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New article by Dr. Matthias Hoben
Effective strategies to motivate nursing home residents in oral healthcare and to prevent or reduce responsive behaviours to oral healthcare: a systematic review protocol
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INTRODUCTION: Oral healthcare in nursing homes is less than optimal, with severe consequences for residents’ health and quality of life. To provide the best possible oral healthcare to nursing home residents, care providers need strategies that have been proven to be effective. Strategies can either encourage and motivate residents to perform oral healthcare themselves or can prevent or overcome responsive behaviours from residents when care providers assist with oral healthcare. This systematic review aims to identify studies that evaluate the effectiveness of such strategies and to synthesise their evidence. METHODS AND ANALYSIS: We will conduct a comprehensive search in the databases MEDLINE, EMBASE, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL and Web of Science for quantitative intervention studies that assess the effectiveness of eligible strategies. 2 reviewers will independently screen titles, abstracts and retrieved full texts for eligibility. In addition, contents of key journals, publications of key authors and reference lists of all studies included will be searched by hand and screened by 2 reviewers. Discrepancies at any stage of the review process will be resolved by consensus. Data extraction will be performed by 1 research team member and checked by a second team member. 2 reviewers will independently assess methodological quality of studies included using 3 validated checklists appropriate for different research designs. We will present a narrative synthesis of study results. ETHICS AND DISSEMINATION: We did not seek ethics approval for this study, as we will not collect primary data and data from studies included cannot be linked to individuals or organisations. We will publish findings of this review in a peer-reviewed paper and present them at an international peer-reviewed conference. TRIAL REGISTRATION NUMBER: CRD42015026439.
New article by Dr. Jo Rycroft-malone
Reducing and managing faecal incontinence in people with advanced dementia who are resident in care homes: protocol for a realist synthesis.
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INTRODUCTION: Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes. METHODS AND ANALYSIS: A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be ‘tested’ through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1. ETHICS AND DISSEMINATION: The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.
New article by Dr. Lars Wallin
Exploring the Role of Line Managers in Implementing Evidence-Based Practice in Social Services and Older People Care
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This qualitative study explored the vital role of line managers, namely the managerial level directly above employees, in effectively implementing evidence-based practice (EBP) from their own perspectives. Interviews were carried out with twenty-eight line managers within social services and older people care in seven Swedish municipalities. Thematic analysis was performed. Findings revealed that managers in social care perceived their role as important in implementing EBP. However, notable differences were observed between the two settings, where social services managers had more knowledge and held more positive attitudes towards working according to EBP, and described a more active role in the implementation process than managers in older people care. Overall, the implementation of EBP was performed ad hoc rather than systematically, and with little consideration to analysis of needs according to the local context and limited focus on follow-up and sustainability. This study highlighted that line managers in social services and older people care have different prerequisites for implementing EBP, and are greatly dependent on organisational strategies and context. Gaining knowledge of line managers’ perceptions is essential for making informed decisions regarding the support required to achieve EBP in social care, and thus for providing the best possible care for clients.
Article recommended by Dr. Carole Estabrooks
Effectiveness of the STOPP/START (Screening Tool of Older Persons’ potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria: systematic review and meta-analysis of randomized controlled studies. 
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WHAT IS KNOWN AND OBJECTIVE: STOPP/START are explicit screening tools that identify potentially inappropriate prescribing in older adults. Our objective was to update our 2013 systematic review that showed limited evidence of impact, using new evidence from randomized controlled trials (RCTs) assessing clinical, humanistic and economic outcomes in older adults. METHODS: We performed a search of PubMed, EMBASE, CINAHL, Web of Science and grey literature for RCTs published in English since the previous review through June 2014. The Cochrane Risk of Bias Tool was used. We performed a meta-analysis on the effect of STOPP on potentially inappropriate medication (PIM) rates and a narrative synthesis on other outcomes. RESULTS AND DISCUSSION: Four RCTs (n = 1925 adults) from four countries were included, reporting both acute (n = 2) and long-term care (n = 2) patients. Studies differed in implementation. Two studies were judged to have low risk, and two to have moderate-to-high risk of bias in key domains. Meta-analysis found that the STOPP criteria reduced PIM rates in all four studies, but study heterogeneity (I2 = 86.7%) prevented the calculation of a meaningful statistical summary. We found evidence that use of the criteria reduces falls, delirium episodes, hospital length-of-stay, care visits (primary and emergency) and medication costs, but no evidence of improvements in quality of life or mortality. WHAT IS NEW AND CONCLUSION: STOPP/START may be effective in improving prescribing quality, clinical, humanistic and economic outcomes. Additional research investigating these tools is needed, especially in frail elderly and community-living patients receiving primary care.
