Background Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managersâ€™ leadership in facilitatingÂ implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the interventionâ€™s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Â Methods Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a fourmonth leadership intervention that included workshops, seminars, and teleconferences. The focus was on developingÂ knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Â Results Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Â Conclusion Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managersâ€™ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.
Background: Systematic review is an essential component of evidence-based health care, yet limited to published academic literature. We aimed to augment an ongoing systematic review on the use of art and narrative as knowledge translation (KT) strategies.Methods: We describe the development of an exploratory process to complement systematic reviews through locating ongoing or unpublished projects. Data were collected through email communication, social media and a secondary analysis of an ongoing database of projects that involve arts in the health care field. Information gathered included: project title, focus, arts or narrative approaches used, anticipated completion date and links to relevant social media, webpages and applicable materials.Results: The inventory captures the ways in which arts and narrative-based KT initiatives are used within a health care context beyond formal research literature.Conclusions: This exploratory process would facilitate updating systematic reviews later while simultaneously capture themes and emerging ideas in unpublished works.; AbstractBackground: Systematic review is an essential component of evidence-based health care, yet limited to published academic literature. We aimed to augment an ongoing systematic review on the use of art and narrative as knowledge translation (KT) strategies.Methods: We describe the development of an exploratory process to complement systematic reviews through locating ongoing or unpublished projects. Data were collected through email communication, social media and a secondary analysis of an ongoing database of projects that involve arts in the health care field. Information gathered included: project title, focus, arts or narrative approaches used, anticipated completion date and links to relevant social media, webpages and applicable materials.Results: The inventory captures the ways in which arts and narrative-based KT initiatives are used within a health care context beyond formal research literature.Conclusions: This exploratory process would facilitate updating systematic reviews later while simultaneously capture themes and emerging ideas in unpublished works.
Calls for Abstracts
We encourage submissions from authors on topics surrounding the care of older adults, including new models of care and the management of multiple chronic conditions among this population. We are interested in work that spans the full range of care settings, including primary care and specialty practices, hospitals, nursing homes and other long-term care settings. There is no deadline for submissions; papers on these topics will be considered on an ongoing basis and considered for publication through 2017. However, it is expected that papers will deal with topics of interest in a timely way so that the arguments and data presented are relevant to current policy concerns.
Grants & Awards
Canadian Frailty Network Fellows and Summer Students
The CFN is reaching out to current and past supervisors of CFN Fellows and Summer Students for your assistance on calls for fellowships and summer student awards in our second funding cycle. A letter has been sent to your host institution’s head of research/research services, but we know that each organization has a different funding approval structure, so we wanted to make sure that you were aware of the opportunities available. They are offering the opportunity to co-fund a number of Fellows and Summer Students over the next five-year funding period, with matching CFN funding where letters of commitment are received. For more information, please contact Jackie at firstname.lastname@example.org or (613) 549-6666, x 6210, and Carol at email@example.com or (613) 549-6666, x 7689.
In the past few decades, prevention scientists have developed and tested a range of interventions with demonstrated benefits on child and adolescent cognitive, affective, and behavioral health. These evidence-based interventions offer promise of population-level benefit if accompanied by findings of implementation science to facilitate adoption, widespread implementation, and sustainment. Though there have been notable examples of successful efforts to scale up interventions, more work is needed to optimize benefit. Although the traditional pathway from intervention development and testing to implementation has served the research community well-allowing for a systematic advance of evidence-based interventions that appear ready for implementation-progress has been limited by maintaining the hypothesis that evidence generation must be complete prior to implementation. This sets up the challenging dichotomy between fidelity and adaptation and limits the science of adaptation to findings from randomized trials of adapted interventions. The field can do better. This paper argues for the development of strategies to advance the science of adaptation in the context of implementation that would more comprehensively describe the needed fit between interventions and their settings, and embrace opportunities for ongoing learning about optimal intervention delivery over time. Efforts to build the resulting adaptome (pronounced “adapt-ohm”) will include the construction of a common data platform to house systematically captured information about variations in delivery of evidence-based interventions across multiple populations and contexts, and provide feedback to intervention developers, as well as the implementation research and practice communities. Finally, the article identifies next steps to jumpstart adaptome data platform development.
