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Article recommended by Dr. Carole Estabrooks
Defeating Alzheimer’s disease and other dementias: a priority for European science and society.
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In view of the lack of progress in developing a cure for Alzhiemers Disease (AD) and the rapidly increasing costs of dementia, policy makers and governments have a powerful incentive to provide more resources to develop AD therapeutics. The Lancet Neurology Commission was formed with the overarching aim to provide information and expert recommendations to policy makers and political leaders about the growing problem of AD and related dementias of ageing.
New articles by Dr. Malcolm Doupe
Mapping Nursing Home Inspections & Audits in Six Countries
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International quality concerns regarding long-term residential care, home to many of the most vulnerable among us, prompted our examination of the audit and inspection processes in six different countries. Drawing on Donabedian’s (Evaluation & Health Professions, 6(3), 363–375, 1983) categorization of quality criteria into structural, process and outcome indicators, this paper compares how quality is understood and regulated in six countries occupying different categories according to Esping Andersen’s (1990) typology: Canada, England, and the United States (liberal welfare regimes); Germany (conservative welfare regime); Norway, and Sweden (social democratic welfare regimes). In general, our review finds that countries with higher rates of privatization (mostly the liberal welfare regimes) have more standardized, complex and deterrence-based regulatory approaches. We identify that even countries with the lowest rates of for profit ownership and more compliance-based regulatory approaches (Norway and Sweden) are witnessing an increased involvement of for-profit agencies in managing care in this sector. Our analysis suggests there is widespread concern about the incursion of market forces and logic into this sector, and about the persistent failure to regulate structural quality indicators, which in turn have important implications for process and outcome quality indicators.
Pressure Ulcers Among Newly Admitted Nursing Home Residents: Measuring the Impact of Transferring From Hospital.
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Objectives: Pressure ulcers (PUs) are reported more often among newly admitted nursing home (NH) residents who transfer from hospital versus community. We examine for whom this increased risk is greatest, further defining hospitalized patients most in need of better PU preventive care. Research Design: Retrospective observational cohort study. Subjects: All NH residents (N=5617) newly admitted between April 1, 2008 and March 31, 2012 in Winnipeg, MB, Canada. Measures: RAI-MDS 2.0 data were linked to administrative health care use files capturing each person’s NH admission date, their presence of a PU at this time, whether they transferred into NH from hospital or community, and their PU susceptibility (eg, amount of help needed to maneuver in bed or to transfer from one surface to another, frequency of incontinence, presence of diabetes, amount of food consistently left uneaten). Log-binomial regression with interaction terms was used to analyze data. Results: 67.6% of our cohort transferred into a NH directly from hospital; 9.2% of these residents were reported to have a stage 1+ PU on NH admission versus 2.6% of those who transferred from community. From regression models, transferring from hospital versus community was associated with increased PU risk equally across various subgroups of less and more susceptible residents. Conclusions: Transferring from hospital versus community places both more and less susceptible newly admitted NH residents at increased PU risk. Using evidence-based preventive care practices is thus needed for all subgroups of hospital patients before NH use, to help reduce PU risk. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.
Kevin Challacombe appointed Health Research Data Repository (HRDR) Co-ordinator
Kevin brings extensive experience in health data management, most recently from the Ontario HIV Treatment Network where he worked for the past 14 years; most recently as a research co-ordinator specializing in questionnaire and clinical data collection, data security, and data management. Kevin recently moved back to Edmonton after living in Toronto Ontario for the past 15 years. Based within the Faculty of Nursing at the University of Alberta, the HRDR is a secure and confidential virtual research environment created to support health related research projects, to support collaboration across research disciplines, to house health research data and meta-data throughout their life-cycle, and to promote the secondary use and re-purposing of health research data. The HRDR also has a mandate to promote and offer educational opportunities regarding research data management best practices. The mission of the HRDR is to stimulate both qualitative and quantitative health related research while building a collaborative culture of respect relating to data management and confidentiality.
Calls for Abstracts
CALL FOR ABSTRACTS:
Putting evidence to work for better policies, programmes and practice: the What Works Global Summit 2016
The What Works Global Summit (WWGS) will be an international culture-shifting event, putting evidence at the heart of policy and practice. It will promote quality evidence and ways of producing and communicating evidence to maximize uptake into policy and practice. The event will be innovative in several ways, in particular its focus on an interchange of ideas, rather than academic presentations: an interchange between the global north and south, and an interchange between researchers and practitioners. It will recognise and incorporate in sessions the role that civil society and media play in promoting evidence informed decision making.
CALL FOR SUBMISSIONS:
Health Affairs ‘Aging and Health’ Series
Health Affairs is continuing its series on Aging and Health through 2016 and 2017. The publication is encouraging submissions from authors on topics surrounding the care of older adults, including new models of care and the management of multiple chronic conditions among this population. They are interested in work that spans the full range of care settings, including primary care and specialty practices, hospitals, nursing homes and other long-term care settings. Likewise, in addition to exploring topics that are directly related to the provision of care, we also welcome papers on a broad array of related dimensions that affect care, access, and affordability, such as financing models, coverage, and size and composition of the workforce. The series is sponsored by The John A. Hartford Foundation, which provides support for ongoing coverage of these topics
Grants & Awards
CIHR Chair: The Wilfred and Joyce Posluns Chair in Women’s Brain Health
The Wilfred and Joyce Posluns Chair in Women’s Brain Health and Aging is a new integrated initiative within CIHR’s Dementia Research Strategy. The Strategy supports research on the latest preventive, diagnostic and treatment approaches to Alzheimer’s disease and related dementia. It consists of an international and a national component. The national component of the strategy, the Canadian Consortium on Neurodegeneration in Aging (CCNA) announced in 2014, represents Canada’s centre of excellence in neurodegeneration research and is comprised of 20 teams, more than 350 researchers and eight platforms spanning all neurodegenerative diseases that have an impact on cognition. The Women, Gender, Sex and Dementia cross-cutting program within the CCNA helps to ensure the gender-responsive representation of women in CCNA clinical trials and aims to clarify the role of sex and gender differences in dementia. This new Chair Program will provide an added opportunity to delve deeper into this area of research and support capacity building in women’s brain health.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice and Methodology
Aging
KT
Integrated knowledge translation (IKT) in health care: a scoping review
Integrated knowledge translation (IKT) refers to collaboration between researchers and decision-makers. While advocated as an approach for enhancing the relevance and use of research, IKT is challenging and inconsistently applied. This study sought to inform future IKT practice and research by synthesizing studies that empirically evaluated IKT and identifying knowledge gaps. Methods We performed a scoping review. We searched MEDLINE, EMBASE, and the Cochrane Library from 2005 to 2014 for English language studies that evaluated IKT interventions involving researchers and organizational or policy-level decision-makers. Data were extracted on study characteristics, IKT intervention (theory, content, mode, duration, frequency, personnel, participants, timing from initiation, initiator, source of funding, decision-maker involvement), and enablers, barriers, and outcomes reported by studies. We performed content analysis and reported summary statistics. Results Thirteen studies were eligible after screening 14,754 titles and reviewing 106 full-text studies. Details about IKT activities were poorly reported, and none were formally based on theory. Studies varied in the number and type of interactions between researchers and decision-makers; meetings were the most common format. All studies reported barriers and facilitators. Studies reported a range of positive and sub-optimal outcomes. Outcomes did not appear to be associated with initiator of the partnership, dedicated funding, partnership maturity, nature of decision-maker involvement, presence or absence of enablers or barriers, or the number of different IKT activities. Conclusions The IKT strategies that achieve beneficial outcomes remain unknown. We generated a summary of IKT approaches, enablers, barriers, conditions, and outcomes that can serve as the basis for a future review or for planning ongoing primary research. Future research can contribute to three identified knowledge gaps by examining (1) how different IKT strategies influence outcomes, (2) the relationship between the logic or theory underlying IKT interventions and beneficial outcomes, and (3) when and how decision-makers should be involved in the research process. Future IKT initiatives should more systematically plan and document their design and implementation, and evaluations should report the findings with sufficient detail to reveal how IKT was associated with outcomes.
Adaptation and Fidelity: a Recipe Analogy for Achieving Both in Population Scale Implementation.
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Balancing adherence to fidelity of evidence-based programs and adaptation to local context is one of the key debates in the adoption and implementation of effective programs. Concern about maintaining fidelity to achieve outcomes can result in replication of research-based models that can be a poor fit with the real world. Equally, unplanned adaptation can result in program drift away from the core elements needed to achieve outcomes. To support implementation of the Maternal Early Childhood Sustained Home-visiting (MECSH) program in multiple sites in three countries, an analogy was developed to identify how both fidelity and adaptation can be managed and successfully achieved. This article presents the Commonsense Cookery Book Basic Plain Cake with Variations recipe analogy to articulate the dual requirements of both fidelity and adaptation to achieve quality implementation of the MECSH program. Components classified by the analogy include identification of core ingredients, methods, and equipment that contribute to fundamental outcomes and fidelity to the evidence-based program, and a planned, collaborative approach to identification of needed variations to suit locally sourced capacity, needs, and tastes. Quality is achieved by identifying and measuring the core ingredients and the variations. Sourcing local ingredients and honoring of context support sustainability of quality practice. Using this analogy has assisted adopters of the MECSH program to understand that effective implementation requires uncompromised commitment to expectations of fidelity to the core components and methods; planned, proactive adaptation; systematic monitoring of both core program and agreed variations; and local ownership and sustainability.
Building capacity in implementation science research training at the University of Nairobi.
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BACKGROUND: Health care systems in sub-Saharan Africa, and globally, grapple with the problem of closing the gap between evidence-based health interventions and actual practice in health service settings. It is essential for health care systems, especially in low-resource settings, to increase capacity to implement evidence-based practices, by training professionals in implementation science. With support from the Medical Education Partnership Initiative, the University of Nairobi has developed a training program to build local capacity for implementation science. METHODS: This paper describes how the University of Nairobi leveraged resources from the Medical Education Partnership to develop an institutional program that provides training and mentoring in implementation science, builds relationships between researchers and implementers, and identifies local research priorities for implementation science. RESULTS: The curriculum content includes core material in implementation science theory, methods, and experiences. The program adopts a team mentoring and supervision approach, in which fellows are matched with mentors at the University of Nairobi and partnering institutions: University of Washington, Seattle, and University of Maryland, Baltimore. A survey of program participants showed a high degree satisfaction with most aspects of the program, including the content, duration, and attachment sites. A key strength of the fellowship program is the partnership approach, which leverages innovative use of information technology to offer diverse perspectives, and a team model for mentorship and supervision. CONCLUSIONS: As health care systems and training institutions seek new approaches to increase capacity in implementation science, the University of Nairobi Implementation Science Fellowship program can be a model for health educators and administrators who wish to develop their program and curricula.