2016 Alzheimer’s Disease Facts and Figures Released
2016 Alzheimer’s Disease Facts and Figures (US)
2016 Alzheimer’s Disease Facts and Figures is a statistical resource for U.S. data related to Alzheimer’s disease, the most common cause of dementia, as well as other dementias. Background and context for interpretation of the data are contained in the Overview. This information includes descriptions of the various causes of dementia and a summary of current knowledge about Alzheimer’s disease. Additional sections address prevalence, mortality and morbidity, caregiving, and use and costs of health care, long-term care and hospice. The Special Report discusses the personal financial impact of Alzheimer’s disease on families.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice and Methodology
Aging
KT
Improving the public value of science: A typology to inform discussion, design and implementation of research
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‘Basic’ and ‘applied’ research do not consider the context of use.•A more complete view of research activities and expectations is described.•A multi-dimensional typology of research activities is introduced.•Attributes are idealized on a spectrum, from science-centric to user-oriented.•Using the typology can inform science-policy planning and decisions.; Decision makers call upon and fund science to solve urgent problems, catalyze innovation, and inform policy decisions. But the standard categories for describing, planning and assessing research, especially the persistence of “basic” and “applied,” conceal much of the complexity and diversity of the contexts for conducting and using research, especially the role of knowledge users in the research process. Here we provide an entirely new typology aimed at allowing a more complete view of research activities and expectations, in order to improve deliberation and decision-making about research and its desired contribution to public values. Our multi-dimensional research typology divides research into three general activities: knowledge production, learning and engagement, and organizational and institutional processes, all of which are further subdivided into fifteen attributes. These idealized attributes are expressed in terms of a spectrum of value criteria ranging from strongly science-centric to strongly user-oriented. This enables consideration of the isolated knowledge value of science, the consideration and context of use, and the engagement of intended users. Used as a heuristic device, the typology can help inform and improve science-policy planning and decisions, aid in assessing the potential of existing projects, programs and institutions to achieve particular goals, and yield insights about the strengths and weaknesses of completed projects.
Toward the sustainability of health interventions implemented in sub-Saharan Africa: a systematic review and conceptual framework.
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BACKGROUND: Sub-Saharan Africa (SSA) is facing a double burden of disease with a rising prevalence of non-communicable diseases (NCDs) while the burden of communicable diseases (CDs) remains high. Despite these challenges, there remains a significant need to understand how or under what conditions health interventions implemented in sub-Saharan Africa are sustained. The purpose of this study was to conduct a systematic review of empirical literature to explore how health interventions implemented in SSA are sustained. METHODS: We searched MEDLINE, Biological Abstracts, CINAHL, Embase, PsycInfo, SCIELO, Web of Science, and Google Scholar for available research investigating the sustainability of health interventions implemented in sub-Saharan Africa. We also used narrative synthesis to examine factors whether positive or negative that may influence the sustainability of health interventions in the region. RESULTS: The search identified 1819 citations, and following removal of duplicates and our inclusion/exclusion criteria, only 41 papers were eligible for inclusion in the review. Twenty-six countries were represented in this review, with Kenya and Nigeria having the most representation of available studies examining sustainability. Study dates ranged from 1996 to 2015. Of note, majority of these studies (30 %) were published in 2014. The most common framework utilized was the sustainability framework, which was discussed in four of the studies. Nineteen out of 41 studies (46 %) reported sustainability outcomes focused on communicable diseases, with HIV and AIDS represented in majority of the studies, followed by malaria. Only 21 out of 41 studies had clear definitions of sustainability. Community ownership and mobilization were recognized by many of the reviewed studies as crucial facilitators for intervention sustainability, both early on and after intervention implementation, while social and ecological conditions as well as societal upheavals were barriers that influenced the sustainment of interventions in sub-Saharan Africa. CONCLUSION: The sustainability of health interventions implemented in sub-Saharan Africa is inevitable given the double burden of diseases, health care worker shortage, weak health systems, and limited resources. We propose a conceptual framework that draws attention to sustainability as a core component of the overall life cycle of interventions implemented in the region.
Measurement resources for dissemination and implementation research in health.
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BACKGROUND: A 2-day consensus working meeting, hosted by the United States National Institutes of Health and the Veterans Administration, focused on issues related to dissemination and implementation (D&I) research in measurement and reporting. Meeting participants included 23 researchers, practitioners, and decision makers from the USA and Canada who concluded that the field would greatly benefit from measurement resources to enhance the ease, harmonization, and rigor of D&I evaluation efforts. This paper describes the findings from an environmental scan and literature review of resources for D&I measures. FINDINGS: We identified a total of 17 resources, including four web-based repositories and 12 static reviews or tools that attempted to synthesize and evaluate existing measures for D&I research. Thirteen resources came from the health discipline, and 11 were populated from database reviews. Ten focused on quantitative measures, and all were generated as a resource for researchers. Fourteen were organized according to an established D&I theory or framework, with the number of constructs and measures ranging from 1 to more than 450. Measure metadata was quite variable with only six providing information on the psychometric properties of measures. CONCLUSIONS: Additional guidance on the development and use of measures are needed. A number of approaches, resources, and critical areas for future work are discussed. Researchers and stakeholders are encouraged to take advantage of a number of funding mechanisms supporting this type of work.
Achieving change in primary care-causes of the evidence to practice gap: systematic reviews of reviews.
