Congratulations to Dr. Carole Estabrooks for being appointed as a Member in the Order of Canada!
The Order of Canada, established in 1967, is one of the country’s highest civilian honours and recognizes Canadians who have been high achievers in their fields, or have shown dedication or service to their community and country.
New TREC Newsletter available!
July 2016 Newsletter
Read the latest news from TREC.
New article by Heather Carleton, Stephanie Chamberlain, Will Bambrick, Dr. Greta Cummings & Dr. Carole Estabrooks
Burnout in the Nursing Home Health Care Aide: A Systematic Review
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Objective To systematically review the evidence on factors that influence burnout in health care aides working in nursing homes. Design Systematic literature review. Data Sources Two search engines (Google and EBSCO Discovery Service) and five databases (MEDLINE, Scopus, CINAHL, PsycINFO and Proquest Dissertations & Theses) through to August 2013. Keywords: nursing home, health care aide and burnout (all synonyms were included). Methods Two authors independently assessed methodological quality, data extraction, analysis and synthesis on the 10 included publications. 100% reliability was found between the first and second authors. Data extracted included precipitating and buffering factors related to burnout, interventions and demographic information for the health care aide population. Data were synthesized according to individual and organizational factors. Results Our search and screening yielded 2787 titles and abstracts resulting in 83 manuscripts for full manuscript review and 10 included publications. Methodological quality assessments revealed 3 (30%) rated as low quality, 7 (70%) rated as medium quality. Independent variables were categorized as either individual or organizational factors. Methodological problems and heterogeneity in independent and dependant variables yielded few significant results. Only personal life (attributes of provider) was found to significantly buffer burnout (depersonalization, emotional exhaustion and personal accomplishment). Equivocal evidence was found for many of the organizational factors (work environment, workload and facility) supporting the need for further robust studies in this field. Of the two intervention studies, only dementia care mapping, and training in organizational respect buffered burnout. Conclusion Factors associated with burnout in health care aides are similar to those reported among nurses, although the level of evidence and low methodological rigor of these studies suggest more robust study designs are warranted. Our findings suggest research focused on this important but largely invisible group of care providers could yield important advances in understanding burnout in this group and yield potential interventions to buffer burnout and its consequences. Without mitigating the effects of burnout on nursing home health care aides, vulnerable older adults in residential care are at risk.
OBJECTIVES: Research into the lived experiences of long-term care residents with dementia has identified perceived conflict, and its impact on sadness, as priorities for quality of life from the perspectives of people with dementia. However, whether and to what extent perceived conflict and sadness are associated has not been previously tested in this population. This study tested the associations between perceived conflicts with staff, family or friends and co-residents and their experience of sadness, and whether cognitive impairment or functional dependence modified these associations. METHODS: The study design was cross-sectional, correlational retrospective. Participants were 5001 residents of 613 long-term care facilities in Ontario, Canada with moderate and severe dementia. Clinical administrative data collected from 2012 to 2013 using the Resident Assessment Instrument 2.0 were used to measure the person’s perception of conflicts with family/friends, staff, or co-residents, as well as verbal and non-verbal indicators of sadness. Hypotheses were tested using logistic regression, with cluster correction. RESULTS: Sadness (adjusting for age, sex, family/friend contact, pain, cognitive impairment, and functional dependence) was positively associated with perceived conflicts with family or friends (OR 1.91; 95% CI 1.26-2.88; p = 0.002) and staff (OR 1.51; 95% CI 1.07-2.13; p = 0.020). These associations did not differ depending on the level of cognitive impairment or functional dependence. The association between co-resident conflict and sadness was statistically significant for people with moderate (OR 2.02; 95% CI 1.45-2.82; p < 0.001) but not for those with severe dementia (OR 1.18; 95% CI 0.72-1.91; p = 0.511). CONCLUSION: Long-term care residents with dementia who perceive conflict with others require support to maintain high quality relationships, particularly with family and friends. Future research should rigorously assess the modifiability of perceived conflict for people with moderate and severe dementia, and whether interventions to ameliorate perceived conflict result in decreased sadness and improved quality of life.
Objectives: Nursing home (NH) residents are a frail and vulnerable population often faced with iatrogenic effects of hospital stays when transferred to emergency departments for acute changes in health status. Avoidable or unnecessary transfers of care need to be identified and defined to prevent unintended harm. The aim of this scoping review was to identify characteristics of avoidable or unnecessary transitions of NH residents to emergency departments, and examine factors influencing decision-making by NH staff, residents, and their family members to transfer nursing home residents to emergency departments. Methods: The search strategy began with 5 electronic databases, and a hand search of gray literature. Published qualitative and quantitative studies were included that examined the definition of avoidable or unnecessary transfers, and/or reported factors associated with decision-making to transfer NH residents to emergency departments. Methods included quality assessments, data extraction, and synthesis using content analysis. Results: A total of 783 titles and abstracts were retrieved and screened resulting in 19 included studies. Results describing “avoidable” or “unnecessary” transfers were grouped into 3 dimensions of factors: management of early-acute or low-acuity symptoms and chronic disease management in NHs, ambulatory care–sensitive indicators, and use of post hoc assessments. Five categories of factors contributing to decision-making to transfer were identified: nursing factors, physician factors, facility/resource factors, NH resident/family factors, and health system factors. A consensus on the definition of “avoidable” or “unnecessary” transfers was not found. Conclusion: Findings suggest that transfers of NH residents to emergency departments may be avoided with increased care capacity within NHs. The decision-making process involved in the transfer is influenced by many factors, with intentions of both improving clinical outcomes and maintaining quality of life for the NH resident. Acute changes in health status are contextually specific and decisions must consider not only the resident’s acute condition, but also resources available in the NH, and resident and family members’ preferences for care. A definition of “avoidable” or “unnecessary” transfer must include reliable measurement, yet remain flexible enough to be generalizable to various care facilities to meet the needs of NH residents and manage required care safely within the NH. Robust research aimed at improving the primary care of NH residents is essential to informing health policy reform and education of those providing care in NHs.
New article by Dr. Joanne Profetto-McGrath
Physical comorbidities increase the risk of psychiatric comorbidity in multiple sclerosis
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Background Risk factors for psychiatric comorbidity in multiple sclerosis (MS) are poorly understood. Objective We evaluated the association between physical comorbidity and incident depression, anxiety disorder, and bipolar disorder in a MS population relative to a matched general population cohort. Methods Using population-based administrative data from Alberta, Canada we identified 9624 persons with MS, and 41,194 matches. Using validated case definitions, we estimated the incidence of depression, anxiety disorder, and bipolar disorder, and their association with physical comorbidities using Cox regression, adjusting for age, sex, socioeconomic status, and index year. Results In both populations, men had a lower risk of depression and anxiety disorders than women, as did individuals who were ?45 years versus <45 years at the index date. The risk of bipolar disorder declined with increasing age. The risks of incident depression (HR 1.92; 1.82?2.04), anxiety disorders (HR 1.52; 1.42?1.63), and bipolar disorder (HR 2.67; 2.29?3.11) were higher in the MS population than the matched population. These associations persisted essentially unchanged after adjustment for covariates including physical comorbidities. Multiple physical comorbidities were associated with psychiatric disorders in both populations. Conclusion Persons with MS are at increased risk of psychiatric comorbidity generally, and some physical comorbidities are associated with additional risk.
Background: Emerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process. Aims: To describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people. Methods: Semistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs. Results: This study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: “realising commitment” “negotiating conditions” and “encouragement to keep momentum going.” The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the “building of a bridge” emerged as one way of understanding the findings. Linking Evidence to Action: Our findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved.
Calls for Abstracts
CALL FOR ABSTRACTS:
9th Annual Conference on the Science of Dissemination and Implementation
The abstract solicitation and conference structure have been designed to focus our thinking and discussion on the highest priorities for dissemination and implementation science now and in the future to help optimize health and health care in the US and elsewhere. Given the breadth of the field and the importance of maximizing opportunities for participants to follow consistent themes throughout the concurrent sessions of the meeting, we are including nine thematic tracks to organize the conference agenda.
Grants & Awards
Amount of funding is dependent on: audience size and reach; scope of activity; alignment to the mandate of Alberta Innovates – Health Solutions (AIHS); funding from other sources; other competing requests received; and anticipated impact of the proposed activity. Applications will be accepted four times a year: April, July, October and January (based upon availability of funds). Support will not be provided for activities occurring prior to, or within 2 months following, the competition deadline.