Why is there variation in the practice of evidence-based medicine in primary care? A qualitative study
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OBJECTIVE: To explore the factors, including barriers and facilitators, influencing the practice of evidence-based medicine (EBM) across various primary care settings in Malaysia based on the doctors’ views and experiences. RESEARCH DESIGN: The qualitative study was used to answer the research question. 37 primary care physicians participated in six focus group discussions and six individual in-depth interviews. A semistructured topic guide was used to facilitate both the interviews and focus groups, which were audio recorded, transcribed verbatim, checked and analysed using a thematic approach. PARTICIPANTS: 37 primary care doctors including medical officers, family medicine specialists, primary care lecturers and general practitioners with different working experiences and in different settings. SETTING: The study was conducted across three primary care settings-an academic primary care practice, private and public health clinics in Klang Valley, Malaysia. RESULTS: The doctors in this study were aware of the importance of EBM but seldom practised it. Three main factors influenced the implementation of EBM in the doctors’ daily practice. First, there was a lack of knowledge and skills in searching for and applying evidence. Second, workplace culture influenced doctors’ practice of EBM. Third, some doctors considered EBM as a threat to good clinical practice. They were concerned that rigid application of evidence compromised personalised patient care and felt that EBM did not consider the importance of clinical experience. CONCLUSIONS: Despite being aware of and having a positive attitude towards EBM, doctors in this study seldom practised EBM in their routine clinical practice. Besides commonly cited barriers such as having a heavy workload and lack of training, workplace ‘EBM culture’ had an important influence on the doctors’ behaviour. Strategies targeting barriers at the practice level should be considered when implementing EBM in primary care.
Evidence-based practice among nurses in Slovenian Hospitals: a national survey.
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AIMS: To identify the extent of evidence-based practice implementation among nurses in Slovenian hospital settings, to establish nurses’ beliefs on evidence-based practice and to identify possible explanatory factors. BACKGROUND: Conducting and applying research are fundamental nurses’ tasks and an essential expectation in nursing practice. INTRODUCTION: Despite verified benefits of evidence-based practice, research evidence across different countries has shown extremely limited implementation of this practice among nurses. METHODS: A cross-sectional research design was employed. Standardized instruments Evidence-Based Practice Beliefs and Implementation Scale were used. The sample included 534 nurses from 19 Slovenian hospitals. The obtained data were analysed using descriptive statistics, correlation and factor analysis, and linear regression. RESULTS: Nurses in Slovenian hospitals have positive beliefs about evidence-based practice, but exhibit a low level of implementation. The beliefs were explained by perceived knowledge on research, job satisfaction and length of employment, whereas a low level of implementation was explained by poor perceived knowledge on research, evidence-based practice and job satisfaction level. DISCUSSION: Nurses in Slovenian hospitals have positive beliefs about evidence-based practice, but exhibit a low level of implementation. According to the results, some resources required for improved implementation are not made sufficiently available. LIMITATIONS: A low response rate; the sample not being balanced for educational achievement; and the accuracy of self-report survey methods. CONCLUSION: In addition to the perceived knowledge and education provided, an important factor is also job satisfaction, which points to the instrumental role of management workers in determining nurses’ professional development. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nursing managers in Slovenian hospitals should promote the development of head nurses in research and evidence-based care, thereby fostering a culture of evidence-based practice.
Reliable implementation of evidence: a qualitative study of antenatal corticosteroid administration in Ohio hospitals.
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BACKGROUND: Antenatal corticosteroids (ANCS) reduce complications of preterm birth; however, not all eligible women receive them. Many hospitals and providers do not have the right processes and conditions to enable ANCS administration with high reliability. The objective of this study was to understand conditions that enable delivery of ANCS with high reliability among hospitals participating in an Ohio Perinatal Quality Collaborative (OPQC) ANCS project. METHODS: We conducted focus groups and semistructured interviews with members of the OPQC project team (n=27) and other care providers (n=70) using a purposeful sample of 6 sites involved in the OPQC ANCS project. Participants including nurses (n=57), attending obstetricians (n=17), physician trainees (n=21) and certified nurse midwives (n=2) were asked to reflect on their experiences and to identify factors contributing to optimal use of ANCS. Focus groups and interviews were transcribed verbatim and were analysed by a multidisciplinary team using an iterative approach that combined inductive and deductive methods to identify and categorise themes. RESULTS: Six major themes supporting reliable implementation of ANCS at these hospitals emerged including: (1) presence of a high reliability culture, (2) processes that emphasise high reliability, (3) timely and efficient administration process, (4) multiple disciplines are involved, (5) evidence of benefit supports ANCS use and (6) benefit is recognised at all levels of the care team. CONCLUSIONS: Our findings identify the key processes and supports needed to ensure delivery of ASCS with high reliability and are reinforced by implementation and reliability science. They are useful for foundation of the successful implementation of other evidence-based practices at high levels of reliability.
Applying Knowledge Translation Concepts and Strategies in Dementia Care Education for Health Professionals: Recommendations From a Narrative Literature Review.
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INTRODUCTION: Dementia education programs are being developed for health professionals, but with limited guidance about “what works” in design and content to promote best practice in dementia care. Knowledge translation (KT) is a conceptual framework for putting evidence to work in health care. This narrative literature review examined the question: What does the field KT offer, conceptually and practically, for education of health professionals in dementia care? It seeks to identify the types of strategies currently used within education to facilitate effective KT for the wide range of health professionals who may be involved in the care of people with dementia, plus explore enablers and barriers to KT in this context. METHODS: From 76 articles identified in academic databases and manual bibliographic searching, 22 met review criteria. RESULTS: The literature synthesis indicated four hallmarks of successful KT-oriented dementia education for health professionals: (1) multimodal delivery, (2) tailored approaches, (3) relationship building, and (4) organizational support for change in the work setting. Participatory action frameworks were also favored, based on interactive knowledge exchange (eg, blended learning) rather than passive unidirectional approaches alone (eg, lectures). DISCUSSION: The following six principles are proposed for educating health professionals in dementia care: (1) Match the education strategy to the KT goal and learner preferences; (2) Use integrated multimodal learning strategies and provide opportunities for multiple learning exposures plus feedback; (3) Build relationships to bridge the research-practice gap; (4) Use a simple compelling message with formats and technologies relevant to the audience; (5) Provide incentives to achieve KT goals; and (6) Plan to change the workplace, not just the individual health professional.
Evidence and the Politics of Deimplementation: The Rise and Decline of the “Counseling and Testing” Paradigm for HIV Prevention at the US Centers for Disease Control and Prevention
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Policy Points: In situations of scientific uncertainty, public health interventions, such as counseling for HIV infection, sometimes must be implemented before obtaining evidence of efficacy. * The history of HIV counseling and testing, which served as the cornerstone of HIV prevention efforts at the US Centers for Disease Control and Prevention (CDC) for a quarter of a century, illustrates the influence of institutional resistance on public health decision making and the challenge of de-implementing well-established programs. Context In 1985, amid uncertainty about the accuracy of the new test for HIV, public health officials at the Centers for Disease Control and Prevention (CDC) and AIDS activists agreed that counseling should always be provided both before and after testing to ensure that patients were tested voluntarily and understood the meaning of their results. As the “exceptionalist” perspective that framed HIV in the early years began to recede, the purpose of HIV test counseling shifted over the next 30 years from emphasizing consent, to providing information, to encouraging behavioral change. With this increasing emphasis on prevention, HIV test counseling faced mounting doubts about whether it “worked”. The CDC finally discontinued its preferred test counseling approach in October 2014. Methods Drawing on key informant interviews with current and former CDC officials, behavioral scientists, AIDS activists, and others, along with archival material, news reports, and scientific and governmental publications, we examined the origins, development, and decline of the CDC’s “counseling and testing” paradigm for HIV prevention. Findings Disagreements within the CDC emerged by the 1990s over whether test counseling could be justified on the basis of efficacy and cost. Resistance to the prospect of policy change by supporters of test counseling in the CDC, gay activists for whom counseling carried important ethical and symbolic meanings, and community organizations dependent on federal funding made it difficult for the CDC to de-implement the practice. Conclusions Analyses of changes in public health policy that emphasize the impact of research evidence produced in experimental or epidemiological inquiries may overlook key social and political factors involving resistance to deimplementation that powerfully shape the relationship between science and policy.
Evidence for Health II: Overcoming barriers to using evidence in policy and practice 
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Even the highest quality evidence will have little impact unless it is incorporated into decision-making for health. It is therefore critical to overcome the many barriers to using evidence in decision-making, including (1) missing the window of opportunity, (2) knowledge gaps and uncertainty, (3) controversy, irrelevant and conflicting evidence, as well as (4) vested interests and conflicts of interest. While this is certainly not a comprehensive list, it covers a number of main themes discussed in the knowledge translation literature on this topic, and better understanding these barriers can help readers of the evidence to be more savvy knowledge users and help researchers overcome challenges to getting their evidence into practice. Thus, the first step in being able to use research evidence for improving population health is ensuring that the evidence is available at the right time and in the right format and language so that knowledge users can take the evidence into consideration alongside a multitude of other factors that also influence decision-making. The sheer volume of scientific publications makes it difficult to find the evidence that can actually help inform decisions for health. Policymakers, especially in low- and middle-income countries, require context-specific evidence to ensure local relevance. Knowledge synthesis and dissemination of policy-relevant local evidence is important, but it is still not enough. There are times when the interpretation of the evidence leads to various controversies and disagreements, which act as barriers to the uptake of evidence. Research evidence can also be influenced and misused for various aims and agendas. It is therefore important to ensure that any new evidence comes from reliable sources and is interpreted in light of the overall body of scientific literature. It is not enough to simply produce evidence, nor even to synthesize and package evidence into a more user-friendly format. Particularly at the policy level, political savvy is also needed to ensure that vested interests do not undermine decisions that can impact the health of individuals and populations.
Evidence for Health III: Making evidence-informed decisions that integrate values and context.
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Making evidence-informed decisions with the aim of improving the health of individuals or populations can be facilitated by using a systematic approach. While a number of algorithms already exist, and while there is no single ‘right’ way of summarizing or ordering the various elements that should be involved in making such health-related decisions, an algorithm is presented here that lays out many of the key issues that should be considered, and which adds a special emphasis on balancing the values of individual patients and entire populations, as well as the importance of incorporating contextual considerations. Indeed many different types of evidence and value judgements are needed during the decision-making process to answer a wide range of questions, including (1) What is the priority health problem? (2) What causes this health problem? (3) What are the different strategies or interventions that can be used to address this health problem? (4) Which of these options, as compared to the status quo, has an added benefit that outweighs the harms? (5) Which options would be acceptable to the individuals or populations involved? (6) What are the costs and opportunity costs? (7) Would these options be feasible and sustainable in this specific context? (8) What are the ethical, legal and social implications of choosing one option over another? (9) What do different stakeholders stand to gain or lose from each option? and (10) Taking into account the multiple perspectives and considerations involved, which option is most likely to improve health while minimizing harms? This third and final article in the ‘Evidence for Health’ series will go through each of the steps in the algorithm in greater detail to promote more evidence-informed decisions that aim to improve health and reduce inequities.
Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury.
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RATIONALE: Optimal, early management following a spinal cord injury (SCI) can limit individuals’ disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting. OBJECTIVES: To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients. METHODS: The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application. RESULTS: Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures. CONCLUSIONS: This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients.