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BACKGROUND: This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care. DESIGN: This study is a systematic review of reviews. METHODS: MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis. RESULTS: Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation. CONCLUSIONS: This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014009410.
An Overview of Research and Evaluation Designs for Dissemination and Implementation
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The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. Methods: This paper is one product of a design workgroup formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. Results: This paper emphasizes randomized and non-randomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.
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Health Care Administration and Organization
Patient participation in special care units for persons with dementia: A losing principle?
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The aim of this study was to explore the experience of nursing personnel with respect to patient participation in special care units for persons with dementia in nursing homes, with focus on everyday life. The study has an explorative grounded theory design. Eleven nursing personnel were interviewed twice. Patient participation is regarded as being grounded in the idea that being master of one’s own life is essential to the dignity and self-esteem of all people. Patient participation was described at different levels as letting the resident make their own decisions, adjusting the choices, making decisions on behalf of the residents and forcing the residents. The educational level and commitment of the nursing personnel and how often they were on duty impacted the level that each person applied, as did the ability of the residents to make decisions, and organizational conditions, such as care culture, leadership and number of personnel.
Health Workforce Policies in OECD Countries
Right Jobs, Right Skills, Right Places
This publication reviews key trends and new policy priorities in relation to the health workforce in OECD countries following the economic crisis.
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Health Care Innovation and Quality Assurance
Balancing stakeholder needs in the evaluation of healthcare quality improvement
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Quality improvement (QI) efforts affect a broader range of people than we often assume. These are the potential stakeholders for QI and its evaluation, and they have valuable perspectives to offer when they are consulted in planning, conducting and interpreting evaluations. QI practitioners are accustomed to consulting stakeholders to assess unintended consequences or assess patient experiences of care, but in many cases there are additional benefits to a broad inclusion of stakeholders. These benefits are better adherence to ethical standards, to assure that all legitimate interests take part, more useful and relevant evaluation information and better political buy-in to improve impact. Balancing various stakeholder needs for information requires skill for both politics and research management. These challenges have few pat answers, but several preferred practices, which are illustrated with practical examples.
How best practices are copied, transferred, or translated between health care facilities: A conceptual framework.
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INTRODUCTION: In spite of significant investment in quality programs and activities, there is a persistent struggle to achieve quality outcomes and performance improvements within the constraints and support of sociopolitical parsimonies. Equally, such constraints have intensified the need to better understand the best practice methods for achieving quality improvements in health care organizations over time.This study proposes a conceptual framework to assist with strategies for the copying, transferring, and/or translation of best practice between different health care facilities. PURPOSE: Applying a deductive logic, the conceptual framework was developed by blending selected theoretical lenses drawn from the knowledge management and organizational learning literatures. FINDINGS: The proposed framework highlighted that (a) major constraints need to be addressed to turn best practices into everyday practices and (b) double-loop learning is an adequate learning mode to copy and to transfer best practices and deuteron learning mode is a more suitable learning mode for translating best practice. We also found that, in complex organizations, copying, transferring, and translating new knowledge is more difficult than in smaller, less complex organizations. We also posit that knowledge translation cannot happen without transfer and copy, and transfer cannot happen without copy of best practices. Hence, an integration of all three learning processes is required for knowledge translation (copy best practice-transfer knowledge about best practice-translation of best practice into new context). In addition, the higher the level of complexity of the organization, the more best practice is tacit oriented and, in this case, the higher the level of K&L capabilities are required to successfully copy, transfer, and/or translate best practices between organizations. PRACTICE IMPLICATIONS: The approach provides a framework for assessing organizational context and capabilities to guide copy/transfer/translation of best practices. A roadmap is provided to assist managers and practitioners to select appropriate learning modes for building success and positive systemic change.
How to Sustain Change and Support Continuous Quality Improvement.
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To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).
The sustainability of healthcare innovations: a concept analysis.
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AIM: To report on an analysis of the concept of the sustainability of healthcare innovations. BACKGROUND: While there have been significant empirical, theoretical and practical contributions made towards the development and implementation of healthcare innovations, there has been less attention paid to their sustainability. Yet many desired healthcare innovations are not sustained over the long term. There is a need to increase clarity around the concept of innovation sustainability to guide the advancement of knowledge on this topic. DESIGN: Concept analysis. DATA SOURCES: We included literature reviews, theoretical and empirical articles, books and grey literature obtained through database searching (ABI/INFORM, Academic Search Complete, Business Source Complete, CINAHL, Embase, MEDLINE and Web of Science) from 1996-May 2014, reference harvesting and citation searching. METHODS: We examined sources according to terms and definitions, characteristics, preconditions, outcomes and boundaries to evaluate the maturity of the concept. RESULTS: This concept is partially mature. Healthcare innovation sustainability remains a multi-dimensional, multi-factorial notion that is used inconsistently or ambiguously and takes on different meanings at different times in different contexts. We propose a broad conceptualization that consists of three characteristics: benefits, routinization or institutionalization, and development. We also suggest that sustained innovations are influenced by a variety of preconditions or factors, which are innovation-, context-, leadership- and process-related. CONCLUSION: Further conceptual development is essential to continue advancing our understanding of the sustainability of healthcare innovations, especially in nursing where this topic remains largely unexplored.