The CIHR Doctoral Research Awards consist of two programs administered through a single application: 1) The Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Awards (CGS-D) program provides special recognition and support to students who are pursuing a doctoral degree in a health-related field in Canada. Canada Graduate Scholarship recipients may be considered for the honour of having their scholarship named a “Canada Graduate Scholarship to Honour Nelson Mandela”. To be considered for this honour, you must complete the Canada Graduate Scholarship to Honour Nelson Mandela Identification Form. 2) The Doctoral Foreign Study Award (DFSA) provides special recognition and support to students who are pursuing a doctoral degree in a health-related field abroad.
Priority Announcements on Doctoral Research Award competitions offer additional sources of funding for highly rated applications that are relevant to specific CIHR research priority areas or mandates. Applications are submitted through the “201610MDR” competition of the Doctoral Research Award: 2016-2017 funding opportunity. Doctoral Research Awards are intended to provide special recognition and support to students who are pursuing a PhD degree in a health-related field in Canada or abroad. These candidates are expected to have an exceptionally high potential for future research achievement and productivity.
Fellowships provide support for highly qualified applicants in all areas of health research at the post-PhD degree or post-health professional degree stages to add to their experience by engaging in health research either in Canada or abroad.
AIMS: To gather, assess and synthesise the currently available evidence of educational interventions on evidence-based nursing (EBN). BACKGROUND: Previous systematic reviews have focused on the items used in reporting educational interventions for facilitating evidence-based practices in medicine and health care or teaching research literacy in nursing as well as on the outcomes of these interventions. DESIGN: A systematic review based on a procedure of the Centre for Reviews and Disseminations for conducting a systematic review of health interventions. DATA SOURCES AND METHODS: Texts from 2008 to 2015 were sought from the Cochrane, CINAHL and PubMed Medline databases. Eight studies were selected for the final data and reviewed for quality. Data were analysed with narrative synthesis including qualitative content analysis. RESULTS: Four main categories and sixteen subcategories were identified. The learning contents included principles of EBN and research, the process of EBN, and planning a change in practice. The most popular teaching/learning methods were lectures/didactic presentations and group work. The interventions encouraged learners to critically examine and evaluate their practice. The interventions also improved participants’ capacity to identify the need for research evidence in clinical practice. CONCLUSION: The educational interventions were fairly similar and had promising results. However, as the level of evidence was modest in the studies, there are several development needs for interventions and further research challenges. Interventions should provide participants with sufficient competences for implementing every step of EBN, with special focus on the implementation of evidence in patient care. The assessment of the outcomes of interventions should cover all learning categories of EBN with focus on medium to long-term effectiveness. The influence of different teaching/learning methods and learning contexts and settings should be investigated further.
BACKGROUND: Nationwide implementation of guaranteed access to evidence-based rehabilitation was established in Sweden in 2009, through an Act of the Swedish Government. The rehabilitation guarantee’s primary goal was to increase the rate of return-to-work, reduce and prevent long-term absenteeism after diagnoses related to back pain and common mental health problems. This study aims to develop knowledge about factors influencing large-scale implementation of complex and extensive interventions in healthcare settings. METHODS: Three different data sources questionnaires, interviews and documents were used in data collection and analysis. The data were analysed using iterative thematic analysis. RESULTS: The following main facilitators contributed to realization of the rehabilitation guarantee: financial incentives, establishment of project organization, recruitment, in-service training and previous experiences of working in similar projects. Barriers were: the rehabilitation guarantee’s short-term project-form, clinicians’ attitudes to and competence in working towards return-to-work, lack of guidelines describing treatment modalities in multimodal rehabilitation, and lack of well-defined criteria for inclusion of patients. Documents revealed that the return-to-work goal became less pronounced during the implementation process. Instead, care and health were more often described in documents used to disseminate information about the rehabilitation guarantee. Intermediate outcomes found were: patients with rehabilitation needs were given more adequate priority, increased readiness for future implementation efforts, and increased general competence in psychotherapy, and team-work, which thus became available to patient groups other than those covered by the rehabilitation guarantee. CONCLUSIONS: To facilitate implementation of established national policy goals in clinical practice, tools are needed that specifically aim at changing clinicians’ attitudes and behaviours in relation to such goals. Our results underline the importance of investing both time and sufficient resources in the activities and in supporting the implementation process.
Implementation science is the scientific study of the methods to promote the uptake of research findings into routine healthcare in clinical, organisational, or policy contexts. The presence of gaps between knowledge and practice is well documented and a range of strategies is available to overcome these gaps. To optimize their impact, it is recommended that implementation strategies are tailored to the target population, setting and goals for improvement. Themes for future research in the field are: implementation of personalized medicine, the economics of implementation, knowledge implementation in various health professions, patient involvement in implementation, and a better understanding of the determinants of implementation. Addressing these challenges requires dedicated training programs, research funding, and networks for effective collaboration with stakeholders in healthcare.
BACKGROUND: A knowledge translation (KT) planning template is a roadmap laying out the core elements to be considered when structuring the implementation of KT activities by researchers and practitioners. Since 2010, the Institut national de sante publique du Quebec (INSPQ; Quebec Public Health Institute) has provided tools and guidance to in-house project teams to help them develop KT plans. This study sought to identify the dimensions included in those plans and which ones were integrated and how. The results will be of interest to funding agencies and scientific organizations that provide frameworks for KT planning. METHODS: The operationalization of KT planning dimensions was assessed in a mixed methods case study of 14 projects developed at the INSPQ between 2010 and 2013. All plans were assessed (rated) using an analytical tool developed for this study and data from interviews with the planning coordinators. The analytical tool and interview guide were based on eight core KT dimensions identified in the literature. RESULTS: Analysis of the plans and interviews revealed that the dimensions best integrated into the KT plans were ‘analysis of the context (barriers and facilitators) and of users’ needs’, ‘knowledge to be translated’, ‘KT partners’, ‘KT strategies’ and, to a lesser extent, ‘overall KT approach’. The least well integrated dimensions were ‘knowledge about knowledge users’, ‘KT process evaluation’ and ‘resources’. CONCLUSIONS: While the planning coordinators asserted that a plan did not need to include all the dimensions to ensure its quality and success, nevertheless the dimensions that received less attention might have been better incorporated if they had been supported with more instruments related to those dimensions and sustained methodological guidance. Overall, KT planning templates appear to be an appreciated mechanism for supporting KT reflexive practices. Based on this study and our experience, we recommend using KT plans cautiously when assessing project efficacy and funding.
BACKGROUND: This study was conducted in the context of a randomized controlled trial where occupational therapists (OTs) in collaboration with researchers implemented a client-centred activity of daily living intervention (CADL) for persons with stroke. OBJECTIVE: The aim was to identify and describe over time the OTs’ experiences regarding the collaboration with the researcher in their role as implementers of a new complex intervention. METHOD: Focus group interviews were conducted with 33 OTs, two, six and 12 months after they had participated in a five-day workshop. The interviews were analysed using a grounded theory approach. RESULTS: Three categories were identified: (1) Including in the scientific world, (2) Involving as an implementer of science and (3) Integrating in a partnership. One core category emerged: The implementation of client-centred intervention enabled the fusion of practice and science. An increased experience of using CADL and support from the researchers changed the OTs’ attitudes towards engaging in research from being an outsider to the scientific world to being included and then becoming a part of the research as an implementer of science. CONCLUSIONS: To create a context built on a collaborative partnership between practitioners and researchers enabled the fusion of practice and science.
Management of pain in the frail elderly presents many challenges in both assessment and treatment, due to the presence of multiple co-morbidities, polypharmacy, and cognitive impairment. At Baycrest Health Sciences, a geriatric care centre, pain in its acute care unit had been managed through consultations with the pain team on a case-by-case basis. In an intervention informed by knowledge translation (KT), the pain specialists integrated within the social network of the acute care team for 6 months to disseminate their expertise. A survey was administered to staff on the unit before and after the intervention of the pain team to understand staff perceptions of pain management. Pre- and post-comparisons of the survey responses were analysed by using t-tests. This study provided some evidence for the success of this interprofessional education initiative through changes in staff confidence with respect to pain management. It also showed that embedding the pain team into the acute care team supported the KT process as an effective method of interprofessional team building. Incorporating the pain team into the acute care unit to provide training and ongoing decision support was a feasible strategy for KT and could be replicated in other clinical settings.