Evaluating factors associated with implementing evidence-based practice in nursing
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RATIONALE, AIMS AND OBJECTIVES: Evidence-based practice (EBP) has emerged as an innovation for quality improvement in health care. Nurses have important role in implementing EBP but they face many challenges in this context. Evaluation of factors influencing implementation of EBP seems necessary. The aims of this study were to examine nurses’ attitude towards EBP, their self-efficacy and training needs, as well as supporting factors and barriers for implementing EBP. METHODS: A cross-sectional study was conducted on 182 nurses from four teaching hospitals in Kerman, Iran. Data were collected using a questionnaire consisting of two main sections; a section to collect socio-demographic information of participants and a section collecting information on five topics (staff’s attitude, self-efficacy skills of EBP, supporting factors, barriers and training needs for implementing EBP). RESULTS: The majority (87.4%) of the nurses had not attended any formal training on EBP and 60% of them were not familiar with the concept of EBP. Nurses’ attitude towards EBP was unfavourable (2.57 +/- 0.99) and their self-efficacy skills of EBP were poor (2.93 +/- 1.06). The most important supporting factor was mentoring by nurses who have adequate EBP experience (3.65 +/- 1.17) and the biggest barrier was difficulty judging the quality of research papers and reports (2.46 +/- 0.95). There was a moderate demand for training in all areas of EBP (3.62 +/- 1.12). CONCLUSIONS: Nursing care needs to move towards quality improvement using EBP. It is necessary to equip nurses with knowledge and skills required for EBP. Managers should design an appropriate strategic plan by considering supporting factors and barriers for integrating EBP into clinical setting.
Handling a challenging context: experiences of facilitating evidence-based elderly care.
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AIM: To explore improvement facilitators’ experiences of handling their commission to implement evidence-based practice in elderly care for frail older persons. BACKGROUND: Improvement facilitators were put in place across Sweden in a time-limited project by the government, with one part of the project being to evaluate the model before establishing this facilitation of evidence-based practice in elderly care. METHOD: Two focus groups were interviewed twice. Each group comprised three respondents. The interviews were analysed using qualitative content analysis. FINDINGS: A main theme, ‘Moving forward by adjusting to the circumstances’, described how the improvement facilitators handle their commitment. Five subthemes emerged: identifying barriers, keeping focus, maintaining motivation, building bridges and finding balance. CONCLUSION: The improvement facilitators’ commitment is ambiguous because of unclear leadership of, and responsibility for the national investment. They have to handle leaders’ different approaches and justify the need for evidence-based practice. The improvement facilitators did not reflect on the impact of programme adaptations on evidence-based practice. IMPLICATIONS FOR NURSING MANAGEMENT: The findings emphasise the need for collaboration between the improvement facilitator and the nurse manager. To fully implement evidence-based practice, negotiations with current practitioners for adaptation to local conditions are necessary. Furthermore, the value of improving organisational performance needs to be rigorously communicated throughout the organisation.
Usefulness of a KT Event to Address Practice and Policy Gaps Related to Integrated Care
There are limited evaluations of the impact of knowledge translation (KT) activities aimed at addressing practice and policy gaps. We report on the impact of an interactive, end-of-grant KT event. Although action items were developed and key stakeholder support attained, minimal follow-through had occurred three months after the KT event. Several organizational obstacles to transitioning knowledge into action were identified: leadership, program policies, infrastructure, changing priorities, workload and physician engagement. Key messages include: (1) ensure ongoing and facilitated networking opportunities, (2) invest in building implementation capacity, (3) target multi-level implementation activities and (4) focus further research on KT evaluation.
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Health Care Administration and Organization
Workplace Participatory Occupational Health/Health Promotion Program: Facilitators and Barriers Observed in Three Nursing Homes.
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Nursing home employees experience high physical and psychosocial workloads, resulting in poor health outcomes. An occupational health/health promotion program, designed to facilitate employee participation, was initiated in three nursing homes. The aim of the current study was to evaluate facilitators and barriers of the program after 3-year implementation. Focus groups with employees and in-depth interviews with top and middle managers were conducted. The Social Ecological Model was used to organize the evaluation. Facilitators and barriers were reported from both managers’ and employees’ perspectives, and were categorized as intrapersonal, interpersonal, institutional, and corporate level. Management support, financial resources, and release time for participation were identified as the three most important factors. Supports from multiple levels including both human and environment, and managers and employees, are important for a successful participatory occupational health/health promotion program.
Implementation Processes and Pay for Performance in Healthcare: A Systematic Review.
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BACKGROUND: Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P. METHODS: We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight. RESULTS: Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence. DISCUSSION: There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.
Finding Common Ground: Interprofessional Collaborative Practice Competencies in Patient-Centered Medical Homes.
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The patient-centered medical home model is predicated on interprofessional collaborative practice and team-based care. While information on the roles of various providers is increasingly woven into the literature, the competencies of those providers have been generally profession-specific. In 2011, the Interprofessional Education Collaborative comprising the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools of Public Health sponsored an expert panel of their members to identify and develop 4 domains of core competencies needed for a successful interprofessional collaborative practice: (1) Values/Ethics for Interprofessional Practice; (2) Roles/Responsibilities; (3) Interprofessional Communication; and (4) Teams and Teamwork. Their findings and recommendations were recorded in their Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. This article explores these 4 domains and how they provide common ground for team-based care within the context of the medical home model approach to patient-centered primary care.
Nursing Home Staff Intentions for Learned Communication Skills: Knowledge to Practice.
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Staff education is critical to improving nursing home dementia care practice. However, a lag in translation to practice is a barrier to improving care. As part of a clinical trial testing effects of a communication intervention on behaviors of residents with dementia, participant-reported likelihood of using learned skills in practice was evaluated in relation to organizational and individual factors in 10 nursing homes. The authors hypothesized that organizational and individual factors would influence staff intention to use new skills in practice. Pre-and post-training comparisons confirmed that staff gained knowledge about communication effectiveness. Staff reported high likelihood for using skills in practice based on modified Duke Diffusion of Innovation (DOI) Scale scores. Care organization was correlated with total DOI scores (r = 0.82, p < 0.01). DOI subscales correlations to organizational and individual attitudes are reported. Evaluating quality improvement interventions in relation to translation to practice is essential in today's nursing home environment.
An Evaluation of Performance Thresholds in Nursing Home Pay-for-Performance.
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OBJECTIVE: Performance thresholds are commonly used in pay-for-performance (P4P) incentives, where providers receive a bonus payment for achieving a prespecified target threshold but may produce discontinuous incentives, with providers just below the threshold having the strongest incentive to improve and providers either far below or above the threshold having little incentive. We investigate the effect of performance thresholds on provider response in the setting of nursing home P4P. DATA SOURCES: The Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) datasets. STUDY SETTING AND DESIGN: Difference-in-differences design to test for changes in nursing home performance in three states that implemented threshold-based P4P (Colorado, Georgia, and Oklahoma) versus three comparator states (Arizona, Tennessee, and Arkansas) between 2006 and 2009. PRINCIPAL FINDINGS: We find that those farthest below the threshold (i.e., the worst-performing nursing homes) had the largest improvements under threshold-based P4P while those farthest above the threshold worsened. This effect did not vary with the percentage of Medicaid residents in a nursing home. CONCLUSIONS: Threshold-based P4P may provide perverse incentives for nursing homes above the performance threshold, but we do not find evidence to support concerns about the effects of performance thresholds on low-performing nursing homes.
Nurses’ views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies.
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AIMS AND OBJECTIVES: To explore nurses’ views regarding implementing advance care planning for older people. BACKGROUND: Advance care planning is recommended as a way for older people to discuss their future care with family members and health professionals. Nurses play key roles in the process of advance care planning, including ensuring that patients are informed of their rights and that decisions are known to, and respected by, the health care team. Thus, understanding of nurses’ experiences and perspectives regarding implementing advance care planning for older people is a significant topic for review. DESIGN: Qualitative meta-synthesis. METHODS: Four databases including CINAHL plus, Medline [EBSCOhost], EMBASE, and PsycINFO were searched, and 1844 articles were initially screened. Finally, 18 articles were critically appraised and a thematic synthesis was undertaken. RESULTS: Four themes were identified regarding implementation of advance care planning: perceived disadvantages and advantages of advance directives; nurses’ responsibility and roles; facilitators and barriers; and nurses’ needs and recommendations. Nurses felt that advance directives provided more advantages than disadvantages. Nurses generally believed that they were well positioned to engage in advance care planning conversations. Nurses perceived barriers relating to older people, families, environment, time, culture, cost, language and knowledge of health care teams with regard to advance care planning. In nurses’ needs, education and support were highlighted. CONCLUSIONS: This study provides useful knowledge for implementing advance care planning through illustrating nurses’ experiences and perspectives. The results showed that nurses were more concerned about barriers in relation to working environment, teamwork, time and knowledge of health care team members than older people’s characteristics, when implementing advance care planning. RELEVANCE TO CLINICAL PRACTICE: The findings provide nurses and administrators with information to develop related policies and education. Additionally, the appointment of nurses to formal roles related to advance care planning is appropriate and warranted.
Does the organisational model of dementia case management make a difference in satisfaction with case management and caregiver burden? An evaluation study
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BACKGROUND: In the Netherlands, various organisational models of dementia case management exist. In this study the following four models are distinguished, based on differences in the availability of the service and in the case management function: Model 1: the case management service is available from first dementia symptoms + is always a separate specialist function; Model 2: the case management service is only available after a formal dementia diagnosis + is always a separate specialist function; Model 3: the case management service is available from first dementia symptoms + is often a combined function; Model 4: the case management service is only available after a formal dementia diagnosis + is often a combined function. The objectives of this study are to give insight into whether satisfaction with dementia case management and the development of caregiver burden depend on the organisational model. METHODS: A survey was carried out in regional dementia care networks in the Netherlands among 554 informal carers for people with dementia at the start of case management (response of 85 %), and one year later. Descriptive statistics and multilevel models were used to analyse the data. RESULTS: The satisfaction with the case manager was high in general (an average of 8.0 within a possible range of 1 to 10), although the caregiver burden did not decrease in the first year after starting with case management. No differences were found between the four organisational models regarding the development of caregiver burden. However, statistically significant differences (p < 0.05) were found regarding satisfaction: informal carers in the organisational model where case management is only available after formal diagnosis of dementia and is often a combined function had on average the lowest satisfaction scores. Nevertheless, the satisfaction of informal carers within all organisational models was high (ranging from 7.51 to 8.40 within a range of 1 to 10). CONCLUSIONS: Organisational features of case management seem to make little or no difference to the development in caregiver burden and the satisfaction of informal carers. Future research is needed to explore whether the individual characteristics of the case managers themselves are associated with case management outcomes.
Development of an Applied Framework for Understanding Health Information Technology in Nursing Homes
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There is growing evidence that Health Information Technology (HIT) can play a role in improving quality of care and increasing efficiency in the nursing home setting. Most research in this area, however, has examined whether nursing homes have or use any of a list of available technologies. We sought to develop an empirical framework for understanding the intersection between specific uses of HIT and clinical care processes. Using the nominal group technique, we conducted a series of focus groups with different types of personnel who work in nursing homes (administrators, directors of nursing, physicians, mid-level practitioners, consultant pharmacists, and aides). The resulting framework identified key domain areas that can benefit from HIT: transfer of data, regulatory compliance, quality improvement, structured clinical documentation, medication use process, and communication. The framework can be used to guide both descriptive and normative research.