BACKGROUND: Operational research (OR) is the discipline of using models, either quantitative or qualitative, to aid decision-making in complex implementation problems. The methods of OR have been used in healthcare since the 1950s in diverse areas such as emergency medicine and the interface between acute and community care; hospital performance; scheduling and management of patient home visits; scheduling of patient appointments; and many other complex implementation problems of an operational or logistical nature. DISCUSSION: To date, there has been limited debate about the role that operational research should take within implementation science. I detail three such roles for OR all grounded in upfront system thinking: structuring implementation problems, prospective evaluation of improvement interventions, and strategic reconfiguration. Case studies from mental health, emergency medicine, and stroke care are used to illustrate each role. I then describe the challenges for applied OR within implementation science at the organisational, interventional, and disciplinary levels. Two key challenges include the difficulty faced in achieving a position of mutual understanding between implementation scientists and research users and a stark lack of evaluation of OR interventions. To address these challenges, I propose a research agenda to evaluate applied OR through the lens of implementation science, the liberation of OR from the specialist research and consultancy environment, and co-design of models with service users. Operational research is a mature discipline that has developed a significant volume of methodology to improve health services. OR offers implementation scientists the opportunity to do more upfront system thinking before committing resources or taking risks. OR has three roles within implementation science: structuring an implementation problem, prospective evaluation of implementation problems, and a tool for strategic reconfiguration of health services. Challenges facing OR as implementation science include limited evidence and evaluation of impact, limited service user involvement, a lack of managerial awareness, effective communication between research users and OR modellers, and availability of healthcare data. To progress the science, a focus is needed in three key areas: evaluation of OR interventions, embedding the knowledge of OR in health services, and educating OR modellers about the aims and benefits of service user involvement.
Background: Collaboration among researchers and research users, or integrated knowledge translation (IKT), enhances the relevance and uptake of evidence into policy and practice. However, it is not widely practiced and, even when well-resourced, desired impacts may not be achieved. Given that large-scale investment is not the norm, further research is needed to identify how IKT can be optimized. Methods: Interviews were conducted with researchers and research users (clinicians, managers) in a health care delivery (HCDO) and health care monitoring (HCMO) organization that differed in size and infrastructure, and were IKT-naïve. Basic qualitative description was used. Participants were asked about IKT activities and challenges, and recommendations for optimizing IKT. Data were analysed inductively using constant comparative technique. Results: Forty-three interviews were conducted (28 HCDO, 15 HCMO) with 13 researchers, 8 clinicians, and 22 managers. Little to no IKT took place. Participants articulated similar challenges and recommendations revealing that a considerable number of changes were needed at the organizational, professional and individual levels. Given the IKT-absent state of participating organizations, this research identified a core set of conditions which must be addressed to prepare an environment conducive to IKT. These conditions were compiled into a framework by which organizations can plan for, or evaluate their capacity for IKT. Conclusions: The IKT capacity framework is relevant for organizations in which there is no current IKT activity. Use of the IKT framework may result in more organizations that are ready to initiate and establish IKT, perhaps ultimately leading to more, and higher-quality collaboration for health system innovation. Further research is needed to confirm these findings in other organizations not yet resourced for, or undertaking IKT, and to explore the resource implications and mechanisms for establishing the conditions identified here as essential to preparing for IKT.
This manuscript details potential benefits for using a research-practice partnership to adapt collaborative depression care for public community long-term care agencies serving older adults. We used sequential, multi-phase, and mixed methods approaches for documenting the process of adaptation within a case study. Systematic adaptation strategies are described, such as leveraging long-term research-practice collaborations, consulting with multiple stakeholders across all levels and disciplines, and balancing demands to monitor treatment fidelity, clinical outcomes, and implementation results. These examples demonstrate that researchers interested in implementation science need skills to negotiate the competing demands that arise from both the research and practice settings.