Given all the available knowledge about effective implementation, why do many organizations continue to have-or appear to have-an implementation problem? Analysis of a 7-year corpus of reports by a Canadian health region’s “embedded” research and evaluation unit sought to discover the source of the region’s intractable difficulty implementing improvement. Findings suggested that the problem was neither a lack of knowledge (decision-makers displayed sophisticated understanding of fundamental issues) nor an inability to take action (there existed sufficient capacity to implement change). However, managers’ high-level knowledge was not made actionable, and micro-level decision-making often produced piecemeal actions inadequately informed by existing knowledge. The problem arose at the stage of “operationalization”-the identification of concrete, executable actions fully informed by knowledge of complex, system-level issues. Yet this crucial phase is a focus of neither the implementation nor knowledge translation (KT) literatures. The organizational decision-making literature reveals how decision-makers initiate operationalization (i.e., by setting the direction for a discovery approach) but not how they can ensure its successful completion. The focus of KT research and practice should expand to explicating and improving decision-making, lest KT become an exercise of infusing content into a broken process.
Obtaining new knowledge accepted and used by practitioners remains a slow process. A dearth of knowledge translation research exists that explores how to effectively move knowledge to practice in the field of older adult mental health. The current article reports findings of a knowledge translation study that examined what factors enabled the adoption of a new clinical assessment framework, P.I.E.C.E.S., into practice in an older adult tertiary mental health unit. Theoretical insights of appreciative inquiry were used to guide the study. Qualitative methods were used, including focus groups with 20 staff and individual interviews with three leaders. The appreciative inquiry approach helped researchers successfully facilitate knowledge translation. Enabling factors included: (a) fostering positive energy to make continuous improvement, (b) working with team members across disciplines at all levels, and (c) using knowledge translation tools to enable and sustain the new practice.
Health Care Administration and Organization
OBJECTIVES: Previous research has indicated that staff in aged residential care (ARC) may be unprepared for their role in palliative care provision. The need for palliative care knowledge among ARC staff has been characterised as ‘pervasive’. Determining the palliative care education, communication and support needs of ARC clinical care staff is, therefore, of critical importance to the delivery of quality healthcare in this setting. METHODS: A survey of clinical staff (n=431) in 52 ARC facilities in 1 urban district health board was conducted, using a paper-based questionnaire. Instruments included the 3-item Experiences with End of Life scale, developed measures of communication and support (13 items), support accessibility (12 items), and palliative care education (19 items). RESULTS: Only 199 (46.2%) of staff participants reported undertaking palliative care education. Nurses were more likely to have engaged in palliative care education in comparison with healthcare assistants (HCAs) (chi2(1, N=387)=18.10, p=0.00). Participants (n=347) who wanted further education preferred an interactive, hands-on applied education (13.9%) in comparison to short topic-specific sessions/seminars (6.5%) or lecture-based courses (7.7%). CONCLUSIONS: The study reveals an ongoing need for staff palliative care education. Results suggest the development of an integrated model of care which draws on both hospice and ARC staff expertise.
BACKGROUND: The delivery of end-of-life care in nursing homes is challenging. This situation is of concern as 20% of the population die in this setting. Commonly reported reasons include limited access to medical care, inadequate clinical leadership and poor communication between nursing home and medical staff. Education for nursing home staff is suggested as the most important way of overcoming these obstacles. OBJECTIVES: To identify educational interventions to enhance end-of-life care for nursing home staff and to identify types of study designs and outcomes to indicate success and benchmark interventions against recent international guidelines for education for palliative and end-of-life care. DESIGN: Thirteen databases and reference lists of key journals were searched from the inception of each up to September 2014. Included studies were appraised for quality and data were synthesised thematically. RESULTS: Twenty-one studies were reviewed. Methodological quality was poor. Education was not of a standard that could be expected to alter clinical behaviour and was evaluated mainly from the perspectives of staff: self-reported increase in knowledge, skills and confidence delivering care rather than direct evidence of impact on clinical practice and patient outcomes. Follow-up was often short term, and despite sound economic arguments for delivering effective end-of-life care to reduce burden on the health service, no economic analyses were reported. CONCLUSIONS: There is a clear and urgent need to design educational interventions that have the potential to improve end-of-life care in nursing homes. Robust evaluation of these interventions should include impact on residents, families and staff and include economic analysis.
BACKGROUND: There has been continuing change in the nature of care homes in the UK with 80 % of residents now living with some form of dementia or memory problem. Caring in this environment can be complex, challenging and stressful for staff; this can affect the quality of care provided to residents, lead to staff strain and burnout, and increase sickness, absence and turnover rates. It is therefore important to find interventions to increase the wellbeing of staff that will not only benefit staff themselves but also residents and care providers. Mindfulness training is known to be effective in treating a variety of physical and mental health conditions. METHODS AND DESIGN: The study uses mixed methods centred on a stepped-wedge cluster randomised trial. Thirty care homes in Wales are implementing a brief web-based mindfulness training course, starting in random sequence. Four to ten consenting staff from each facility undertake the course and complete validated questionnaires at baseline and after eight and 20 weeks. We shall also interview a stratified sample of ten trained staff and analyse the transcripts thematically. The primary outcome is stress; secondary outcomes include job satisfaction, attitudes towards residents and sickness absence rates. DISCUSSION: With increasing numbers of people living with dementia in care homes and causing stress in their carers, it is important to evaluate support strategies for staff. Mindfulness-based therapies may be of potential benefit and need detailed examination. TRIAL REGISTRATION: ISRCTN registry. ISRCTN80487202. Registered 24 July 2013.
Certified nursing assistants (CNAs) provide most direct care in nursing homes, and they often experience daily life stressors and exposure to trauma. Adverse reactions to trauma can influence interpersonal relationships. In formal caregiving, the highest quality care is provided by those who are able to sustain a life-giving relationship, characterized by connection, genuine care, competence, and professional distance. The study described here examined a hypothesized relationship among demographics, the experience of potentially traumatic life events, and CNAs’ caregiving behaviors. CNAs in this study had high rates of lifetime exposure to various potentially traumatic events. No relationship was found with caregiving behaviors because of a lack of variability on the caregiving instrument. The most important finding was the confirmation that CNAs are at risk for and do experience many potentially traumatic events. Given the effect that trauma can have on relationships, and the nature of their interactions with vulnerable nursing home residents, it is important to consider the ways that nursing homes can provide support to CNAs to allow them to create meaningful relationships with residents.
Health Care Innovation and Quality Assurance
Ensuring that people living in nursing homes (NHs) are afforded with dignity in their daily lives is an essential and humane concern. Promoting dignity-conserving care is fundamentally important. By nature, however, this care is all-encompassing and holistic, and from current knowledge it is challenging to create explicit strategies for measuring dignity-conserving care. In practice the majority of current NH indicators of quality care are derived from information that is routinely collected on NH residents using the RAI-Minimum Data Set (MDS). In this regard, issues that are more tangible to resident dignity such as being treated with respect, compassion, and having opportunities to engage with others are not adequately captured in current NH quality of care indicators. An initial set of markers was created by conducting an integrative literature review of existing markers and indicators of dignity in the NH setting. A modified Delphi process was used to prioritize essential dignity-conserving care markers for use by NH providers, based on factors such as the importance to fostering a culture of dignity, the impact it may have on the residents, and how achievable it is in practice. Through this consensus building technique, we were able to develop a comprehensive set of markers that capture the range and diversity of important dignity-conserving care strategies for use in NHs. The final 10 markers were judged as having high face validity by experts in the field and have explicit implications for enhancing the provision of daily dignified care to NH residents. These markers make an important addition to the traditional quality indicators used in the NH setting and as such, bridge an important gap in addressing the psychosocial and the less easily quantified needs of NH residents.
This article presents the findings of a pre-test, post-test quality improvement project that describes the change in knowledge from prior to and following an evidence-based education presentation. The presentation addressed the clinical symptoms, diagnostic processes, interventions, and responsibilities of licensed and unlicensed health care workers employed in long-term care facilities related to prevention and detection of non-catheter-related urinary tract infections. Results indicate that the education presentation improved knowledge in specific.