Barriers and enablers to advanced practitioners’ ability to enact their leadership role: A scoping review
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Background Advanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are increasing across the world. In most countries, clinical practice, education, leadership and research are the four components that define the advanced practitioner’s role. Of these, leadership is perhaps the most important part of the role, but its study has largely been neglected. There is a risk that failure to identify and respond to barriers to enacting the advanced practitioners? leadership role will limit the extent to which they can become strategic leaders for professional development, and jeopardise the long-term sustainability of the role.; BackgroundAdvanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are increasing across the world. In most countries, clinical practice, education, leadership and research are the four components that define the advanced practitioner’s role. Of these, leadership is perhaps the most important part of the role, but its study has largely been neglected. There is a risk that failure to identify and respond to barriers to enacting the advanced practitioners? leadership role will limit the extent to which they can become strategic leaders for professional development, and jeopardise the long-term sustainability of the role.
Comparison of Long-term Care in Nursing Homes Versus Home Health: Costs and Outcomes in Alabama.
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Purpose of the Study: To compare acute care outcomes and costs among nursing home residents with community-dwelling home health recipients. DESIGN AND METHODS: A matched retrospective cohort study of Alabamians aged more than or equal to 65 years admitted to a nursing home or home health between March 31, 2007 and December 31, 2008 (N = 1,291 pairs). Medicare claims were compared up to one year after admission into either setting. Death, emergency department and inpatient visits, inpatient length of stay, and acute care costs were compared using t tests. Medicaid long-term care costs were compared for a subset of matched beneficiaries. RESULTS: After one year, 77.7% of home health beneficiaries were alive compared with 76.2% of nursing home beneficiaries (p < .001). Home health beneficiaries averaged 0.2 hospital visits and 0.1 emergency department visits more than nursing home beneficiaries, differences that were statistically significant. Overall acute care costs were not statistically different; home health beneficiaries' costs averaged $31,423, nursing home beneficiaries' $32,239 (p = .5032). Among 426 dual-eligible pairs, Medicaid long-term care costs averaged $4,582 greater for nursing home residents (p < .001). IMPLICATIONS: Using data from Medicare claims, beneficiaries with similar functional status, medical diagnosis history, and demographics had similar acute care costs regardless of whether they were admitted to a nursing home or home health care. Additional research controlling for exogenous factors relating to long-term care decisions is needed.
Preparing national health systems to cope with the impending tsunami of ageing and its associated complexities: Towards more sustainable health care.
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Healthcare systems across the world are experiencing increased financial, organizational and social pressures attributable to a range of critical issues including the challenge of ageing populations. Health systems need to adapt, in order to sustainably provide quality care to the widest range of patients, particularly those with chronic and complex diseases, and especially those in vulnerable and low-income groups. We report on a workshop designed to tackle such issues under the auspices of ISQua, with representatives from Argentina, Australia, Canada, Columbia, Denmark, Emirates, France, Ireland, Jordan, Qatar, Malaysia, Norway, Oman, UK, South Africa and Switzerland. We discuss some of the challenges facing healthcare systems in countries ageing rapidly, to those less so, and touch on current and future reform options.
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Health Care Innovation and Quality Assurance
Ready, Set, Change! Development and usability testing of an online readiness for change decision support tool for healthcare organizations.
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BACKGROUND: To address challenges related to selecting a valid, reliable, and appropriate readiness assessment measure in practice, we developed an online decision support tool to aid frontline implementers in healthcare settings in this process. The focus of this paper is to describe a multi-step, end-user driven approach to developing this tool for use during the planning stages of implementation. METHODS: A multi-phase, end-user driven approach was used to develop and test the usability of a readiness decision support tool. First, readiness assessment measures that are valid, reliable, and appropriate for healthcare settings were identified from a systematic review. Second, a mapping exercise was performed to categorize individual items of included measures according to key readiness constructs from an existing framework. Third, a modified Delphi process was used to collect stakeholder ratings of the included measures on domains of feasibility, relevance, and likelihood to recommend. Fourth, two versions of a decision support tool prototype were developed and evaluated for usability. RESULTS: Nine valid and reliable readiness assessment measures were included in the decision support tool. The mapping exercise revealed that of the nine measures, most measures (78 %) focused on assessing readiness for change at the organizational versus the individual level, and that four measures (44 %) represented all constructs of organizational readiness. During the modified Delphi process, stakeholders rated most measures as feasible and relevant for use in practice, and reported that they would be likely to recommend use of most measures. Using data from the mapping exercise and stakeholder panel, an algorithm was developed to link users to a measure based on characteristics of their organizational setting and their readiness for change assessment priorities. Usability testing yielded recommendations that were used to refine the Ready, Set, Change! decision support tool . CONCLUSIONS: Ready, Set, Change! decision support tool is an implementation support that is designed to facilitate the routine incorporation of a readiness assessment as an early step in implementation. Use of this tool in practice may offer time and resource-saving implications for implementation.
Evaluating the capabilities model of dementia care: a non-randomized controlled trial exploring resident quality of life and care staff attitudes and experiences.
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BACKGROUND: This 12 month, Australian study sought to compare the Capabilities Model of Dementia Care (CMDC) with usual long-term care (LTC), in terms of (1) the effectiveness of the CMDC in assisting care staff to improve Quality Of Life (QOL) for older people with dementia; and (2) whether implementation of the CMDC improved staff attitudes towards, and experiences of working and caring for the person with dementia. METHODS: A single blind, non-randomized controlled trial design, involving CMDC intervention group (three facilities) and a comparison usual LTC practice control group (one facility), was conducted from August 2010 to September 2011. Eighty-one staff members and 48 family members of a person with dementia were recruited from these four LTC facilities. At baseline, 6 and 12 months, staff completed a modified Staff Experiences of Working with Demented Residents questionnaire (SEWDR), and families completed the Quality of Life – Alzheimer’s Disease questionnaire (QOL-AD). RESULTS: LTC staff in the usual care group reported significantly lower SEWDR scores (i.e. less work satisfaction) than those in the CMDC intervention group at 12 months (p = 0.005). Similarly, family members in the comparison group reported significantly lower levels of perceived QOL for their relative with dementia (QOL-AD scores) than their counterparts in the CMDC intervention group at 12 months (p = 0.012). CONCLUSIONS: Although the study has a number of limitations the CMDC appears to be an effective model of dementia care – more so than usual LTC practice. The CMDC requires further evaluation with participants from a diverse range of LTC facilities and stages of cognitive impairment.
What factors are important for deprescribing in Australian long-term care facilities? Perspectives of residents and health professionals
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OBJECTIVES: Polypharmacy and multimorbidity are common in long-term care facilities (LTCFs). Reducing polypharmacy may reduce adverse events and maintain quality of life. Deprescribing refers to reducing medications after consideration of therapeutic goals, benefits and risks, and medical ethics. The objective was to use nominal group technique (NGT) to generate then rank factors that general medical practitioners (GPs), nurses, pharmacists and residents or their representatives perceive are most important when deciding whether or not to deprescribe medications. DESIGN: Qualitative research using NGT. SETTING: Participants were invited if they worked with, or resided in LTCFs across metropolitan and regional South Australia. PARTICIPANTS: 11 residents/representatives, 19 GPs, 12 nurses and 14 pharmacists participated across six separate groups. METHODS: Individual groups of GPs, nurses, pharmacists and residents/representatives were convened. Using NGT each group ranked factors perceived to be most important when deciding whether or not to deprescribe. Then, using NGT, the prioritised factors from individual groups were discussed and prioritised by a multidisciplinary metropolitan and regional group comprised of resident representatives, GPs, nurses and pharmacists. RESULTS: No two groups had the same priorities. GPs ranked ‘evidence for deprescribing’ and ‘communication with family/resident’ as most important factors. Nurses ranked ‘GP receptivity to deprescribing’ and ‘nurses ability to advocate for residents’ as most important. Pharmacists ranked ‘clinical appropriateness of therapy’ and ‘identifying residents’ goals of care’ as most important. Residents ranked ‘wellbeing of the resident’ and ‘continuity of nursing staff’ as most important. The multidisciplinary groups ranked ‘adequacy of medical and medication history’ and ‘identifying residents’ goals of care’ as most important. CONCLUSIONS: While each group prioritised different factors, common and contrasting factors emerged. Future deprescribing interventions need to consider the similarities and differences within the range of factors prioritised by residents and health professionals.
Implementation of a Psychiatric Nurse-led Outreach Service for Adults Residing at Subvented Old Age Homes: A Hong Kong Experience.
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This paper reports on the implementation of a pioneering psychiatric nurse-led service that was designed to address the unmet mental healthcare needs of adults residing at subvented old age homes. It also describes features of potentially wider relevance to nurses interested in developing healthcare service for other underserved populations. We highlight the view that the crux of developing a successful service involves understanding existing service gaps; grasping the pulse of changing healthcare service policies; involving relevant stakeholders in the planning process; validating service outcomes; and seeking support from management. A central goal of the service was to enhance the accessibility of mental healthcare services to the needy. The data was collected over a 5-year period. Our study suggests that this model of service is preferred by service users (both the care providers and the residents in the old age homes); is efficient in terms of providing prompt psychiatric nursing interventions; is able to supply primary care advisors with practical advice in response to enquiries; and helps primary care providers to detect and manage the mental healthcare needs of older adults.
Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents.
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INTRODUCTION: Care by Design (CBD) (Canada), a model of coordinated team-based primary care, was implemented in long-term care facilities (LTCFs) in Halifax, Nova Scotia, Canada, to improve access to and continuity of primary care and to reduce high rates of transfers to emergency departments (EDs). METHODS: This was an observational time series before and after the implementation of CBD (Canada). Participants are LTCF residents with 911 Emergency Health Services calls from 10 LTCFs, representing 1424 beds. Data were abstracted from LTCF charts and Emergency Health Services databases. The primary outcome was ambulance transports from LTCFs to EDs. Secondary outcomes included access (primary care physician notes in charts) and continuity (physician numbers and contacts). RESULTS: After implementation of CBD (Canada), transports from LTCFs to EDs were reduced by 36%, from 68 to 44 per month (P = .01). Relational and informational continuity of care improved with resident charts with >/=10 physician notes, increasing 38% before CBD to 55% after CBD (P = .003), and the median number of chart notes increased from 7 to 10 (P = .0026). Physicians contacted before 911 calls and onsite assessment increased from 38% to 54% (P = .01) and 3.7% to 9.2% (P = .03), respectively, before CBD to after CBD. CONCLUSION: A 34% reduction in overall transports from LTCFs to EDs is likely attributable to improved onsite primary care, with consistent physician and team engagement and improvements in continuity of care.
Person-centredness in the care of older adults: a systematic review of questionnaire-based scales and their measurement properties.