Best practice and needs for improvement in the chain of care for persons with dementia in Sweden: a qualitative study based on focus group interviews.
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BACKGROUND: Persons with dementia receive health care and social services from a wide range of professional care providers during the disease trajectory, presenting risks of miscommunication, duplication and/or missed nursing interventions. Accordingly, the aim of this study was to investigate professional care providers’ views on conditions for best practice in terms of collaboration and improvement needs in the chain of care from early to end-of-life stage for persons with dementia in Sweden. METHODS: The study had a qualitative design based on three focus group interviews. A strategic sample of 23 professional care providers was included. Data were subjected to content analysis based on the three stages of dementia (early, moderate, end-of-life). RESULTS: The results were divided into five categories: Diagnosis is a prerequisite for specialized dementia care, Creating routines in the chain of care, Competent staff a prerequisite for high-quality care, Day care facilitates transition in the chain of care and Next-of-kin participation is a prerequisite for continuity in the chain of care. It was clear that, according to the participants, best practice in dementia care in Sweden is not achieved in every respect. It appeared that transitions of care between different organizations are critical events which need to be improved. The further the disease progresses, the less collaboration there seems to be among professional care providers, which is when the next of kin are usually called upon to maintain continuity in the chain of care. CONCLUSIONS: The results indicate that, according to the care providers, best practice in terms of collaboration is achieved to a higher degree during the early stage of dementia compared with the moderate and end-of-life stages. Lack of best practice strategies during these stages makes it difficult to meet the needs of persons with dementia and reduce the burden for next of kin. These are experiences to be taken into account to improve the quality of dementia care. Implementation research is needed to develop strategies for best practice on the basis of national knowledge-based guidelines and to apply these strategies in the moderate and end-of-life stages.
Appropriate prescribing in nursing homes demonstration project (APDP) study protocol: pragmatic, cluster-randomized trial and mixed methods process evaluation of an Ontario policy-maker initiative to improve appropriate prescribing of antipsychotics
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BACKGROUND: Antipsychotic medications are routinely prescribed in nursing homes to address the behavioral and psychological symptoms of dementia. Unfortunately, inappropriate prescribing of antipsychotic medications is common and associated with increased morbidity, adverse drug events, and hospitalizations. Multifaceted interventions can achieve a 12-20 % reduction in antipsychotic prescribing levels in nursing homes. Effective interventions have featured educational outreach and ongoing performance feedback. METHODS/DESIGN: This pragmatic, cluster-randomized control trial and embedded process evaluation seeks to determine the effect of adding academic detailing to audit and feedback on prescribing of antipsychotic medications in nursing homes, compared with audit and feedback alone. Nursing homes within pre-determined regions of Ontario, Canada, are eligible if they express an interest in the intervention. The academic detailing intervention will be delivered by registered health professionals following an intensive training program including relevant clinical issues and techniques to support health professional behavior change. Physicians in both groups will have the opportunity to access confidential reports summarizing their prescribing patterns for antipsychotics in comparison to the local and provincial average. Participating homes will be allocated to one of the two arms of the study (active/full intervention versus standard audit and feedback) in two waves, with a 2:1 allocation ratio. Homes will be randomized after stratifying for geography, baseline antipsychotic prescription rates, and size, to ensure a balance of characteristics. The primary outcome is antipsychotic dispensing in nursing homes, measured 6 months after allocation; secondary outcomes include clinical outcomes and healthcare utilization. DISCUSSION: Policy-makers and the public have taken note that antipsychotics are used in nursing homes in Ontario far more than other jurisdictions. Academic detailing can be an effective technique to address challenges in appropriate prescribing in nursing homes, but effect sizes vary widely. This opportunistic, policy-driven evaluation, embedded within a government-initiated demonstration project, was designed to ensure policy-makers receive the best evidence possible regarding whether and how to scale up the intervention. TRIAL REGISTRATION: ClinicalTrials.gov NLM Identifier: NCT02604056 .
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Organizational Change
Sustaining organizational culture change in health systems.
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Purpose – The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues. Design/methodology/approach – The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts. Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application. Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.
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Research Practice and Methodology
Mixed Methods for Policy Research and Program Evaluation
This practical text equips students, researchers, and policymakers in the social sciences with the tools they need for applying mixed methods in policy research and program evaluation, from design, through data collection, and dissemination. Emphasizing the “how-to”—the set of conceptual and active tasks carried out by mixed methods researchers—the book is illustrated with rich case studies from the authors’ own research projects in education and public policy. These examples help readers identify and explain policy and program impacts and better understand the “why” and “how” of observed effects. Throughout the book, the authors describe challenges that both beginners and advanced scholars are likely to encounter when doing mixed methods research and recommend practical tools available to address them.