BACKGROUND: Hospital avoidance programmes aim to reduce the number of emergency transfers from nursing homes to hospitals and facilitate early discharge for hospitalised residents. Nursing staff are at the forefront of these efforts, yet little is known about how the programmes affect them and their management of the deteriorating resident. This information is needed to inform hospital avoidance programmes and better understand their work. AIM: To examine nursing home nursing staff perceptions regarding their management of the deteriorating resident after the introduction of a hospital avoidance programme. METHODS: A thematic analysis was conducted of focus group data collected from nursing staff 14 to 15 months after the introduction of a pilot hospital avoidance programme at an Australian nursing home. FINDINGS: The programme was well received and filled a gap in nursing staff management of residents with deteriorating health by providing structure and support. Staff were more confident and focused on this area of their work. Nursing assistants felt more integrated into the system and were supported and learning from nurses. Workload remained heavy and there was a shift in how time was allocated, but nursing staff preferred to keep residents at the facility. CONCLUSION: Nursing staff welcomed the programme and benefitted from its implementation. However, strategies must be explored to accommodate the staffing needs associated with providing emergency and subacute care in the nursing home setting.
OBJECTIVE: We report on a skilled nursing facility (SNF) that added designated heart failure (HF) beds and created a patient registry to track the number and reasons for rehospitalization. BACKGROUND: Targeting the reduction of rehospitalizations from SNFs is an important goal and patients with HF are particularly vulnerable for rehospitalizations as HF disease management programs in SNFs are rare. METHODS: A case study of a local quality improvement initiative. RESULTS: The data from the registry revealed, that compared to patients without HF, patients with HF were more often rehospitalized for cardiopulmonary symptoms and less often for infection. In addition, patients with HF were most often rehospitalized during the first 7 days of their SNF stay and if they had a primary hospital discharge diagnosis of HF. CONCLUSION: We highlight the benefits of a patient registry to guide future quality improvement initiatives to reduce patient rehospitalization rates.
OBJECTIVES: To assess the effects of elder-clowning on moderate to severe behavioral and psychological symptoms of dementia (BPSD) in nursing home residents with dementia, primarily of the Alzheimer’s type. DESIGN: Before-and-after study. SETTING: Nursing home. PARTICIPANTS: Nursing home residents with moderate to severe BPSD, as defined according to a Neuropsychiatric Inventory-Nursing Home version (NPI-NH) score of 10 or greater (N = 23), and their care aides. INTERVENTION: A pair of elder-clowns visited all residents twice weekly (~10 minutes per visit) for 12 weeks. They used improvisation, humor, empathy, and expressive modalities such as song, musical instruments, and dance to individualize resident engagement. MEASUREMENTS: Primary outcomes were BPSD measured using the the NPI-NH, quality of life measured using Dementia Care Mapping (DCM), and nursing burden of care measured using the Modified Nursing Care Assessment Scale (M-NCAS). Secondary outcomes were occupational disruptiveness measured using the NPI-NH, agitation measured using the Cohen Mansfield Agitation Inventory (CMAI), and psychiatric medication use. RESULTS: Over 12 weeks, NPI-NH scores declined significantly (t22 = -2.68, P = .01), and DCM quality-of-life scores improved significantly (F1,50 = 23.09, P < .001). CMAI agitation scores decreased nominally, but the difference was not statistically significant (t22 = -1.86, P = .07). Occupational disruptiveness score significantly improved (t22 = -2.58, P = .02), but there was no appreciable change in M-NCAS scores of staff burden of care. CONCLUSION: Results suggest that elder-clowning reduced moderate to severe BPSD of nursing home residents with dementia, primarily of the Alzheimer’s type. Elder-clowning is a promising intervention that may improve Alzheimer’s disease care for nursing home residents.
Each year in the United States, 31% of elders who die do so in hospitals, accounting for over half a million deaths often involving expensive and unnecessary treatments (Zhao & Encinosa, 2010 ). Re-hospitalizations of frail elders with end-stage illnesses are a concern for the hospitals that have discharged them and for the facilities in which they live. In 2011, Schervier Nursing Care Center, a 364-bed skilled nursing and rehabilitation facility in the Bronx, NY, looked at its re-hospitalization rates. It was discovered that a large percentage of the residents being sent to the hospital were from the long-term and subacute populations with end-stage diseases that were no longer responding to treatment. This article describes the development of two innovative programs whose goals were to increase the number of residents receiving palliative care, increase the number of completed advance directives, reduce re-hospitalizations, and increase hospital referrals to the nursing home for palliative care. The key components of both programs and their outcomes are described. The development and implementation of these programs were the author’s capstone project for the Zelda Foster Social Work Leadership Fellowship in Palliative and End-of-Life Care.
BACKGROUND: To produce a practice guideline that includes a set of detailed consensus principles regarding the prescription of antipsychotics (APs) amongst people with dementia living in care homes. METHODS: We used a modified Delphi consensus procedure with three rounds, where we actively specified and optimized statements throughout the process, utilizing input from four focus groups, carried out in UK, Norway, and the Netherlands. This was done to identify relevant themes and a set of statement that experts agreed upon using the Research and Development/University of California at Los Angeles (RAND/UCLA) methodology. RESULTS: A total of 72 scientific and clinical experts and 14 consumer experts reached consensus upon 150 statements covering five themes: (1) General prescription stipulations, (2) assessments prior to prescription, (3) care and treatment plan, (4) discontinuation, and (5) long-term treatment. CONCLUSIONS: In this practice guideline, novel information was provided about detailed indication and thresholds of symptoms, risk factors, circumstances at which APs should be stopped or tapered, specific criteria for justifying long-term treatment, involvement of the multidisciplinary team, and family caregiver in the process of prescription. The practice guideline is based on formal consensus of clinicians and consumer experts and provides clinicians relevant practical information that is lacking in current guidelines.
Evaluating the effectiveness and cost-effectiveness of Dementia Care Mapping to enable person-centred care for people with dementia and their carers (DCM-EPIC) in care homes: study protocol for a randomised controlled trial
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BACKGROUND: Up to 90 % of people living with dementia in care homes experience one or more behaviours that staff may describe as challenging to support (BSC). Of these agitation is the most common and difficult to manage. The presence of agitation is associated with fewer visits from relatives, poorer quality of life and social isolation. It is recommended that agitation is treated through psychosocial interventions. Dementia Care Mapping (DCM) is an established, widely used observational tool and practice development cycle, for ensuring a systematic approach to providing person-centred care. There is a body of practice-based literature and experience to suggests that DCM is potentially effective but limited robust evidence for its effectiveness, and no examination of its cost-effectiveness, as a UK health care intervention. Therefore, a definitive randomised controlled trial (RCT) of DCM in the UK is urgently needed. METHODS/DESIGN: A pragmatic, multi-centre, cluster-randomised controlled trial of Dementia Care Mapping (DCM) plus Usual Care (UC) versus UC alone, where UC is the normal care delivered within the care home following a minimum level of dementia awareness training. The trial will take place in residential, nursing and dementia-specialist care homes across West Yorkshire, Oxfordshire and London, with residents with dementia. A random sample of 50 care homes will be selected within which a minimum of 750 residents will be registered. Care homes will be randomised in an allocation ratio of 3:2 to receive either intervention or control. Outcome measures will be obtained at 6 and 16 months following randomisation. The primary outcome is agitation as measured by the Cohen-Mansfield Agitation Inventory, at 16 months post randomisation. Key secondary outcomes are other BSC and quality of life. There will be an integral cost-effectiveness analysis and a process evaluation. DISCUSSION: The protocol was refined following a pilot of trial procedures. Changes include replacement of a questionnaire, whose wording caused some residents distress, to an adapted version specifically designed for use in care homes, a change to the randomisation stratification factors, adaption in how the staff measures are collected to encourage greater compliance, and additional reminders to intervention homes of when mapping cycles are due, via text message. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82288852 . Registered on 16 January 2014. Full protocol version and date: v7.1: 18 December 2015.
The long-term care sector is characterized by high morbidity and employee turnover, along with associated costs. Effective health protection and health promotion are important to improve physical and psychosocial well-being of caregivers. Assessment of organizational readiness for change is an essential precursor to the successful implementation of workplace programs addressing work climate, structure of tasks and relationships, and other issues that may be perceived as challenging by some within the institution. This study qualitatively assessed readiness of five skilled nursing facilities for a participatory occupational health/health promotion intervention. Selection criteria were developed to screen for program feasibility and ability to conduct prospective evaluations, and information was collected from managers and employees (interviews and focus groups). Three centers were selected for the program, and the first year of formative evaluation and intervention experience was then reviewed to evaluate and modify our selection criteria after the fact. Lessons learned include adding assessment of communication and the structure of problem solving to our selection criteria, improving methods to assess management support in a concrete (potentially nonverbal) form, and obtaining a stated financial commitment and resources to enable the team to function. Assessment of organizational readiness for change is challenging, although necessary to implement effective and sustainable health promotion programs in specific organizations.