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BACKGROUND: Person-centredness is promoted as a central feature of the long-term care of older adults. Measures are needed to assist researchers, service planners and regulators in assessing this feature of quality. However, no systematic review exists to identify potential instruments and to provide a critical appraisal of their measurement properties. METHOD: A systematic review of measures of person-centredness was undertaken. Inclusion criteria restricted references to multi-item instruments designed for older adult services, or otherwise with measurement properties tested in an older adult population. A two-stage critical appraisal was conducted. First, the methodological quality of included references was assessed using the COSMIN toolkit. Second, seven measurement properties were rated using widely-recognised thresholds of acceptability. These results were then synthesised to provide an overall appraisal of the strength of evidence for each measurement property for each instrument. RESULTS: Eleven measures tested in 22 references were included. Six instruments were designed principally for use in long-stay residential facilities, and four were for ambulatory hospital or clinic-based services. Only one measure was designed mainly for completion by users of home care services. No measure could be assessed across all seven measurement properties. Despite some instruments having promising measurement properties, this was consistently undermined by the poor methodological quality underpinning them. Testing of hypotheses to support construct validity was of particularly low quality, whilst measurement error was rarely assessed. Two measures were identified as having been the subject of the most rigorous testing. CONCLUSION: The review is unable to unequivocally recommend any measures of person-centredness for use in older adult care. Researchers are advised to improve methodological rigour when testing instruments. Efforts may be best focused on testing a narrower range of measurement properties but to a higher standard, and ensuring that translations to new languages are resisted until strong measurement properties are demonstrated in the original tongue. Limitations of the review include inevitable semantic and conceptual challenges involved in defining ‘person-centredness’. The review protocol was registered with PROSPERO (ref: CRD42014005935).
Measuring the Dose of Quality Improvement Initiatives.
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Although intervention dose-defined as the quality and quantity of an intervention and participation-might be key to understanding why some multisite quality improvement (QI) initiatives work and others do not, evaluations rarely consider dose, and there is no widely accepted method for measuring it. In this exploratory study, the authors examined the literature on QI dose, identified four methods for measuring QI dose, applied them to 14 communities participating in a QI initiative, examined whether the dose scores aligned with perceptions of QI dose among individuals knowledgeable of the initiative, and report on lessons learned. They conclude it is feasible to measure QI dose and found a high level of concordance between scores on a comprehensive dose measure and knowledgeable informants’ perceptions. However, measuring QI dose presents many challenges, including subjective decisions about the elements of dose to include in a measure and the need for extensive data collection.
Ageing has become a worldwide reality and presents new challenges for the health-care system. Research has shown that potentially inappropriate prescribing, both potentially inappropriate medications and potentially prescribing omissions, is highly prevalent in older people, especially in the nursing home setting. The presence of potentially inappropriate medications/potentially prescribing omissions is associated with adverse drug events, hospitalisations, mortality and health-care costs. The Collaborative approach to Optimise MEdication use for Older people in Nursing homes (COME-ON) study aims to evaluate the effect of a complex, multifaceted intervention, including interdisciplinary case conferences, on the appropriateness of prescribing of medicines for older people in Belgian nursing homes.
Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations
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OBJECTIVE: Potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents are common, costly, and can have significant economic consequences. Telemedicine has been shown to reduce emergency department and hospitalization of NH residents, yet adoption has been limited and little is known about provider’s perceptions and desired functionality for a telemedicine program. The goal of this study was to survey a nationally representative sample of NH physicians and advanced practice providers to quantify provider perceptions and desired functionality of telemedicine in NHs to reduce PAHs. DESIGN/SETTING/PARTICIPANTS/MEASUREMENT: We surveyed physicians and advanced practice providers who attended the 2015 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their perceptions of telemedicine and desired attributes of a telemedicine program for managing acute changes of condition associated with PAHs. RESULTS: We received surveys from 435 of the 947 conference attendees for a 45.9% response rate. Providers indicated strong agreement with the potential for telemedicine to improve timeliness of care and fill existing service gaps, while disagreeing most with the ideas that telemedicine would reduce care effectiveness and jeopardize resident privacy. Responses indicated clear preferences for the technical requirements of such a program, such as high-quality audio and video and inclusion of an electronic stethoscope, but with varying opinions about who should be performing the consults. CONCLUSION: Among NH providers, there is a high degree of confidence in the potential for a telemedicine solution to PAHs in NHs, as well as concrete views about features of such a solution. Such consensus could be used to drive an approach to telemedicine for PAHs in NHs that retains the theoretical strengths of telemedicine and reflects the needs of facilities, providers, and patients. Further research is needed to objectively study the impact of successful telemedicine implementations on patient, provider, and economic outcomes.
Nursing Home Stakeholder Views of Resident Involvement in Medical Care Decisions.
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Demand by nursing home residents for involvement in their medical care, or, patient-centered care, is expected to increase as baby boomers begin seeking long-term care for their chronic illnesses. To explore the needs in meeting this proposed demand, we used a qualitative descriptive method with content analysis to obtain the joint perspective of key stakeholders on the current state of person-centered medical care in the nursing home. We interviewed 31 nursing home stakeholders: 5 residents, 7 family members, 8 advanced practice registered nurses, 5 physicians, and 6 administrators. Our findings revealed constraints placed by the long-term care system limited medical involvement opportunities and created conflicting goals for patient-centered medical care. Resident participation in medical care was perceived as low, but important. The creation of supportive educational programs for all stakeholders to facilitate a common goal for nursing home admission and to provide assistance through the long-term care system was encouraged.
Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework.
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OBJECTIVES: To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay for performance scheme. DESIGN: Retrospective longitudinal study. SETTING: Data for 644 general practices, from 2004/05 to 2011/12, extracted from the Clinical Practice Research Datalink. PARTICIPANTS: All patients registered with any of the practices over the study period-13,772,992 in total. INTERVENTION: Removal of financial incentives for aspects of care for patients with asthma, coronary heart disease, diabetes, stroke, and psychosis. MAIN OUTCOME MEASURES: Performance on eight clinical quality indicators withdrawn from a national incentive scheme: influenza immunisation (asthma) and lithium treatment monitoring (psychosis), removed in April 2006; blood pressure monitoring (coronary heart disease, diabetes, stroke), cholesterol concentration monitoring (coronary heart disease, diabetes), and blood glucose monitoring (diabetes), removed in April 2011. Multilevel mixed effects multiple linear regression models were used to quantify the effect of incentive withdrawal. RESULTS: Mean levels of performance were generally stable after the removal of the incentives, in both the short and long term. For the two indicators removed in April 2006, levels in 2011/12 were very close to 2005/06 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn from April 2011, no significant effect on performance was seen following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (such as blood pressure control) was generally unaffected. CONCLUSIONS: Following the removal of incentives, levels of performance across a range of clinical activities generally remained stable. This indicates that health benefits from incentive schemes can potentially be increased by periodically replacing existing indicators with new indicators relating to alternative aspects of care. However, all aspects of care investigated remained indirectly or partly incentivised in other indicators, and further work is needed to assess the generalisability of the findings when incentives are fully withdrawn.
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Organizational Change
Implementing culture change in long-term dementia care settings.
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The approach to nursing in long-term care settings for people living with dementia continues to evolve from a traditional, task-oriented culture to one that is person-centred. Such change can be difficult to manage and may encounter considerable opposition; having an understanding of change management and leadership styles may help to make this transition easier. This article discusses the differences between task-oriented and person-centred care, theories of management, motivation and leadership styles, and focuses on those that are most appropriate for this type of change. An improved understanding of these theories will enable nurses to support others in the delivery of person-centred care.
Context, mechanisms and outcomes in end of life care for people with advanced dementia.
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BACKGROUND: The majority of people with dementia in the UK die in care homes. The quality of end of life care in these environments is often suboptimal. The aim of the present study was to explore the context, mechanisms and outcomes for providing good palliative care to people with advanced dementia residing in UK care homes from the perspective of health and social care providers. METHOD: The design of the study was qualitative which involved purposive sampling of health care professionals to undertake interactive interviews within a realist framework. Interviews were completed between September 2012 and October 2013 and were thematically analysed and then conceptualised according to context, mechanisms and outcomes. The settings were private care homes and services provided by the National Health Service including memory clinics, mental health and commissioning services in London, United Kingdom. The participants included 14 health and social care professionals including health care assistants, care home managers, commissioners for older adults’ services and nursing staff. RESULTS: Good palliative care for people with advanced dementia is underpinned by the prioritisation of psychosocial and spiritual care, developing relationships with family carers, addressing physical needs including symptom management and continuous, integrated care provided by a multidisciplinary team. Contextual factors that detract from good end of life care included: an emphasis on financial efficiency over person-centred care; a complex health and social care system, societal and family attitudes towards staff; staff training and experience, governance and bureaucratisation; complexity of dementia; advance care planning and staff characteristics. Mechanisms that influence the quality of end of life care include: level of health care professionals’ confidence, family uncertainty about end of life care, resources for improving end of life care and supporting families, and uncertainty about whether dementia specific palliative care is required. CONCLUSIONS: Contextual factors regarding the care home environment may be obdurate and tend to negatively impact on the quality of end of life dementia care. Local level mechanisms may be more amenable to improvement. However, systemic changes to the care home environment are necessary to promote consistent, equitable and sustainable high quality end of life dementia care across the UK care home sector.
The mediating role of an innovative culture in the relationship between absorptive capacity and technical and non-technical innovation.
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Unlike previous research, this study operationalizes the two dimensions of absorptive capacity (ACAP)-potential absorptive capacity (PACAP) and realized absorptive capacity (RACAP)-separately. This study builds and tests an integrated model to investigate the relationship among PACAP, RACAP, innovative culture (IC), and organizational innovation (OI). This study explores these relationships using a multivariate data analysis technique: partial least square (PLS), a structural equation modeling (SEM) approach along with reflective-formative type hierarchical latent variables, with data sample of 347 from a multiple industrial sector in Korea. The results suggest that PACAP and RACAP happen in sequence and influence OI directly and through the intervening variable IC. The study provides several theoretical and practical implications for further research. © 2015 Elsevier Inc.
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Research Practice and Methodology
A theoretical framework to support research of health service innovation
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OBJECTIVE: Health service managers and policy makers are increasingly concerned about the sustainability of innovations implemented in health care settings. The increasing demand on health services requires that innovations are both effective and sustainable; however, research in this field is limited, with multiple disciplines, approaches and paradigms influencing the field. These variations prevent a cohesive approach, and therefore the accumulation of research findings, in the development of a body of knowledge. The purpose of this paper is to provide a thorough examination of the research findings and provide an appropriate theoretical framework to examine sustainability of health service innovation. METHODS: This paper presents an integrative review of the literature available in relation to sustainability of health service innovation and provides the development of a theoretical framework based on integration and synthesis of the literature. RESULTS: A theoretical framework serves to guide research, determine variables, influence data analysis and is central to the quest for ongoing knowledge development. This research outlines the sustainability of innovation framework; a theoretical framework suitable for examining the sustainability of health service innovation. CONCLUSION: If left unaddressed, health services research will continue in an ad hoc manner, preventing full utilisation of outcomes, recommendations and knowledge for effective provision of health services. The sustainability of innovation theoretical framework provides an operational basis upon which reliable future research can be conducted.
Engaging older adults in healthcare research and
planning: a realist synthesis
The importance of citizen involvement in healthcare research and planning has been widely recognized. There is however, a lack of understanding of how best to engage older adults, Canada’s fastest growing segment of the population and biggest users of the healthcare system. We aimed to address this gap by developing an understanding of the engagement of older adults and their caregivers in healthcare research and planning. We conducted a review of available knowledge on engagement in healthcare research and planning with a focus on older adults and their caregivers. A five stage engagement framework emerged from this study that can be used to guide engagement efforts. We are continuing to collaborate with older adults and decision makers to develop and test strategies based on the presented framework.