Using the Nine Common Themes of Good Practice checklist as a tool for evaluating the research priority setting process of a provincial research and program evaluation program.
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BACKGROUND: Given the context-specific nature of health research prioritization and the obligation to effectively allocate resources to initiatives that will achieve the greatest impact, evaluation of priority setting processes can refine and strengthen such exercises and their outcomes. However, guidance is needed on evaluation tools that can be applied to research priority setting. This paper describes the adaption and application of a conceptual framework to evaluate a research priority setting exercise operating within the public health sector in Ontario, Canada. METHODS: The Nine Common Themes of Good Practice checklist, described by Viergever et al. (Health Res Policy Syst 8:36, 2010) was used as the conceptual framework to evaluate the research priority setting process developed for the Locally Driven Collaborative Projects (LDCP) program in Ontario, Canada. Multiple data sources were used to inform the evaluation, including a review of selected priority setting approaches, surveys with priority setting participants, document review, and consultation with the program advisory committee. RESULTS: The evaluation assisted in identifying improvements to six elements of the LDCP priority setting process. The modifications were aimed at improving inclusiveness, information gathering practices, planning for project implementation, and evaluation. In addition, the findings identified that the timing of priority setting activities and level of control over the process were key factors that influenced the ability to effectively implement changes. CONCLUSIONS: The findings demonstrate the novel adaptation and application of the ‘Nine Common Themes of Good Practice checklist’ as a tool for evaluating a research priority setting exercise. The tool can guide the development of evaluation questions and enables the assessment of key constructs related to the design and delivery of a research priority setting process.
Lessons learned from recruiting nursing homes to a quantitative cross-sectional pilot study.
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Background A growing older adult population is leading to increased admission rates to long-term care facilities such as nursing homes and residential care homes. Assisted healthcare services should be flexible, integrated, and responsive to older adults’ needs. However, there is a limited body of empirical evidence because of the recruitment challenges in these settings. Aim To describe the barriers and challenges faced in recruiting to a recent pilot study, consider previously implemented and proposed recruitment strategies, and propose a new multi-method approach to maximising recruitment of care homes. Discussion The proposed multi-method approach harnesses key recruitment strategies previously highlighted as effective in navigating the many challenges and barriers that are likely to be encountered, such as mistrust, scepticism and concerns about disruption to routines. This includes making strategic use of existing personal and professional connections within the research team, engaging with care homes that have previously engaged with the research process, forming relationships of trust, and employing a range of incentives. Conclusion Implementing carefully planned recruitment strategies is likely to improve relationships between nursing homes and researchers. As a consequence, recruitment can be augmented which can enable the production of rigorous evidence required for achieving effective nursing practice and patient wellbeing. Implications for practice Boosting recruitment rates is crucial in helping to build new and less biased research evidence and for informing and underpinning all forms of evidence-based practice. The lessons learned from our pilot and the review of the literature highlight these issues and better enable investigators to access research settings that commonly possess many complex recruitment barriers and challenges.
Health and medical research funding agencies’ promotion of public engagement within research: a qualitative interview study exploring the United Kingdom context
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BACKGROUND: Public engagement (PE) has become a common feature of many liberal governmental agendas worldwide. Since the turn of this century there has been a succession of United Kingdom policy initiatives to encourage research funding agencies, universities and researchers to reconsider how they engage with citizens and communities. Although most funding agencies now explicitly promote PE within research, little empirical work has been carried out in this area. In this study, we explored why and how health and medical research funding agencies in the United Kingdom have interpreted and implemented their role to promote PE within research. METHODS: Semi-structured interviews were carried out with 30 key informants from 10 agencies that fund health or medical research. Data were also gathered from agencies’ websites and documentation. The analysis was based on the constant comparative method. RESULTS: Across agencies, we found that PE was being interpreted and operationalised in various different ways. The terminology used within funding agencies to describe PE seems to be flexibly applied. Disciplinary differences were evident both in the terminology used to describe PE and the drivers for PE highlighted by participants – with applied health science funders more aligned with participatory models of PE. Within the grant funding process PE was rarely systematically treated as a key component of research. In particular, PE was not routinely incorporated into the planning of funding calls. PE was more likely to be considered in the application and assessment phases, where it was largely appraised as a tool for enhancing science. Concerns were expressed regarding how to monitor and evaluate PE within research. CONCLUSIONS: This study suggests funding agencies working within specific areas of health and medicine can promote particular definitions of PE and aligned practices which determine the boundaries in which researchers working in these areas understand and practice PE. Our study also highlights how the research grant process works to privilege particular conceptions of PE and its purpose. Tensions are evident between some funders’ core concepts of traditional science and PE, and they face challenges as they try to embed PE into long-standing systems that prioritise particular conceptions of ‘scientific excellence’ in research.
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Aging
Care-Delivery Interventions to Manage Agitation and Aggression in Dementia Nursing Home and Assisted Living Residents: A Systematic Review and Meta-analysis.
