Marie Skłodowska–Curie Actions, and is excitedly planning her move to Cambridge, UK, for two years. Marianne completed her PhD in a hair short of three years, and wrote and published a small number of articles while writing her doctoral dissertation. In this post, she outlines why this is a useful strategy also for people writing “the big book”.
Older people in need ‘let down by NHS’ (UK)
Older people in need of urgent help are being failed by the NHS, a group of English and Welsh health leaders say. Too many over-65s end up in accident and emergency unnecessarily, says the NHS Confederation’s Commission on Improving Urgent Care for Older People.
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. For the first time, the profile will enable bespoke comparison between local authorities and CCG’s in England in one, interactive online platform.
The Doctor’s Computer Will Email You Now
A health care startup made a wild pitch to Cara Waller, CEO of the Newport Orthopedic Institute. The company said it could get patients more engaged with their care by automating physician empathy. It “almost made me nauseous,” she said. How can you automate something as deeply personal as empathy?
Small Questions, Big Improvements in Patient-Centered Care
Rose, an 88-year-old woman with advanced dementia, was admitted to a geriatric unit in Scotland following a fall at home. She couldn’t talk, became agitated easily, and often tried to get up and walk on her own, which led to more falls. To keep her safe, a staff member had to sit with her nearly full time.
Long-term health care workers at highest risk of injury on the job
Nurses aides and orderlies report injuries at a rate four times higher than the B.C. average.
EvidenceNOW: Helping Primary Care Offices Keep Their Resolutions To Put Evidence Into Practice (US)
AHRQ has found that something similar happens for doctors and nurses and the teams of other clinicians who work in their offices. Learning about new medical science is relatively simple. Knowing how to put into practice, like new resolutions, can be harder.
Carl Amrhein said Wednesday his department is working with Alberta Health Services on a proposal to roll out a single health information system starting in 2017 in the areas of Edmonton, Calgary and Red Deer.
Home care not keeping up with seniors’ population growth in B.C., advocate finds
Health authorities throughout the province are trimming hours and the types of work they fund that helps seniors stay at home, advocate Isobel Mackenzie said today in Victoria.
Short home care visits ‘plague system’ (UK)
Unacceptably short 15-minute home care visits to elderly and disabled people are still plaguing the care system in England, a report suggests.
Serving Seniors Better through Equity and Diversity in Long-Term Care
When it comes to where you live, culture matters. Growing media and public attention is shining a light on how long-term care (LTC) is structured and delivered right now in Ontario. And while there is a growing understanding about the need to reform Ontario’s LTC services there has been less discussion about how to ensure access and quality for Ontario’s diverse populations.
Alberta must act on health system’s alternative level of care
Each day 400 to 600 hospital beds are occupied by elderly Albertans waiting for spaces in an alternative level of care facility, or ALC, in the continuing care system.
Are We Correctly Using PDSA Cycles?
The widespread appeal of the Plan-Do-Study-Act cycle stems from its simple, practical approach to improvement. But within its simplicity lies some inherent complexity that too many of us may overlook. In a response to a recently published critique of PDSA cycles, IHI Vice President Bob Lloyd asserts that the main problem is that too few people are true to the spirit of this iterative approach to improvemen
Carers for people with dementia struggling in silence (UK)
The UK’s largest research trial of support for carers of people with dementia was launched on February 4th.
Video series from Government of Canada: Dementia and Caregiving
The videos include vignettes of people sharing their personal experiences of caregiving and the importance of their social connections. Common themes throughout the videos include coping with feelings of loneliness, feeling overwhelmed and maintaining balance and self-care as a caregiver.
Resources
Evidence on Topics Related to Long‑Term Care
CADTH has pulled together evidence based resources on long term care.
Guideline on Person and family-centred care
To promote the evidence-based practices associated with person- and family-centred care, and to help nurses and other healthcare providers acquire the knowledge and skills necessary to become more adept at practising person- and family-centred care.
Writing a publishable literature review paper – four options
After you’ve spent loads of time reading, summarising and synthesising the literatures for your research, it’s hardly surprising that you might wonder whether all of this work can be turned into something publishable. I certainly encounter many doctoral researchers who want to do just this. I was a bit surprised to see that while there is a lot of material around about how to do different kinds of literature reviews – there is actually very little around about how to write a publishable paper afterwards – a paper based solely on ‘the literatures’.
Opportunities
Richard and Susan Levy Chair in Health Care Delivery Science
Dartmouth invites applications for the inaugural Richard and Susan Levy Chair, a newly established endowed tenured professorship in the field of health care delivery science. This is the first of several hires at The Dartmouth Institute for Health Policy & Clinical Practice at Geisel School of Medicine. The holder of the Levy Chair will work with other schools, centers, and institutes across campus to lead an interdisciplinary effort in developing Dartmouth’s vision of becoming the institution shaping and accelerating the transformation of health care in the United States.
Paul Batalden Chair in Health Care Delivery Science
The Batalden Professor will lead efforts at Dartmouth to measurably improve health and health care at a patient, system, and population level using scientific methods. The holder of the position will also help implement novel interventions and mentor providers in leading quality improvement throughout the Dartmouth-Hitchcock Health System, as well as lead Dartmouth’s educational programs in health care improvement.
Funded PhD studentship: An investigation of the health and wellbeing of UK migrant communities
Non UK born individuals living in the in the UK are known to experience poorer health outcomes than the UK population as a whole. Differences in health status may be driven by a greater risk of chronic disease among some migrant communities (e.g. cardiometabolic disease among South Asian populations) and changing patterns and re-emergence of infectious diseases (eg HIV, Hep B and C, TB). Migrants are likely to experience different societal determinants of health, including socioeconomic position and access to healthcare due to restrictions and the complex administrative processes. Differences in individual stressors/behaviours, language and culture can also hinder access to and treatment from health services resulting in multiple morbidities and adverse health trajectories. Left unaddressed this could result in a significant future burden to the NHS and health and social care services.