Community-Academic Partnerships: A Systematic Review of the State of the Literature and Recommendations for Future Research
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Policy Points: Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research, to provide firsthand knowledge and insight. * Based on our systematic review of major literature databases, we recommend using a single term, community-academic partnership (CAP), and a conceptual definition to unite multiple research disciplines and strengthen the field. * Interpersonal and operational factors that facilitate or hinder the collaborative process have been consistently identified, including “trust among partners†and “respect among partners†(facilitating interpersonal factors) and “excessive time commitment†(hindering operational factor). * Once CAP processes and characteristics are better understood, the effectiveness of collaborative partner involvement can be tested. Context Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research. Community stakeholders can provide firsthand knowledge and insight, thereby increasing research relevance and feasibility. Despite the greater emphasis and use of community-academic partnerships (CAP) across multiple disciplines, definitions of partnerships and methodologies vary greatly, and no systematic reviews consolidating this literature have been published. The purpose of this article, then, is to facilitate the continued growth of this field by examining the characteristics of CAPs and the current state of the science, identifying the facilitating and hindering influences on the collaborative process, and developing a common term and conceptual definition for use across disciplines. Methods Our systematic search of 6 major literature databases generated 1,332 unique articles, 50 of which met our criteria for inclusion and provided data on 54 unique CAPs. We then analyzed studies to describe CAP characteristics and to identify the terms and methods used, as well as the common influences on the CAP process and distal outcomes. Findings CAP research spans disciplines, involves a variety of community stakeholders, and focuses on a large range of study topics. CAP research articles, however, rarely report characteristics such as membership numbers or duration. Most studies involved case studies using qualitative methods to collect data on the collaborative process. Although various terms were used to describe collaborative partnerships, few studies provided conceptual definitions. Twenty-three facilitating and hindering factors influencing the CAP collaboration process emerged from the literature. Outcomes from the CAPs most often included developing or refining tangible products. Conclusions Based on our systematic review, we recommend using a single term, community-academic partnership, as well as a conceptual definition to unite multiple research disciplines. In addition, CAP characteristics and methods should be reported more systematically to advance the field (eg, to develop CAP evaluation tools). We have identified the most common influences that facilitate and hinder CAPs, which in turn should guide their development and sustainment.
Scoping review of complexity theory in health services research.
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BACKGROUND: There are calls for better application of theory in health services research. Research exploring knowledge translation and interprofessional collaboration are two examples, and in both areas, complexity theory has been identified as potentially useful. However, how best to conceptualize and operationalize complexity theory in health services research is uncertain. The purpose of this scoping review was to explore how complexity theory has been incorporated in health services research focused on allied health, medicine, and nursing in order to offer guidance for future application. Given the extensiveness of how complexity theory could be conceptualized and ultimately operationalized within health services research, a scoping review of complexity theory in health services research is warranted. METHODS: A scoping review of published research in English was conducted using CINAHL, EMBASE, Medline, Cochrane, and Web of Science databases. We searched terms synonymous with complexity theory. RESULTS: We included 44 studies in this review: 27 were qualitative, 14 were quantitative, and 3 were mixed methods. Case study was the most common method. Long-term care was the most studied setting. The majority of research was exploratory and focused on relationships between health care workers. Authors most commonly used complexity theory as a conceptual framework for their study. Authors described complexity theory in their research in a variety of ways. The most common attributes of complexity theory used in health services research included relationships, self-organization, and diversity. A common theme across descriptions of complexity theory is that authors incorporate aspects of the theory related to how diverse relationships and communication between individuals in a system can influence change. CONCLUSION: Complexity theory is incorporated in many ways across a variety of research designs to explore a multitude of phenomena.. Although complexity theory shows promise in health services research, particularly related to relationships and interactions, conceptual confusion and inconsistent application hinders the operationalization of this potentially important perspective. Generalizability from studies that incorporate complexity theory is, therefore, difficult. Heterogeneous conceptualization and operationalization of complexity theory in health services research suggests there is no universally agreed upon approach of how to use this theory in health services research. Future research should include clear definitions and descriptions of complexity and how it was used in studies. Clear reporting will aid in determining how best to use complexity theory in health services research.
Developing the DESCARTE Model: The Design of Case Study Research in Health Care.
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Case study is a long-established research tradition which predates the recent surge in mixed-methods research. Although a myriad of nuanced definitions of case study exist, seminal case study authors agree that the use of multiple data sources typify this research approach. The expansive case study literature demonstrates a lack of clarity and guidance in designing and reporting this approach to research. Informed by two reviews of the current health care literature, we posit that methodological description in case studies principally focuses on description of case study typology, which impedes the construction of methodologically clear and rigorous case studies. We draw from the case study and mixed-methods literature to develop the DESCARTE model as an innovative approach to the design, conduct, and reporting of case studies in health care. We examine how case study fits within the overall enterprise of qualitatively driven mixed-methods research, and the potential strengths of the model are considered.
Doing Interdisciplinary Mixed Methods Health Care Research: Working the Boundaries, Tensions, and Synergistic Potential of Team-Based Research.
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Current trends in health care research point to a shift from disciplinary models to interdisciplinary team-based mixed methods inquiry designs. This keynote address discusses the problems and prospects of creating vibrant mixed methods health care interdisciplinary research teams that can harness their potential synergy that holds the promise of addressing complex health care issues. We examine the range of factors and issues these types of research teams need to consider to facilitate efficient interdisciplinary mixed methods team-based research. It is argued that concepts such as disciplinary comfort zones, a lack of attention to team dynamics, and low levels of reflexivity among interdisciplinary team members can inhibit the effectiveness of a research team. This keynote suggests a set of effective strategies to address the issues that emanate from the new field of research inquiry known as team science as well as lessons learned from tapping into research on organizational dynamics.
Why, when and how to update a meta-ethnography qualitative synthesis.
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BACKGROUND: Meta-ethnography is a unique, systematic, qualitative synthesis approach widely used to provide robust evidence on patient and clinician beliefs and experiences and understandings of complex social phenomena. It can make important theoretical and conceptual contributions to health care policy and practice. RESULTS: Since beliefs, experiences, health care contexts and social phenomena change over time, the continued relevance of the findings from meta-ethnographies cannot be assumed. However, there is little guidance on whether, when and how meta-ethnographies should be updated; Cochrane guidance on updating reviews of intervention effectiveness is unlikely to be fully appropriate. This is the first in-depth discussion on updating a meta-ethnography; it explores why, when and how to update a meta-ethnography. Three main methods of updating the analysis and synthesis are examined. Advantages and disadvantages of each method are outlined, relating to the context, purpose, process and output of the update and the nature of the new data available. Recommendations are made for the appropriate use of each method, and a worked example of updating a meta-ethnography is provided. CONCLUSIONS: This article makes a unique contribution to this evolving area of meta-ethnography methodology.
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Aging
Are psychotherapeutic effects on family caregivers of people with dementia sustainable? Two-year long-term effects of a telephone-based cognitive behavioral intervention.
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OBJECTIVES: Evaluation of long-term effects of an individualized short-term telephone intervention (seven sessions), based on a comprehensive cognitive behavioral therapy (CBT) approach. The study goal was to evaluate the maintenance of intervention effects regarding well-being, quality of life, and health at two years post treatment. METHOD: Participants (n = 105) were (partly) randomized after baseline assessment in a two-arm study (intervention, control group/usual care). Depressive symptoms were assessed with the German version of the Center for Epidemiologic Studies Depression Scale (CES-D). Caregivers’ physical complaints were measured with the Giessener Beschwerdebogen (GBB-24), and quality of life with the World Health Organization quality of life -BREF (WHOQOL-BREF). Emotional well-being and perceived health status were assessed using thermometer scaling. Data were analyzed by intention-to-treat analyses, including for those who terminated the intervention prematurely but still delivered data, using ANCOVAs. RESULTS: Long-term intervention effects were found for emotional well-being (p = 0.019). For the subgroup of caregivers who were still caring at home at follow-up, the intervention led to an increased health status (p = 0.023), fewer bodily complaints (global measure p= 0.014, rheumatic pain p = 0.027, heart trouble p = 0.042), and a higher quality of life (overall p = 0.044 and subscale environment p = 0.030). CONCLUSION: The short-term CBT intervention via telephone showed long-term effects two years after treatment on emotional well-being, health status, bodily complaints, and quality of life.
A pilot trial of acceptance and commitment therapy for symptoms of depression and anxiety in older adults residing in long-term care facilities.
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OBJECTIVES: The aim of this study was to evaluate the efficacy and acceptability of a psychological intervention based on acceptance and commitment therapy (ACT) to improve symptoms of depression and anxiety among older adults living in long-term care. METHOD: Forty one residents aged between 63 and 97 years (M = 85.3 years) participated in this study. Residents were allocated to receive either a 12 session ACT intervention implemented by trainee psychology therapists or a wait-list control group. Measures of depression and anxiety were collected at baseline and 8 week post-intervention, and residents who received the intervention were tracked for three months. A treatment satisfaction questionnaire was administered to residents who received the intervention and a sample of 10 facility staff members. RESULTS: Using an intention to treat approach and controlling for baseline scores, scores on depression measures were significantly lower after the ACT intervention than after the wait-list control. These outcomes were maintained at three-month follow-up. Treatment satisfaction was rated highly by both residents and their care staff. CONCLUSION: This preliminary trial suggests that ACT shows promise as a therapeutic approach to address symptoms of depression in long-term care.
An evaluation of a novel alternating mattress and cushion technology.
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Pressure ulcer prevention and management remain a challenge across all health-care settings, and the incidence and prevalence of pressure ulcers in nursing homes and residential homes continues to remain unknown. The use of suitable support surfaces has been found to be beneficial in the prevention and management of pressure ulcers. Carrying out a holistic assessment of the patient and recording the patient’s at-risk score would help the clinician to determine the most suitable pressure-relieving surface for the patient. The clinician’s clinical experience and judgment are also important. The Domus Auto (by APEX) mattress system and Dynamic Seat Cushion (by APEX) are effective dynamic, support surfaces in the prevention and management of pressure ulceration. They meet the recommendations by both national and international guidelines; they also partly fulfil the SSKIN bundle. From a four-week evaluation carried out in a nursing home, it has been demonstrated that, together with regular assessments and repositioning of the patients, these devices are useful tools in preventing patients’ risk of tissue damage and improving the patients’ quality of life.
Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem).
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Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population. To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population. We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care. The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care. The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD. Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity. The National Institute for Health Research Health Services and Delivery Research programme.
Effects of an Oral Nutritional Supplementation Plus Physical Exercise Intervention on the Physical Function, Nutritional Status, and Quality of Life in Frail Institutionalized Older Adults: The ACTIVNES Study.