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OBJECTIVES: To evaluate the efficacy of nonpharmacological care-delivery interventions (staff training, care-delivery models, changes to the environment) to reduce and manage agitation and aggression in nursing home and assisted living residents. DESIGN: Three bibliographic databases, references of systematic reviews, ClincalTrials.gov, and the International Controlled Trials Registry Platform were systematically searched for randomized controlled trials reporting behavioral outcomes for nonpharmacological care-delivery interventions in nursing homes and assisted living facilities. Five investigators independently assessed study eligibility, extracted data, rated risk of bias, and graded strength of evidence. Inclusion was limited to studies with low to moderate risk of bias. SETTING: Nursing homes and assisted living facilities. PARTICIPANTS: Facility caregiving staff. MEASUREMENTS: Agitation, aggression, antipsychotic and other psychotropic use, general behavior. RESULTS: Nineteen unique studies met entry criteria, addressing several categories of facility caregiver training interventions: dementia care mapping (DCM; n = 3), person-centered care (PCC; n = 3), clinical protocols to reduce the use of antipsychotic and other psychotropic drugs (n = 3), and emotion-oriented care (n = 2). Eleven additional studies evaluated other unique interventions. Results were pooled for the effect of each type of intervention on agitation and aggression: DCM (standardized mean difference -0.12, 95% confidence interval (CI) = -0.66 to 0.42), PCC (standardized mean difference -0.15, 95% CI = -0.67 to 0.38), and protocols to reduce antipsychotic and other psychotropic use (Cohen-Mansfield Agitation Inventory mean difference -4.5, 95% C = -38.84 to 29.93). Strength of evidence was generally insufficient to draw conclusions regarding efficacy or comparative effectiveness. CONCLUSION: Evidence was insufficient regarding the efficacy of nonpharmacological care-delivery interventions to reduce agitation or aggression in nursing home and assisted living facility residents with dementia.
Sources of Discomfort in Persons with Dementia: Scale and Initial Results.
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The Sources of Discomfort Scale (SODS) assesses discomfort manifestations based on source of discomfort, thus making it both distinct from and complementary to pain assessments for persons with dementia. Sources were categorized as pertaining to physical discomfort, to body position, and to environmental sources. Body position sources of discomfort were related to poor functional status and to pain. The SODS scores were not related to cognitive functioning, and sources of discomfort other than those pertaining to body position were not correlated with pain. This paper demonstrates a direct and enhanced method to detect the manifestations of discomfort separately from pain indicators in a population with advanced dementia. The determination of the source of discomfort has direct implications for intervention.
End-of-life care in residential care homes: a retrospective study of the perspectives of family members using the VOICES questionnaire.
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BACKGROUND: In Europe, residential care homes (RCHs) are replacing hospitals as the place where death occurs, and they play an important role in end-of-life (EOL) care. OBJECTIVE: The aim was to describe the quality of care during the last 3 months and last 3 days of life of those who died in RCHs as reported by family members. We also investigated whether there were differences in the EOL care of younger patients (/=85 years) as reported by family members. DESIGN: A retrospective survey design. METHODS: Deaths (n = 189) at 19 RCHs in one municipality in Sweden were included. Family members were sent the VOICES questionnaire 1 month after their elderly relative had died. Descriptive statistics were used. RESULTS: In the last 3 days before death, most family members reported there was enough help with nursing (93%) and personal care (78.5%). Among the family members, 86% were told that the resident was likely to die shortly. Most (94.1%) of residents were reported to have died at their preferred place. No significant difference was found between age groups. Family members also reported that about half of the elderly had pain (46.5%) and 86.4% received treatment; 55.9% had breathlessness and 39.7% received treatment. Breathlessness was significantly (p = 0.01) more common in the younger group, and they were treated more often (p = 0.006) than the oldest old. CONCLUSION: This study revealed an overall positive picture of personal and nursing care and communication. These findings indicate that the quality of EOL care at RCHs is high. Inadequate management was found for symptom relief the last days of life. This suggests that this subject merits further attention by care professionals. To achieve better quality of EOL care at RCHs, we emphasise the importance of systematically working to improve symptom relief.
The impact of facility characteristics on the use of antipsychotic medications in nursing homes: a cross-sectional study.
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BACKGROUND: Antipsychotic medications (APMs) are commonly prescribed in nursing homes (NHs) and their excessive use raises concerns about the quality of care. They are often seen as “chemical restraints”, and were shown to increase morbidity and mortality risks in NH residents. The objective of this study was to investigate the variability in prevalence in APM use in a sample of Israeli NHs and to examine the effect of facility characteristics on the use of APMs. METHODS: A retrospective cross-sectional study was conducted in 2011 using data which were collected in a sample of NHs in the Tel Aviv district during the annual certification process. Prevalence of APMs was determined on the basis of all residents using antipsychotics on a regular basis. The association between facility characteristics and APM use was assessed by multivariate analysis. RESULTS: Forty-four NHs providing care for 2372 residents were investigated. The prevalence of APM use varied between facilities from 14.8 to 70.6 %, with an overall prevalence of 37.3 %. Multiple linear regression analysis revealed that greater use of APMs was associated with for-profit facilities, facilities in which most of the residents were self-pay, the presence of a “mentally frail” unit, a medical director non-specialized in geriatrics, shortage of social workers and occupational therapists, presence of unsafe/non-fitting equipment or self-aids (e.g., unsafe bath/toilet seats, unsuitable height of tables) and shortage of recreational activities. CONCLUSIONS: A wide variation in APM use was recorded in NHs in the Tel Aviv district. This variation was associated with facility characteristics that undermine quality of care. Application of APM use as a measure of quality in NHs and publicizing their utilization may decrease their overall use.