Research Practice and Methodology
As compassion has become established in the organizational literature as an important area of study, calls for increased compassion in our own work and research have increased. Compassion can take many forms in academic work, but in this article we propose a framework for compassionate research methods. Not only driven by caring for others and a desire for improving their lot, compassionate research methods actually immerse the researcher in compassionate work. We propose that compassionate research methods include three important elements: ethnography, aesthetics, and emotionality. Together, these provide opportunities for emergent theoretical experimentation that can lead to both the alleviation of suffering in the immediate research context and new theoretical insights. To show the possibilities of this method, we use empirical data from a unique setting—the first U.S. permanent death penalty defense team.
AIM: This article presents key ethical challenges that were encountered when conducting a participatory qualitative research project with a very specific, small group of nurses, in this case with practice development nurses in Malta. BACKGROUND: With the small number of nurses employed in practice development roles in Malta, there are numerous difficulties of maintaining confidentiality. Poorly constructed interventions by the researcher could have resulted in detrimental effects to research participants and the overall trustworthiness of the research. Generally, ethical guidelines for research exist to reinforce validity of research; however, there is not an established consensus on how these strategies can be utilised in some types of qualitative field work. RESEARCH DESIGN: The researcher used an exploratory case study methodology. The sample consisted of 10 participants who were interviewed twice using face-to-face interviews, over a period of 2 months. ETHICAL CONSIDERATIONS: The study was ethically reviewed by the University Research Ethics Committee and the Faculty Research Ethics Committee, University of Malta. The participants referred to in this article have been given adequate information about the study and their consent has been obtained. DISCUSSION: Numerous strategies for ensuring confidentiality during recruitment of the participants, during data collection, during transcription and data analysis and during dissemination of research results assisted the researcher in responding to potential and actual ethical issues. CONCLUSION: This article emphasises the main strategies that can be used to respond to ethical challenges when researching with a small easily identifiable group. The learning discussed here may be relevant to or even transferable to other similar research studies or research contexts. These methods fostered a greater credibility throughout the research process and predisposed the participants to greater trust, and thus, they disclosed their experiences and speak more freely, thus enhancing the quality of the study.
BACKGROUND: The increase in medical ethical regulations and bureaucracy handled by institutional review boards and healthcare institutions puts the researchers using qualitative methods in a challenging position. METHOD: Based on three different cases from three different research studies, the article explores and discusses research ethical dilemmas. OBJECTIVES AND ETHICAL CONSIDERATIONS: First, and especially, the article addresses the challenges for gatekeepers who influence the informant’s decisions to participate in research. Second, the article addresses the challenges in following research ethical guidelines related to informed consent and doing no harm. Third, the article argues for the importance of having research ethical guidelines and review boards to question and discuss the possible ethical dilemmas that occur in qualitative research. DISCUSSION AND CONCLUSION: Research ethics must be understood in qualitative research as relational, situational, and emerging. That is, that focus on ethical issues and dilemmas has to be paid attention on the spot and not only at the desktop.
AIM: The aim of this study was to discuss: (1) how methodologies are constructed and perpetuated in the context of research paradigms; (2) what exactly constitutes a paradigm; (3) how the proposed conceptual map of discourse development provides a new and original method for understanding knowledge production. BACKGROUND: In nursing research, methodologies are constructed by several external and internal contextually driven influences. Our focus is on how two methodological paradigms – evidence-based practice and mixed methods – continue to impact and be impacted by patterns of knowledge production. DESIGN: Discussion paper. DATA SOURCES: This discussion is based on our own experiences and supported by literature and theory using examples from the two paradigms to illustrate how discourses are developed, perpetuated and deconstructed and how these have specific impacts on qualitative nursing research. IMPLICATIONS FOR NURSING: The conceptual map should be used to cultivate an awareness in practitioners, researchers and policy makers of how discourses surrounding research evidence and research practices are generated. This level of awareness will facilitate critical reflection on how certain practices assume dominance, potentially leading to hegemony in nursing research, practice and scholarship. CONCLUSION: This research offers a critical examination of the meaning of paradigms and a meta-perspective on the production and practice of methodologies using a conceptual map of discourse development as a heuristic device. We anticipate that these examples will encourage debate and discussion on how methodologies and paradigms are perpetuated in academia and the impact this has on nursing knowledge.
There is an increasingly widespread policy momentum to increase patient-centred care and to improve quality of life outcomes within health services. Qualitative research methods are used to elicit in-depth and detailed insights into people’s attitudes, beliefs, emotions and experiences-much of which may remain unspoken during clinical encounters. Questions about patients’ beliefs and preferences for treatment can be addressed by qualitative research and inform evidence-based strategies for delivering patient-centred care. Systematic reviews of multiple primary qualitative studies bring together findings from different studies to offer new and more comprehensive understandings of social phenomena across various healthcare contexts and populations and are an emerging methodology in the literature including for care in chronic kidney disease. This article will provide a framework for the systematic review of qualitative research so readers can make sense of these study types and use them in clinical care and policy.
Internet based methods of communication are becoming increasingly important and influencing researchers’ options. VoIP (Voice over Internet Protocol) technologies (such as Skype and FaceTime) provide us with the ability to interview research participants using voice and video across the internet via a synchronous (real-time) connection. This paper highlights the advantages of using Skype to conduct qualitative interviews and weighs these advantages against any limitations and issues that using this tool may raise. This paper argues that Skype opens up new possibilities by allowing us to contact participants worldwide in a time efficient and financially affordable manner, thus increasing the variety of our samples. At the same time, the use of Skype affects the areas of rapport, non-verbal cues and ethics by creating limitations but also new opportunities. The observations in this paper stem from two different researches, carried out by the authors, on dance (as a form of trans/cultural heritage) and wayfinding (the experience of getting from A to B in various settings). These studies lent themselves to using Skype for qualitative interviews, because of the need to reach an international, varied and purposeful sample. The researchers’ experiences, combined with feedback from participants in Skype interviews, are used in this paper. The conclusion is that, although VoIP mediated interviews cannot completely replace face to face interaction, they work well as a viable alternative or complimentary data collection tool for qualitative researchers. This paper argues that VoIP based interviews offer new opportunities for researchers and should be embraced with confidence.
WHAT IS KNOWN ON THE SUBJECT?: Frailty and multimorbidity are common in later life. A higher level of frailty is associated with a higher risk of adverse physical and psychological health situations. Older adults with pain have been reported to be lonelier and more depressed, as well as less happy and less satisfied with their life as compared to those without pain. In view of the high prevalence of pain among older adults and the reversibility of frailty, it is important to explore the relationship between pain, frailty and psychological parameters in order to devise patient-centred interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Frailty index is positively correlated with the presence of pain, and associated with gender, functional mobility and loneliness. Among these significant variables, loneliness was the factor that contributed the most to the frailty index. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is essential to put the focus of healthcare on both the physical and psychological aspects of well-being. All nurses are advised to improve the management of pain in older people in order to lower the levels of pain, frailty and psychological distress among this population. Nursing care should address the loneliness level especially the problem of social loneliness among older adults particularly those living in nursing homes. ABSTRACT: Introduction In view of the high prevalence of pain among older adults and the reversibility of frailty, it is important to explore the relationship between pain, frailty and psychological parameters in order to devise patient-centred interventions. Aim To examine the levels of frailty, pain and psychological parameters among older adults living in Hong Kong nursing homes, and the cross-sectional relationships among these items. Methods A cross-sectional study was conducted among 178 residents from six nursing homes. Frailty, pain, mobility, happiness, loneliness and life satisfaction of participants were assessed using validated questionnaires. Results A multiple linear regression (R(2) = 0.338, P < 0.05) showed that the frailty index was associated with loneliness, functional mobility and gender. Among these significant variables, loneliness was the factor that contributed the most to the frailty index. Discussion It is essential to put the focus of healthcare on both the physical and psychological aspects of well-being. Findings suggest that apart from improving mobility and reducing pain, loneliness could be a target of psychosocial interventions to reduce frailty and improve quality of life. Implications for practice It is advised that nursing care should address loneliness, especially the problem of social loneliness among older adults particularly those living in nursing homes.