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OBJECTIVES: The objective of this study was to assess the effects of a hyperproteic, hypercaloric oral nutritional supplement with prebiotic fiber, vitamin D, and calcium, plus a standardized physical intervention, in the functional status, strength, nutritional status, and quality of life of frail institutionalized older adults. DESIGN: Multicentric prospective observational study under usual clinical practice conditions. SETTING: Four nursing homes from Burgos (2), Albacete, and Madrid, Spain. PARTICIPANTS: Participants included 91 institutionalized older adults (age >/=70), able to walk 50 m, and meeting at least 3 of the Fried frailty phenotype criteria. INTERVENTION: Daily intake of two 200-mL bottles of an oral nutritional supplement, each bottle containing 300 kcal, 20 g protein, 3 g fiber, 500 IU vitamin D, and 480 mg calcium, plus a standardized physical exercise training consisting of flexibility, balance, and strengthening exercises for arms and legs, 5 days per week. MEASUREMENTS: Short Physical Performance Battery (SPPB), Short-Form-Late-Life Function and Disability Instrument (SF-LLFDI) function subscale, handgrip strength, EuroQoL-5 Dimensions visual analogic scale (EQ5DVAS), weight, body mass index (BMI), and Short-Form Mini Nutritional Assessment (MNA-SF) at baseline and 6 and 12 weeks. RESULTS: Forty-eight participants (52.7%) improved at least 1 point in the SPPB at week 6, and 44 (48.4%) did so at week 12; 39 participants (42.9%) improved at least 2 points in the SF-LLFDI at week 6, and 46 (50.5%) at week 12. Participants improved their quality of life measured with the EQ5DVAS by 6% (95% confidence interval [CI] 3%-10%) at week 6, and by 5% (95% CI 0%-10%) at week 12. They also improved their nutritional status (weight gain, BMI increase, and higher MNA-SF scores at 6- and 12-week follow-up). This improvement was higher in participants with more frailty criteria, lower functional level, lower vitamin D levels, and poorer nutritional status. CONCLUSION: A 12-week intervention with oral nutritional supplementation plus physical exercise improves function, nutritional status, and quality of life in frail institutionalized older adults.
Lack of Energy and Negative Health-Related Outcomes in Nursing Home Residents: Results From the INCUR Study.
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OBJECTIVE: “Lack of energy” or anergia is a common complaint associated with adverse outcomes in older people. There is a lack of knowledge on this symptom in the nursing home (NH) setting. The aim of this study was to investigate whether lack of energy was associated with hospitalization and mortality in NH residents. DESIGN: Longitudinal observational cohort study. SETTING AND PARTICIPANTS: A total of 575 NH residents (72% women) in 13 French NHs from the Incidence of pNeumonia and related ConseqUences in nursing home Residents (INCUR) study cohort. MEASUREMENTS: Lack of energy was measured at the baseline visit as part of the 10-item Geriatric Depression Scale. Unadjusted and adjusted Cox proportional hazard regression models were performed to test the association of lack of energy with hospitalization events and mortality over 12 months of follow-up. RESULTS: The mean age of the study sample was 86.3 (SD = 7.5) years. At the baseline, 250 (43.5%) residents complained about lack of energy. Overall, 192 (33.4%) individuals experienced at least 1 hospitalization event and 98 (17.0%) died during the 12-month follow-up. Lack of energy was significantly associated with a higher risk of hospitalization (HR 1.35; 95% CI 1.02-1.80; P = .03), even after adjustment for potential confounders (HR 1.41; 95% CI 1.04-1.91; P = .02). No statistically significant association was found between lack of energy and 12-month mortality. CONCLUSION: Lack of energy is a predictor of hospitalization in older people living in NHs. It may be considered a relevant clinical feature for identifying individuals at risk of adverse health outcomes, thus potentially serving as a screening tool for subsequently conducting a comprehensive geriatric assessment in this highly vulnerable and complex population.
Nursing assistants: “he seems to be ill” – a reason for nurses to take action: validation of the Early Detection Scale of Infection (EDIS).
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BACKGROUND: Signs and symptoms of infection in frail elderly are atypical, causing delay in diagnosis and treatment. To improve communication between healthcare staff of signs and symptoms of infection we developed an instrument, using qualitative data from observations by nursing assistants when they suspected infection. The aim of this study was to assess the validity of nursing assistants observations by developing and testing the instrument for early detection of infection in elderly nursing home residents. METHODS: The early detection of infection (EDIS) instrument was based on data from focus interviews with nursing assistants. Over one year the nursing assistants used EDIS to document episodes of suspected early signs and symptoms of infection in 204 nursing home residents. Two physicians classified documented episodes as “no infection”, “possible infection”, and “infection”. The content validity of the 13 items of the EDIS was established to explore the relationships between the items. The construct validity was used to explore the relationship between the items and the presence or absence of infection. The predictive value of the developed model was evaluated by the percentage of correct classifications of the observed cases. Generalized linear model (ordinal multinomial distribution and logit link) was used. RESULTS: Of the 388 events of suspected infection, 20 % were assessed as no infection, 31 % as possible infection and 49 % as infection. Content validity analysis showed that 12/13 of the items correlated significantly with at least one other statement. The range in number of significant inter-correlations was from 0 (“pain”) to 8 (“general signs and symptoms of illness”). The construct validity showed that the items “temperature” , “respiratory symptoms” and “general signs and symptoms of illness” were significantly related to “infection”, and these were also selected in the model-building. These items predicted correct alternative responses in 61 % of the cases. CONCLUSION: The validation of EDIS suggests that the observation of “general signs and symptoms of illness”, made by nursing assistants should be taken seriously in detecting early infection in frail elderly. Also, the statement “He/She is not as usual” should lead to follow-up.
The use of cognitive behaviour therapy in the management of BPSD in dementia (Innovative Practice).
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Psychosocial approaches to the management of behavioural and psychological symptoms of dementia have received much support in the scientific literature. The following paper focuses on cognitive behaviour therapy as a valid framework in assessing and treating people with behavioural and psychological symptoms of dementia. The importance of identifying symptoms of depression and anxiety is emphasized, as cognitive behaviour therapy has been shown to be an effective intervention for these conditions in older adults. Modifications of cognitive behaviour therapy for those with dementia are discussed based on available evidence, with emphasis on incorporating nursing home staff in treatment programs and focusing on behavioural elements of cognitive behaviour therapy such as activity scheduling. The paper concludes with suggestions regarding how to incorporate and promote the use of cognitive behaviour therapy in dementia care settings.
Profiles of Loneliness in the Caregiving Unit.
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PURPOSE OF THE STUDY: The study evaluated profiles (a typology) of loneliness within the caregiving unit, which was composed of an older care recipient with functional impairment, a family member, and a home care worker. DESIGN AND METHODS: Overall, 223 complete caregiving units completed the 3-item Revised-University of California San Francisco Loneliness scale. Latent profile analysis was used to identify profiles of loneliness within the caregiving unit. Subsequently, latent profile membership was used as a between-subject variable to examine correlates of the latent profiles. RESULTS: A 2-profile solution was deemed most plausible. This classification consisted of a large (174 caregiving units; 78%) more favorable profile in terms of loneliness and a smaller (49 caregiving units; 22%) lonelier profile. Profile classification was associated with a variety of quality of life, well-being, social relations, and sociodemographic indicators of the 3 members of the caregiving unit. IMPLICATIONS: The study provides a needed recognition of the potential interdependence among members of the caregiving unit and calls for research and practice that go beyond the individual level. The assessment of loneliness at the caregiving unit can provide valuable information about at-risk units as well as about the potential effectiveness of interventions that target the entire caregiving unit.
The Seniors’ Outdoor Survey: An Observational Tool for Assessing Outdoor Environments at Long-Term Care Settings
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PURPOSE OF THE STUDY: To describe the development and psychometric testing of the Seniors’ Outdoor Survey (SOS), an instrument for evaluating how well the outdoor space in a long-term care setting supports the preferences and outdoor usage of residents. DESIGN AND METHODS: Content validity of the main SOS items initially was based on relevant literature and preliminary studies in diverse long-term care settings. After conducting a multiregional pilot study with 152 outdoor spaces at 68 assisted living facilities, the instrument was substantially revised and tested for interrater and test-retest reliability with 22 outdoor spaces at 12 long-term care settings, using 2 raters. Validity was examined using content analysis of resident survey responses (N = 1,128) from the multiregional study and specific item validation by subject matter experts (N = 53). RESULTS: The final instrument contains 60 ratable items organized in 5 domains: access to nature (14 items), outdoor comfort and safety (15 items), walking and outdoor activities (14 items), indoor-outdoor connection (11 items), and connection to the world (6 items). Intraclass correlation coefficient (ICC) estimates of interrater reliability were .91 for the overall instrument, ranging from .83 to .98 for the 5 domains. Interrater reliability (ICC) was above .70 for more than 79% of individual items. Test-retest reliability (ICC) was .92, ranging from .81 to .98 for domains. IMPLICATIONS: The SOS tool fills a gap in the available environmental assessment instruments, providing a reliable way for researchers, providers, and designers to evaluate and compare the supportive potential of outdoor spaces for long-term care residents.
The contribution of immigration to the size and ethnocultural diversity of future cohorts of seniors
This article analyzes the impact of immigration on the size and ethnocultural composition of future cohorts of seniors in Canada, using data from the Population Estimates Program, the Population Projections Program and other sources of demographic data.
Challenge on dementia 2020: implementation plan (UK)
The Prime Minister’s challenge on dementia 2020 set out more than 50 specific commitments that aim to make England the world-leader in dementia care, research and awareness by 2020. The implementation plan sets out how these commitments will be met. It sets out priority actions, and the organisation responsible, across 4 themes:
-risk reduction
-health and care
-awareness
-social action
This plan was developed in partnership with a range of stakeholders, including people with dementia and carers.
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Events
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Active Living for Healthy Brains: A Community Engagement Event
Objective To review the latest expert opinions and research findings on the beneficial effects of exercise and physical activity on brain health (cerebrovascular outcomes), sleep, and cognitive performance in older adults.
Topics Covered Includes impact of physical activity on vascular reactivity, vascular biomarkers, and brain structure & function using neuroimaging techniques such as magnetic resonance imaging (MRI). Identification of knowledge gaps about the mechanisms underlying the pro-cognitive effects of exercise by examining potential factors such as the required exercise “dose” and type and the potential modifying effects of sleep quality, genetic variation, cognitive stimulation, socialization, and a healthy lifestyle.
Format The day will include a series of topic-specific seminars, a keynote talk followed by an expert panel discussion on the role of exercise in delaying and/or preventing Alzheimer’s disease and dementia.
Target Audience Researchers, clinician scientists, and trainees.
Countless opportunities arise for enhancing health from the growing capacity to collect and share health information from a variety of sources for a number of uses. The creation of electronic health records provide hospitals with the opportunity to reduce risk and improve outcomes; and to empower patients with the opportunity to take more responsibility for their health. Similarly, the collection and use of data (digital and biological) at a system level offer public health benefits, coordination of care, and research platforms for adding to the store of knowledge. These benefits do not come without risks, however, some of which can be mitigated by good policy, and others require more creative approaches. This talk will discuss some ways to anticipate and address the challenges arising from health data collection and sharing.
Caregivers: Lessons from the UK, Opportunities for Ontario
With the recent introduction of caregiver legislation in the UK, Heléna Herklots, Chief Executive, Carers UK will give a keynote address on the progress that has been made so far, and what lessons exist for similar efforts in Ontario. Dr. Joshua Tepper, President and CEO, Health Quality Ontario, and Katherine Arnup, PhD, Family Caregiver and Author, will also give remarks.