Recommendations on Physical Activity and Exercise for Older Adults Living in Long-Term Care Facilities: A Taskforce Report
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A taskforce, under the auspices of The International Association of Gerontology and Geriatrics-Global Aging Research Network (IAGG-GARN) and the IAGG European Region Clinical Section, composed of experts from the fields of exercise science and geriatrics, met in Toulouse, in December 2015, with the aim of establishing recommendations of physical activity and exercise for older adults living in long-term care facilities (LTCFs). Due to the high heterogeneity in terms of functional ability and cognitive function that characterizes older adults living in LTCFs, taskforce members established 2 sets of recommendations: recommendations for reducing sedentary behaviors for all LTCF residents and recommendations for defining specific, evidence-based guidelines for exercise training for subgroups of LTCF residents. To promote a successful implementation of recommendations, taskforce experts highlighted the importance of promoting residents’ motivation and pleasure, the key factors that can be increased when taking into account residents’ desires, preferences, beliefs, and attitudes toward physical activity and exercise. The importance of organizational factors related to LTCFs and health care systems were recognized by the experts. In conclusion, this taskforce report proposes standards for the elaboration of strategies to increase physical activity as well as to prescribe exercise programs for older adults living in LTCFs. This report should be used as a guide for professionals working in LTCF settings.
Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity
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To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. Design Retrospective cohort study. Setting Public Health System. Participants A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. Measurements Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. Results Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants’ time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. Conclusions This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED.
How people with dementia and their families decide about moving to a care home and support their needs: development of a decision aid, a qualitative study
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BACKGROUND: People with dementia and their relatives find decisions about the person with dementia living in a care home difficult. METHODS: We interviewed 20 people with dementia or family carers around the time of this decision in order to design a decision-aid. RESULTS: Decision-makers balanced the competing priorities of remaining somewhere familiar, family’s wish they remain at home, reduction of risk and effects on carer’s and person with dementia’s physical health. The person with dementia frequently resented their lack of autonomy as decisions about care home moves were made after insight and judgment were impaired. Family consultation usually helped carers but sometimes exacerbated tensions. Direct professional support was appreciated where it was available. There is a need for healthcare professionals to facilitate these conversations around decision-making and to include more than signposting to other organisations. CONCLUSIONS: There is a need for a healthcare professional facilitated decision-aid. This should detail what might change for the person with dementia and their carer, possible resources and alternatives and assist in facilitating discussion with the wider family; further research will develop and test a tool to facilitate decision making about place of care needs.
Longitudinal Changes in Nursing Home Resident-Reported Quality of Life: The Role of Facility Characteristics.
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Improving quality of nursing homes (NHs) is a major social priority, yet few studies examine the role of facility characteristics for residents’ quality of life (QOL). This study goes beyond cross-sectional analyses by examining the predictors of NH residents’ QOL on the facility level over time. We used three data sources, namely resident interviews using a multidimensional measure of QOL collected in all Medicaid-certified NHs in Minnesota (N = 369), resident clinical data from the minimum data set, and facility-level characteristics. We examined change in six QOL domains from 2007 to 2010, using random coefficient models. Eighty-one facilities improved across most domains and 85 facilities declined. Size, staffing levels (especially activities staff), and resident case mix are some of the most salient predictors of QOL over time, but predictors differ by facility performance status. Understanding the predictors of facility QOL over time can help identify facility characteristics most appropriate for targeting with policy and programmatic interventions.
This chapter of Women in Canada examines many aspects related to senior women in Canada including their socio-demographic characteristics, life expectancy, living arrangements, social participation, Internet use, health, assistance with daily living and leading causes of death, as well as economic characteristics including their labour force participation and income. The focus will be on recent patterns, with discussion of historical trends where appropriate, including selected analysis by ethnocultural diversity and geographic region.
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Events
Online
Patient-mediated knowledge translation (PKT) interventions for clinical encounters
Learning Objectives:
-Learn about a variety of approaches and strategies for engaging patients in their own health care
-Understand how those approaches and strategies have been employed for patients with arthritis or cancer
-Identify outcomes associated with these interventions
-Discuss gaps in knowledge that warrant further research
Mobilizing Knowledge to Improve Pediatric Health Care
We will present on work we have been involved in with a National Center of Excellence in Knowledge Mobilization called Translating Emergency Knowledge for Kids (TREKK). TREKK addresses an identified gap between “what we know and what we do” in the context of pediatric emergency care, particularly in the context of general emergency departments. The vision of TREKK is that every child receives the highest standard of care, whether they are treated in a pediatric or general emergency department. We will give an overview of the goals and purpose of TREKK; discuss the results of a national needs assessment we conducted to identify information needs and priorities; and, present strategies we developed to mobilize knowledge to healthcare providers and parents, including use of knowledge pyramids, social media, and electronic tools. We will close with reflections on our experience to date including factors that have helped us achieve our goals.