BACKGROUND: Nursing home residents undergoing surgery have a higher rate of postoperative adverse outcomes than nonnursing home patients. This study seeks to determine what contribution nursing home status makes to theses occurrences, independent of comorbid conditions. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, the 30-day postoperative outcomes of the 5 commonest nonemergent inpatient procedures performed on nursing home residents were compared with those in nonnursing home residents using logistic regression analysis. RESULTS: Nursing home status was found to be an independent risk factor for septic complications in all procedures, for blood transfusion requirement after lower leg amputation, for pneumonia and stroke/cerebrovascular accident after thromboendarterectomy, and for mortality after partial colectomy with primary anastomosis. CONCLUSIONS: These data suggest that, in addition to serving as a surrogate indicator of health status and current morbidity, residence in a nursing home makes an independent contribution to adverse postoperative outcomes.
We examined whether the relationship between activities of daily living and quality of life was mediated by depression, and identified differences of the mediating effects by age group. In this cross-sectional survey, 231 older adults were recruited from eight nursing homes. The path analysis indicated that depression played an important mediating role in the relationship between activities of daily living and quality of life. Depression appeared to be more significant for the mental health component as an outcome compared to the physical health component of quality of life. The impact of depression as a mediator for the older old group was greater than the young-middle group. This finding increases our understanding of the impact of age on the mediating effect of depression on the relationship between activities of daily living and quality of life. Healthcare providers should consider older adults’ age differences when integrating physical or depression programs into clinical practice to enhance quality of life.
BACKGROUND: Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes. The aim of this study was to examine the relationship between frailty and health-related Quality of Life (QoL) in older nursing home patients. METHODS: The study sample consisted of 590 patients aged 65 years or older. QoL was measured with the Visual Analogue Scale. Frailty was assessed using the Frailty Index as proposed by Rockwood and colleagues. RESULTS: Mean age of the participants was 85.9 (standard deviation [SD] 7.6) years, with 73.6% being female. The mean Frailty Index was 0.40 (SD 0.07) and the mean value of QoL was 67.4 out of 100 (SD 25.9). Before and after adjusting for age, and stratification for sociodemographic, and health-related variables, no significant associations between frailty and QoL were reported. CONCLUSION: In our study, the Frailty Index was not associated with QoL in nursing home residents.
Introduction Delirium is a common and distressing condition associated with frailty, dementia and comorbidity. These are common in long-term care settings. Residents in care homes are therefore at particular risk of delirium. Despite this, methods to detect delirium in care homes are lacking, with existing diagnostic tools taking too long, or requiring specific training to deliver. This limits their feasibility for use for the routine detection of delirium by care home staff. Routine screening for delirium in care homes would allow timely attention to exacerbating factors to attenuate the episode, and facilitate future research into delirium in the care home environment.Methods Residents from 4 large care homes will be asked to consent (or their consultees asked to provide a declaration of agreement) to participate in the study. Care home staff will administer the 25-item Delirium Observation Screening Scale (DOSS)—a delirium screening tool based on observed behaviours—and this will be tested against the research standard Confusion Assessment Method (CAM) administered by trained research assistants performed two times per week for all participating residents.Analysis Sensitivity, specificity, positive and negative predictive values, likelihood ratios and a diagnostic OR will be calculated for the detection of delirium with the 25-item DOSS. The feasibility of routine delirium screening and the scaling properties of the 25-item DOSS will also be explored.Ethics and Dissemination For residents lacking capacity to participate, a consultee will be approached for a declaration of agreement for inclusion in the study. Results will be published in peer-reviewed journals and disseminated in written format to clinical commissioning groups, general practitioners and relevant third parties.Trial registration number ISRCTN14608554.
OBJECTIVE: To perform a systematic search of the literature for currently available evidence on frailty as a predictor of dementia and to conduct a meta-analysis to synthesize the pooled risk estimates among community-dwelling older people. DESIGN: A systematic review and meta-analysis. DATA SOURCES: Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library from 2000 to January 2016, and reference lists of relevant articles. ELIGIBILITY CRITERIA: Any studies that prospectively examined the incident risks of dementia with frailty among community-dwelling older people without language restriction. RESULTS: Of 2565 studies identified through the systematic review, 7 studies were included in this review. Of these, 4 studies reported hazard ratios (HR) of incident dementia for physical frailty defined by Cardiovascular Health Study criteria and were included in a meta-analysis. Frailty was a significant predictor of incident Alzheimer disease (4 studies: pooled HR = 1.28, 95% confidence interval (95% CI) = 1.00-1.63, P = .05), vascular dementia (2 studies: pooled HR 2.70, 95% CI 1.40-5.23, P = .003), and all dementia (3 studies: pooled HR 1.33, 95% CI 1.07-1.67, P = .01). Heterogeneity across the studies was low to modest (I2 = 0%-51%). A random-effects meta-regression analysis showed that the female proportion of the cohort primarily mediated the association of frailty with Alzheimer disease (female proportion coefficient = 0.04, 95%CI = 0.01-0.08, P = .01). CONCLUSION: This systematic review and meta-analysis suggests that frailty was a significant predictor of Alzheimer disease, vascular dementia, and all dementia among community-dwelling older people. Frail women may have a higher risk of incident Alzheimer disease than frail men.
OBJECTIVES: To investigate whether it is possible to determine signs of imminent dying and change in pain and symptom intensity during pharmacological treatment in nursing home patients, from day perceived as dying and to day of death. DESIGN: Prospective, longitudinal trajectory trial. SETTING: Forty-seven nursing homes within 35 municipalities of Norway. PARTICIPANTS: A total of 691 nursing home patients were followed during the first year after admission and 152 were assessed carefully in their last days of life. MEASUREMENTS: Time between admission and day of death, and symptom severity by Edmonton symptom assessment system (ESAS), pain (mobilization-observation-behavior-intensity-dementia-2), level of dementia (clinical dementia rating scale), physical function (Karnofsky performance scale), and activities of daily living (physical self-maintenance scale). RESULTS: Twenty-five percent died during the first year after admission. Increased fatigue (logistic regression, odds ratio [OR] 1.8, P = .009) and poor appetite (OR 1.2, P = .005) were significantly associated with being able to identify the day a person was imminently dying, which was possible in 61% of the dying (n = 82). On that day, the administration of opioids, midazolam, and anticholinergics increased significantly (P < .001), and was associated with amelioration of symptoms, such as pain (mixed-models linear regression, 60% vs 46%, P < .001), anxiety (44% vs 31%, P < .001), and depression (33% vs 15%, P < .001). However, most symptoms were still prevalent at day of death, and moderate to severe dyspnea and death rattle increased from 44% to 53% (P = .040) and 8% to 19% (P < .001), respectively. Respiratory symptoms were not associated with opioids or anticholinergics. CONCLUSION: Pharmacological treatment ameliorated distressing symptoms in dying nursing home patients; however, most symptoms, including pain and dyspnea, were still common at day of death. Results emphasize critical needs for better implementation of guidelines and staff education. TRIAL REGISTRATION: ClinicalTrials.govNCT01920100.
BACKGROUND: Communication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents’ impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Aim of this study was the analysis of differences in assessment and pharmacological treatment of pain in nursing home residents relative to their cognitive state and ability to articulate pain. METHODS: Data stems from the baseline of a non-experimental pre-post-study in 12 Austrian nursing homes. Residents’ pain prevalence in relation to pain assessment and cognitive decline was assessed, data on medical diagnoses and prescriptions were retrieved from the nursing homes’ documentation (n = 425). Residents were first divided into two groups: Residents with MMSE >/= 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE </= 17 were selected into group CI (cognitively moderately to severely impaired). CI residents were then sub-grouped according to their ability to communicate pain via the Verbal Rating Scale (VRS) (i.e. group CI-V, group CI-NV). Pain behavior of CI residents was assessed with a modified German version of PAINAD. Group differences were tested with ANOVA and H-test, 95 % confidence intervals were calculated and associations were tested with log-binomial regression. RESULTS: Pain prevalence in CI residents irrespective of their ability to communicate pain was 80 % and exceeded the CUS group prevalence significantly by 14 %. CI residents had significantly less analgesic prescriptions. Furthermore, CI residents have a significantly higher risk of getting no analgesics when in pain than CUS residents (CI-V: RR =2.6, CI-NV: RR =3.4). Use of antipsychotics was high in all groups (49 – 65 %) with more prescriptions in the cognitively impaired group. CONCLUSION: Results point toward an underuse of pain medication in cognitively impaired residents, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.