2016 Patient-Oriented Research Summer Institute
Connecting, engaging and capacity-building: The 2016 Patient-Oriented Research Summer Institute, May 2-4, 2016 Westin Calgary, will help you learn best practices and trends in patient-oriented research.
Hear from leaders in patient-oriented research
Share best practices in patient-oriented research
Learn how to incorporate patient-oriented research into your studies
Connect with colleagues
Get inspired!
ASILA case-simulation prototype on cognitive and physical outcomes of frail seniors in nursing homes
The Ontario Ministry of Health & Long-Term Care’s report Living Longer, Living Well highlights a rapidly increasing need to care for seniors requiring complex care in nursing home (NH) settings. As the number of seniors rises, pressure increases on the care capacity in these organizations. It is estimated that by 2020, Canadian healthcare staff will spend 75% of their time with seniors requiring complex care. The majority of these workers will be registered nursing and unregulated healthcare staff. However, insufficient geriatric content in Canadian health care education persists, leading to serious concerns that staff do not have adequate knowledge to assess, plan, provide and document care. This deficit is especially acute in NH settings with negative consequences for seniors. Difficulties in providing appropriate care to frail seniors are compounded by unfamiliarity with data and assessment systems used in NHs.
Online
Making Culture Change Work: An Integrated Approach
The long-term care sector is a complex adaptive system receiving input from multiple stakeholders and levels, making implementation of new practices challenging. Culture change is most effective when change is targeted at all system levels (i.e., individual, organisational, socio-political) in an integrated way. Drawing on culture change work conducted by the Partnerships in Dementia Care (PiDC) Alliance, this presentation identifies specific strategies and recommendations for targeting change at multiple levels.
How research can help shape policy and practice on aging: Lessons from Newfoundland and Labrador
Speaker: Dr. Stephen Bornstein, professor in the Department of Political Science and in the Division of Community Health and Humanities at Memorial University and director of the Newfoundland and Labrador Centre for Applied Health Research. Dr. Bornstein completed his M.A. and Ph. D. in Political Science at Harvard University. He has been the Director of the Newfoundland and Labrador Centre for Applied Health Research (NLCAHR) since the Centre’s establishment in 1999. At NLCAHR, he leads the Contextualized Health Research Synthesis Program, an integrated knowledge translation program that addresses pressing health services, policy and technology questions for the provincial health system. He is also Director of SafetyNet, Memorial University’s centre for research on occupational health and safety.
Courses
Implementation Science Masterclass 2016
This is a two-day course organised by the NIHR CLAHRC South London for health professionals, researchers, patients and service users who want to make sure health services routinely offer treatment and care that is based on the most recent research evidence. The Implementation Science Masterclass includes lectures from world-renowned experts in the field plus guidance to help participants work more effectively on their own implementation projects.
The Dementia Certificate Program is a comprehensive educational program offered by the Alzheimer Society of Toronto for healthcare professionals, like doctors, personal support workers, and caregivers. The program is composed of two courses: the Dementia Care Training Program (DCTP) and the Behavioural Support Training Program (BSTP). DCTP covers general awareness of the disease and how it impacts care. BSTP allows workers and frontline staff to develop skills for dealing with responsive behaviors when working with people living with dementia. This two-part program will give you:
-The dementia care training employers look for
-A better understanding of how dementia affects people physically, mentally, and socially
-The skills and confidence necessary to provide the most effective and up-to-date care
Online
The European Hydration Institute has developed an online hydration course. The course is designed to help health care professionals advance their understanding of hydration. The four interactive modules cover: water and hydration; perioperative care; care homes and physical activity.
News
How Do I Write a Cover Letter to Someone I Work With?
I am currently a postdoctoral researcher and am applying for a tenure-track position at the same university. One of the people I work with directly on a day-to-day basis is the chair for the position. My question is: how should I phrase the introductory paragraph when I already know the search-committee chair and s/he knows me and what I work on?
Health Care For Seniors Often Goes Beyond Their Desires
As people get older, their health care goals may shift from living as long as possible to maintaining a good quality of life: quality over quantity. In many cases, the medical treatment older people receive often doesn’t reflect this change in priorities.
Two Valuable Lessons for Redesigning Geriatric Care
What is the most effective way to avoid falling in the hospital? I’m not being facetious when I say the best way is to not be in the hospital in the first place. Of course, avoiding a stay in the hospital isn’t an option for many geriatric patients. That’s where the work of redesigning care comes in — and where these two lessons our team has learned can be helpful.
Making a Writing Group that Works
Writing for Inside Higher Ed’s “Grad Hacker” feature, Travis Grandy discusses forming a writing group as a way of providing external accountability (i.e., outside the structures of courses and their assignments). Beginning with assessing where you work best (or don’t work best) and a sense of your personal writing process, he recommends the formation of a writing group with different variations on that theme.
Not your great-grandma’s nursing home: Innovations in seniors’ living
Just as home care is allowing the elderly to stay in their own homes longer, new and innovate types of accommodation are changing the way Canadians live their final years.
Tapping into personal networks to share research and improve evidence uptake
Stakeholder networks play a key role in the dissemination and uptake of IWH research. As an occupational therapist providing services on return-to-work issues to employers, Gabriele Wright strives as much as possible to base her processes and recommendations on research evidence. That’s why she values her involvement in the Institute for Work & Health (IWH)’s Educationally Influential Network for Occupational Therapists.
Why Is ClinicalTrials.gov Still Struggling?
ClinicalTrials.gov was launched as a voluntary registry in the 1990s, but the stakes were raised after a number of scandals, leading to the Food and Drug Administration Amendments Act (FDAAA), which in 2005 mandated that clinical trials be registered.
Health Secretary unveils plans for safer 7 day dementia service (UK)
A 7 day NHS, and helping people live well with the dementia, will help make UK the most dementia friendly society in the world by 2020.
Dementia Declaration has potential for step change in care (UK)
Good quality post-diagnostic care helps the individual with dementia to stay at home, when it is in their best interests to do so, which enables them to remain independent for longer.
Drugging seniors still too prevalent, advocate says
Too many seniors in residential facilities are still being given antipsychotic drugs, warns B.C. seniors advocate Isobel MacKenzie in response to a national report.
World Dementia Council goes global
The World Dementia Council (WDC) has re-formed at a meeting in London, in recognition of the urgent need to tackle the global dementia crisis. The re-formed Council is now chaired by Dr Yves Joanette, Scientific Director at the Canadian Institutes of Health Research (CIHR) Institute of Aging, and Vice-Chair, Raj Long, Senior Advisor at the Bill & Melinda Gates Foundation.
How to Use Patient-Reported Measures to Ensure Patient-Centered Care
Health care providers often overlook the best way to determine the success or failure of a clinical treatment or procedure: Ask the patient. Although some clinicians in the US have been using PRMs for a long time, the use has often been limited to single practices and largely tied to episodes of care for selected procedures — most commonly in orthopedics, pain management, and physical therapy. Even when programs and practices do collect PRMs, they do not always collect data in ways that support improvement, help them identify population management opportunities across the care continuum, or inform health policies. (The CMS-mandated Comprehensive Care for Joint Replacement demonstration project is an example of a program that requires inclusion of PRMs.)
More PhDs? Define the “demand” first
In a post last year I wrote about how usually, when it’s argued there is an “overproduction” of PhDs, “demand” for doctoral graduates is being implicitly defined by the number of tenure-stream jobs available while “overproduction” usually points to “not enough academic jobs for doctoral graduates.” So how do you define the demand for doctorates when we’re not just talking about faculty jobs anymore?
Care home offers a step between hospital and home for patients (UK)
New initiative sees independent care homes working with hospitals to provide a place for people to recuperate and alleviate pressures on acute care.
Putting my life on hold to live with my parents lost to Alzheimer’s
In 2010, Elizabeth Wolf, then 30, was living in Vermont, working for a non-profit and happily exploring new pursuits, from raising chickens to contra dancing. But after several disturbing phone calls from and about her parents, Louis and Nancy Brood, Wolf moved back into the split-level in Mt. Laurel, N.J., where she and her siblings had grown up, with her now husband, Casey Wolf. She expected to arrange caregiving help for her parents, then return to Vermont.
The Institute of Medicine is now the Health and Medicine Division
The division of the National Academies of Sciences, Engineering, and Medicine (the Academies) that focuses on health and medicine was renamed the Health and Medicine Division (HMD) instead of using the name Institute of Medicine (IOM). This new name builds on the heritage of the IOM’s work in medicine while emphasizing its increased focus on a wider range of health matters.
‘The global race to find a cure for dementia is on and I want the UK to win it’ – Jeremy Hunt Boosting dementia diagnosis and helping people live well with the condition are key elements of Health Secretary Jeremy Hunt’s plans to make the UK the most dementia friendly society in the world by 2020. The Government’s dementia plan published today sets out a series of commitments to boost diagnosis rates, raise awareness and encourage research.
Resources
PARO Therapeutic Robot Available for Trial!
If your organization (Canada) is interested in testing the positive impact that Paro may have in your care setting, the IFA has a Paro that is available on loan (no cost other that shipping) for 6 week trials.
Eating and Drinking Well: Supporting People Living with Dementia
A new workbook and training film are now available. These training tools are designed to equip frontline nurses and care home staff with the skills needed to improve the delivery of nutrition and hydration for people living with dementia.
Pain Matters: A Family Guide to Pain Management in Dementia
A new guide called Pain Matters is now available to help family members, friends and caregivers of people with dementia recognize the relationship between responsive behaviour and pain. Behaviour has meaning and it may be an expression of pain. The guide was created in partnership with the brainXchange and Alzheimer Society of Ontario.
Meaningful Patient Engagement: A How-To
Are you creating or expanding your patient advisory council? Health Quality Ontario’s new guides feature insights and practical tools on recruiting for diversity, choosing meaningful projects and writing an effective terms of reference. Photographs of our patient, family and public advisors also appear throughout the guides. Learn more about patient engagement in our latest patient and family advisory council resources.
Achieving Patient Experience Excellence: An Idea Book
Great work is happening in Ontario’s hospitals to improve the patient experience, and there is a lot of power in telling these stories. Initially, the intent of the idea book was to choose a handful of the outstanding improvement projects and develop case studies to help other hospitals achieve similar successes. It quickly became apparent that featuring only a handful would mean that a lot of great ideas, inspiring plans, quick wins and painstaking work would go unmentioned. And we didn’t want that. Some projects have wide-ranging mandates seeking a “cultural shift” within the organization and strategies to reflect true values of care. Others are simply focused on a single tactical improvement. Whatever the change, the goal is better patient care.
Baycrest describes late-life depression on their website through a combination of video clips, written content and a depression self-check tool which employs the valid and reliable Geriatric Depression Scale to assess depression in older adults.
The MoMA Alzheimer’s Project: Making Art Accessible to People with Dementia
This project aims at giving guidance to those who want to engage individuals with Alzheimer’s disease with art. There are two sets of videos: a set of videos about how to plan and implement discussion programs about art with groups of individuals with Alzheimer’s disease and another set of videos to plan and implement art making session with groups of individuals with Alzheimer’s disease.