Facilitation: An Evidence-based Implementation Strategy
This CyberSeminar will present 1) an overview of an implementation facilitation strategy we applied at VA clinics identified as being unable to implement primary-care mental health integration without assistance; and 2) outcomes of our evaluation of the strategy utilizing both quantitative and qualitative methods.
This 3-year project was designed to increase the uptake of evidence-based end-of-life (EOL) care for elderly patients with advanced illness. It involved the development of quality indicators associated with primary care best practices and their integration within electronic medical records (EMR) and take-up by primary care physicians in British Columbia.
Care planning and Decision Making in Dementia: Controversies and Solutions
This presentation will use cases to outline some of the challenges to care planning and decision making for patients with dementia in addition to other complex health issues.
We will explore the unique needs of patients and their caregivers when dementia is present and how dementia and frailty interact to inform the decision making process.
Policy and Economic Considerations for Frailty Screening in the Canadian Health Care System
HealthCareCAN, in collaboration with the Canadian Frailty Network (CFN), is conducting a study of the policy and economic considerations for frailty screening in the Canadian healthcare system. Guided by an expert advisory committee, and based on interviews with key informants, the study aims to assess selected policy and economic considerations, both from within Canada and internationally, to be taken into account around frailty screening that will benefit patients, families and the broader health system
News
Seven Things Every Researcher Should Know About Scholarly Publishing
Almost all researchers have at least two regular, direct relationships with scholarly publishing: as authors, and as readers. Many also interact with scholarly publishing as reviewers or editors. But the multi-dimensional world of scholarly communications, of which publishing is just one part, affects so much more of what researchers do — how their work is funded, promoted, circulated, evaluated, and archived.
New Brunswick program aims to curb overuse of anti-psychotics in seniors
The New Brunswick government, in collaboration with Ottawa and the New Brunswick Association of Nursing Homes (NBANH), has launched a $1.1-million funding program aimed at curbing the number of anti-psychotics prescribed to seniors in a province with one of the highest rates of anti-psychotic use among the elderly.
The Health Care Workforce of the Future (US)
Health care entities are in the process of designing the organization and structure that supports population health management. We are striving to meet the Triple Aim: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. This is a big transition for the industry.
Long-distance caregivers of the elderly torn between two locations
When it comes to caring for her sister-in-law Bea, who at 62 has had Alzheimer’s for 14 years and lives alone, Janice Kraayenhof has tried to think of everything. She has had medications blister-packed to ensure her sister-in-law takes them as prescribed, organized Meals on Wheels to deliver dinners and arranged for safety assessments to be done at her home in Welland, Ont. She checks in regularly with her sister-in-law’s neighbour. And, like many Canadians, she’s doing all this at a distance: Ms. Kraayenhof, 54, lives 222 kilometres away from her sister-in-law.
Five Tips for Publishing Your QI Work
Quality improvement work isn’t done until you’ve shared it. So says Dr. Greg Ogrinc, a foremost expert in QI publishing, who helped establish the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines. Here are a few of Dr. Ogrinc’s tips for sharing (and doing) QI work.
Dear IHI: How Do I Give an Elevator Pitch on QI in Health Care?
I’m new in the quality department of my hospital, and when I see people in the cafeteria or the elevator, they often ask me to explain what I do or to ask if my team can help them with a clinical problem. I need an elevator pitch for QI and what my department does. What would you say to someone who’s only giving you two minutes of their attention? — NEED TO BE BRIEF
Why Are Some Academics So Unprofessional?
Calls go unreturned, emails are ignored. That’s the way business is conducted too often in higher education.
Does Ontario have too many under-regulated health workers?
In recent years, various health care professions have called for better regulation – including paramedics, personal support workers, physician assistants and others. Inadequate regulation has led to confusion that can put the public at risk, representatives of the professions say.
Resources
Alberta SPOR KT Platform is accepting applications from Alberta-based health science researchers for consultation in the areas of knowledge synthesis, knowledge translation and implementation science.
They are currently able to provide the following services:
-Methodological advice and/or specialized staff assistance for knowledge synthesis projects (e.g. meta-analyses, systematic reviews, scoping reviews, etc.);
-Guidance on writing end-of-project KT plans for grant applications;
-Assistance in designing research that incorporates principles related to integrated knowledge translation or implementation science;
-Assistance in designing research to develop and/or evaluate KT strategies and interventions
To find out more about these services, contact Dr. Meghan Sebastianski for knowledge synthesis consultations or Dr. Gabrielle Zimmermann for knowledge translation and implementation science consultations.