China’s formal long-term care (LTC) system is in its developmental stage due to lack of standardized health assessments for resident admission, limited government funding, an acute shortage of qualified staff at all levels, and regional disparities in quality of care. Relocation to LTC facilities changes the lives of older adults because they have to leave behind their homes and previous social networks. The current study aimed to provide an in-depth exploration of 25 older adult residents’ lives in four LTC facilities in China. A conventional content analysis approach was used to interpret participant interviews. Residents experienced losses and gains from residential life. Three themes emerged: (a) influences of cultural beliefs, (b) basic care needs fulfilled in LTC facilities, and (c) lack of quality care in LTC facilities. Findings show that residents’ basic needs were met in Chinese LTC facilities, but there is room for improvement in delivering quality care.
OBJECTIVES: to measure sex differences in the risk of receiving potentially inappropriate prescription drugs and to examine what are the factors that contribute to these differences. DESIGN: a retrospective cohort study. SETTING: community setting of British Columbia, Canada. PARTICIPANTS: residents of British Columbia aged 65 and older (n = 660,679). MEASUREMENTS: we measured 2013 period prevalence of prescription dispensations satisfying the American Geriatrics Society’s 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. We used logistic regressions to test for associations between this outcome and a number of clinical and socioeconomic factors. RESULTS: a larger share of women (31%) than of men (26%) filled one or more potentially inappropriate prescription in the community. The odds of receiving potentially inappropriate prescriptions are associated with several clinical and socioeconomic factors. After controlling for those factors, community-dwelling women were at 16% higher odds of receiving a potentially inappropriate prescription than men (adjusted odds ratio = 1.16, 95% confidence interval = 1.12-1.21). Much of this sex difference stemmed from women’s increased odds of receiving potentially inappropriate prescriptions for benzodiazepines and other hypnotics, for tertiary tricyclic antidepressants and for non-selective NSAIDs. CONCLUSION: there are significant sex differences in older adults’ risk of receiving a potentially inappropriate prescription as a result of complex intersections between gender and other social constructs. Appropriate responses will therefore require changes in the information, norms and expectations of both prescribers and patients.
Background Close to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF. Objectives To describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs. Design Trained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period. Setting SNFs from across the United States. Participants 64 of 88 SNFs randomized to the intervention group submitted RCAs. Interventions SNFs were implementing the INTERACT quality improvement program. Measures Data were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. Results Among 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital. Conclusion RCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.
Objectives This study assessed the frequency of physician contacts for individual nursing home residents (NHRs) and investigated whether the frequency of contacts influences the appropriateness of pain medication in NHRs. Design Observational cross-sectional study conducted between March 2009 and April 2010. Setting Forty nursing homes in Berlin and Brandenburg, Germany. Participants A total of 560 NHRs. Measurements The number and type of NHR physician contacts were obtained by face-to-face interviews. To assess the appropriateness of pain medication, the German version of the Pain Medication Appropriateness Scale (PMASD) was used. The influence of physician contacts on the appropriateness of pain medication was calculated with a linear mixed-effect model. Results The proportions of NHRs with at least 1 contact with their attending physicians were 61.8% (primary care physicians), 55.2% (general practitioners), 9.6% (neurologists), 9.4% (other), 5.4% (internists), 2.2% (orthopedic surgeons), and 0.7% (psychiatrists). The number of all physician contacts correlated weakly with the appropriateness of pain medication (r = 0.166, P = .039). With every physician contact, the PMASD score rose by about 2 points (P = .056). Conclusions Physician care in German nursing homes is mainly provided by primary care physicians. A higher number of physician contacts had a modest impact on more appropriate pain medication use.
Background Potentially inappropriate medications (PIMs) are often found in high proportion among the elderly population. The STOPP criteria have been suggested to detect more PIMs in European elderly than the Beers criteria. Objective This study aimed to determine the prevalence of PIMs and potential prescribing omissions (PPOs) in a sample of Portuguese nursing homes residents. Setting Four elderly facilities in mainland Portugal Method A descriptive cross-sectional study was used. Elderly polypharmacy patients were included in the study and their medication (registered in patient clinical records) analysed using the Beers (2012 original version and 2008 version adapted to Portugal), STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria. Data were analysed using univariate and bivariate descriptive statistics, considering a confidence interval of 95 %. MAIN OUTCOME MEASURES: Prevalence of PIMs and PPOs. Results The sample included 161 individuals, with a mean age of 84.7 years (SD = 6.35), 68.9 % being female. A total of 807 PIMs and 90 PPOs were identified through the application of the three set of criteria. The prevalence of PIMs using the most recent version of the Beers criteria was 85.1 and 42.1 % for independent and dependent of diagnosis, respectively. The Portuguese adaptation of this same tool indicated a lower prevalence of PIMs, 60.3 and 16.7 %, respectively. The prevalence of PIMs using the STOPP criteria was 75.4 %, whilst the prevalence of PPOs, using START, was 42.9 %. There were significant differences in the mean number of PIMs detected depending on the tool used. (p < 0.001). Conclusions The application of the studied criteria in an elderly sample enabled the identification of a notable amount of PIMs and PPOs, indicating there is room for improving the quality of care. The variation in prevalence indicates careful choice of the tool is a prerequisite for engaging in medication review. Using START/STOPP criteria enabled a more holistic approach to the quality of prescribing in the elderly, highlighting low levels of cardiovascular risk prevention and abuse of psychotropic drugs, aside with system failures largely preventable by electronic prescribing and alert generation.
BACKGROUND AND PURPOSE: Frailty has been recognized as a medical syndrome characterized by decreased physiological reserve and vulnerability to poor resolution of homeostasis. Frailty is common in nursing homes and as many as 90% of nursing home patients are frail or prefrail. Previous studies have examined frailty as a risk factor for nursing home placement and yielded inconsistent results. The current study aims to systematically review the literature and to conduct a meta-analysis to combine the risk measures to provide the evidence on frailty as a predictor of nursing home placement among community-dwelling older adults. METHODS: A systematic literature search was performed in July 2015 using 6 databases (Scopus, Embase, CINAHL Plus, MEDLINE, PsycINFO, and the Cochrane Library). Any cohort studies examining associations between frailty and risk of subsequent nursing home placement among community-dwelling older adults published from 2000 to July 2015 were potentially eligible. The numbers of those who were admitted to nursing homes and who were not, according to frailty categories, were used to calculate pooled odds ratio (OR) using fixed-effect models. The included studies were assessed for heterogeneity, methodological quality, and publication bias. The systematic literature search and hand-search identified 885 potentially relevant studies, among which 5 studies including 3528 community-dwelling older adults were selected for this review. RESULTS: Meta-analyses were performed using data from these studies and showed that both frailty and prefrailty significantly predicted nursing home placement (5 studies: pooled OR = 5.58, 95% confidence interval [CI] = 2.94-10.60, P < .00001; 3 studies: pooled OR = 3.26, 95% CI = 1.21-8.78, P = .02, respectively). Heterogeneity across the studies was low or moderate and there was no evidence of publication bias. DISCUSSION: Frailty generally progresses but can also be potentially modified by appropriate interventions such as physical exercise. Evidence especially has shown that aerobic and resistance exercises improve frailty components. Furthermore, a multifactorial interdisciplinary intervention, including tailored exercise programs, has shown to decrease prevalence of frailty among frail community-dwelling older adults. It is noteworthy that adherence to the exercise programs was high and adverse events were not reported in most of the trials. These findings suggest that physical exercise can potentially prevent or reverse frailty and may lead to decreased risks of nursing home placement in older adults. CONCLUSIONS: This systematic review and meta-analysis study is the first to report pooled evidence that both frailty and prefrailty are significant predictors of nursing home placement among community-dwelling older adults.
BACKGROUND AND OBJECTIVES: More than 8% of Iran’s populations are elderly. The greatest challenge in this generation is improvement of health and QoL.The main goal of this study was QoL for elderly residents in nursing homes over 65 years in Golestan Province – Iran. METHODS: This research was an analytical cross study. The population society includes the elderly over 65 years in Golestan Province – Iran. The sample size was calculated based on the correlation of 193 elderly men and women. Therefore, if the correlation is 2.0 or greater is statistically significant at 80% and 0.95 confidence. The needed data collected from two questionnaires Consumer product Safety Commission (CPSC) to assess the QOL of nursing homes and the SF-36 for health QOL the elderly indicators through interviews and observation. The reliability of the CPSC questionnaire was estimated using Cronbach’s alpha with a coefficient of 0.838. The SF-36 questionnaire was validated with Cronbach’s alpha with a coefficient of 0.95. To analyze data, ANOVA one-way test was used that after investigating homogenization of variances with Levin statistic, if homogenization reported P is rejected, the independent T-test was used to interpret it. RESULTS: Among QOL dimensions only General Health (GH) status showed a significant association with supporting organizations covering status (P = 0.01). The relationship between QOL with marital status in both genders was observed that the General Health (GH) (P = 0.001), Physical Functioning (PF) P = (0.007) Mobility Restricts (MR) P = (0.002), Emotional Problems (EP) (P = 0.001), vitality (V) (P = 0.001), Mental Health (MH) (P = 0.001) were significantly related. CONCLUSIONS: There was a significant relationship between the Physical Functioning (PF) mean and the mean of other QOL indicators in two groups of male and female (P = 0.007), also the safety of nursing homes just related respectively with residence variable (P = 0.01) and their employment (P = 0.031).
Pain is a frequent cause of discomfort and distress in residents in residential aged care facilities (RACFs). Despite the benefits of adequate pain management, there is inconsistency in the literature regarding analgesic use and pain in residents with dementia. The aim of this systematic review was to determine the prevalence of analgesic drug use among residents with and without dementia or cognitive impairment in RACFs. A systematic search of MEDLINE and EMBASE (inception to January 2014) was conducted using Medical Subject Headings and Emtree terms, respectively. Studies were included if they reported prevalence of analgesic use for residents both with and without dementia within the same study. Data extraction and quality assessment was performed independently by two investigators. Data on the prevalence of analgesic use, pain and painful conditions were extracted. Meta-analyses were performed using random effect models. The 7 included studies were of high quality (>/= 5 out of 7 on the adapted Newcastle-Ottawa Scale). Analgesic use in residents with and without dementia or cognitive impairment ranged from 20.2% to 61.2% and 38.8% to 79.6%, respectively. Paracetamol was the most prevalent analgesic in people with and without dementia. Residents with dementia or cognitive impairment had a significantly lower prevalence of analgesic use (odds ratio [OR] 0.576, 95% confidence interval [CI] = 0.406-0.816) and of self-reported and clinician-observed pain (OR 0.355, 95% CI = 0.278-0.454) than residents without cognitive impairment, despite a comparable prevalence of painful conditions. These findings may indicate under-reporting and under-detection of pain in persons with dementia, and subsequent suboptimal treatment.
The Office of the Seniors Advocate releases its review of incidents of resident to resident aggression in B.C.’s licensed residential care facilities. The review gathered and examined data from a variety of sources, including Health Authorities, reporting systems, and facilities themselves.
We are pleased to offer a webinar on the fundamentals of KT, and how KT can inform research and practice. This webinar will be beneficial to anyone interested learning more about how KT relates to their own work. We welcome individuals and organizations involved in all dimensions of health (acute care, long-term care, public health, mental health, etc.) to attend. Presenter: Dr. Julia E. Moore, Manager at the Knowledge Translation Program, St. Michael’s Hospital, Toronto. All registration requests should be sent to Melissa Courvoisier: email@example.com . When requesting registration please specify which date you would like attend, July 20th. We will register participants on a first come first serve basis.
Care Transitions to and from the Hospital for Individuals with Alzheimer’s disease – This webinar presents core competencies on how to best prepare and ease the difficulties surrounding care transitions, particularly to and from a hospital environment for adults with dementia. During transitions of care, communication — between the individual with dementia and his or her family, within the home care team, and among all providers involved in caring for the person — is especially important to ensure medication safety, understanding of the care plan, clarity of roles and responsibilities, and care coordination. Registration link coming soon!
The KT Program in the Li Ka Shing Knowledge Institute at St. Michael’s Hospital offers the Practicing Knowledge Translation (PKT): Implementing evidence. Achieving outcomes course, which is an intensive course in knowledge translation (KT) that focuses on teaching best practices in high-quality implementation. It offers in-depth instruction on methods of encouraging practice changes to achieve desired outcomes by using evidence-based implementation strategies. The course is specifically designed to address practical applications of KT; participants directly apply implementation evidence and theories to their own projects throughout the duration of the course, and receive support from course instructors to help strengthen the design and operationalization of their work using KT methods. The PKT course equips participants with the core competencies required to effectively integrate evidence-informed practices into their own projects.
Urinary tract infections (UTIs) in nursing home residents can often have serious effects, including delirium, debilitating falls and even fatal blood infections. Now, new research finds the infections are common in nursing homes, often due to a lack of proper prevention.
The Canadian Association for Retired Persons (CARP) recently released their findings from the CARP Health Survey Poll™ on healthy aging and the effects influenza (flu) can have on seniors. With almost 10,000 Canadian respondents, the survey results highlighted seniors’ misconceptions about the flu’s impact and almost half of respondents said their biggest fear of aging was loss of independence.
CBC News asked Dr. Samuel Campbell, the chief of the emergency department at the Halifax Infirmary, to write an editorial regarding the increasing number of long-term care patients coming to the ER.
More than one in three Canadian seniors fills a prescription for a risky medication that should be avoided in older patients, say researchers who estimate $419 million a year is spent on such drugs.
Many elderly adults in nursing homes face aggressive or disturbing behavior from their fellow residents, a new study suggests. The study found that one in five nursing home residents had been involved in an incident with a fellow resident within the past month.
Researchers are calling for a national strategy on the appropriate use of medicines, after a new study estimates that more than $400 million a year is spent in Canada on drugs prescribed to seniors, even though those drugs should be avoided by older patients.
A new study offers surprising findings about end-of-life care — specifically, physicians tend to be more likely to accommodate the advanced-care wishes of patients with cancer or dementia than renal disease, congestive heart failure, pulmonary disease or frailty.
The lives of elderly people are being put at risk because of worryingly low uptake of flu vaccines among healthcare workers, public health experts have warned.
We’ve made some critical changes in the types of support we provide in order to focus our work and increase our effectiveness. These changes have moved us more strongly into implementation research, and I’d like to explain why.
The changes, which took effect at the nursing facility in June, are part of a nationwide movement to phase out personal alarms and other long-used fall prevention measures in favor of more proactive, attentive care. Without alarms, nurses have to better learn residents’ routines and accommodate their needs before they try to stand up and do it themselves.
We can intervene earlier in life to try to delay the onset of dementia. That’s where the bulk of the research activity is now leading us in terms of advances. But an effective, mass education campaign for the population — as part of a National Dementia Strategy and Action Plan — cannot happen without a concerted effort from government, at all levels.
What to do when the life of the mind subsumes all of the other parts of the body.
Lots of us have writing tics. A writing tic is involuntary, something we do without thinking. Many of us get a writing tic or two when producing a first draft. But we only find this out afterwards, when we read through what we’ve written.
Nearly 1000 Canadian researchers are demanding that the government immediately reverse “radical” changes that the nation’s main biomedical research funder has made to its grantsmaking process, arguing that they are wreaking havoc on the science community. In particular, the researchers want the Canadian Institutes of Health Research (CIHR) to reinstate face-to-face meetings of peer-review panels, which the agency has ended in favor of an online system for evaluating grant proposals.
This framework and checklist can be used by anyone in public health who is developing evidence briefings on issues to inform decision-makers in a timely fashion.
If you are interested in doing your own reality check within your organization, The Michener Institute’s Aging Suit and Working With Seniors curriculum can be a key part of patient experience learning in health care organizations. The aging suit simulation is now available to individuals and organizations.
The tool aimed at searching for research evidence provides specific resources for public health research. Research resources are outlined according to a hierarchy of different levels of evidence. This tool is designed to promote more effective evidence-informed public health decision-making by outlining the most direct method for retrieving the highest level of evidence available.
Any academic with an email spam folder realizes that the problem of predatory conferences continues to grow at an alarming rate. Predatory conferences are for-profit, low-quality academic meetings that exploit researchers’ need to share and present their research. Given the rise in the number of predatory conferences and the increasingly sophisticated organizations selling them, I believe it has become necessary to develop a set of criteria to identify predatory conferences.
The goal of this guideline is to improve the care of patients with dementia who are exhibiting agitation or psychosis. More specifically, this guideline focuses on the judicious use of antipsychotic medications when agitation or psychosis occurs in association with dementia and does not review evidence for or focus on other pharmacological interventions.
Should you incorporate social media into your programming as a tool for health promotion and knowledge translation? It sounds like a good idea, but you want to know what the best available research says about the subject. You decide to search for a tool that will help you collect and process this information, so you can make a decision.