Health Care Administration and Organization
AIM: Provide insight into the concept of stress in the context of challenging behaviour of nursing home residents with dementia and its causes and consequences. BACKGROUND: Challenging behaviour is frequent in residents with dementia, but consequences for nursing staff are unclear. INTRODUCTION: Challenging behaviour of residents can be enervating for nurses and may lead to stress. Although stress in general is associated with negative outcomes, an overview of stress in this context would be a welcome addition to the field. METHOD: Concept analysis according to Walker and Avant. RESULTS: Identified antecedents of stress: physical and verbal aggression, conflicts, excessive demands and being unresponsive (residents), age, experience, tenure, nursing level and training (nursing staff). Defining attributes: disturbed homoeostasis and the personal appraisal of the situation. Identified consequences regard health, psychological aspects and behaviour. DISCUSSION: Intervening in the identified factors may contribute to prevention of stress in nursing staff. LIMITATIONS: Given a lack of strong empirical studies, our analysis is not based on a high level of evidence and needs to be tested. Papers from before 1990 might have been missed. CONCLUSION: The concept analysis revealed that nursing staff stress in the context of challenging behaviour may result from resident and nursing staff factors. Besides health and psychological consequences, behavioural consequences can enormously impact the well-being of residents. IMPLICATIONS: Application in daily care to support teams in influencing resident and nursing staff factors could prevent stress, for instance using behavioural management training or recruiting higher educated nursing staff. Given the increasing complexity of care, creating specialized units with specifically trained staff for different groups of people with dementia may be desirable.
This study investigated the relationship between nurse staffing and quality of life (QOL) in Western New York State nursing homes. This was a cross-sectional, correlational study. The independent variables were hours per resident day (HPRD), skill mix, and turnover rate of nursing staff. The outcomes were measured using the self-reported QOL instrument. No coefficients were statistically significant with registered nurses’ (RNs) HPRD. Certified nursing assistant (CNA) HPRD had a statistically significant positive impact on the spiritual well-being domain. There was a statistically negative relationship between the amount of licensed practical nurse (LPN) HPRD and food enjoyment; and the ratio of more RNs to fewer LPNs and CNAs had a statistically significant negative influence on the meaningful-activity, food-enjoyment, and security domains. The turnover of RNs had a statistically negative relationship with the sum of each domain. None of the coefficients was statistically significant with LPN turnover.
PURPOSE OF THE STUDY: To date, no research has investigated how the organizational climate of aged care influences the self-efficacy of staff in caring for residents with dementia, or, how self-efficacy is associated with the strain experienced by staff. This study sought to investigate the extent to which the self-efficacy of aged care staff mediates the association between organizational climate variables (such as autonomy, trusting and supportive workplace relations, and the recognition of competence and ability, and perceptions of workplace pressure) and staff strain. DESIGN AND METHODS: A cross-sectional survey design was implemented in which 255 residential aged care staff recruited across aged care facilities in Melbourne, Australia. Staff completed self-report measures of organizational climate, self-efficacy, and strains in caring for residents with dementia. RESULTS: Indirect effects analyses using bootstrapping indicated that self-efficacy of staff mediated the association between the organizational climate variables of autonomy, trust, support, pressure, and staff strain. IMPLICATIONS: The findings of this study emphasize that the aged care sector needs to target organizational climate variables that enhance the self-efficacy of staff, and that this in turn, can help ameliorate the strain experienced by staff caring for residents experiencing dementia.
BACKGROUND: Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. METHODS: In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. RESULTS: Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. CONCLUSIONS: When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. TRIAL REGISTRATION: ClinicalTrial.gov, NCT00636675.
AIMS AND OBJECTIVE: The aim was to describe registered nurses’ experience in the context of delegating the administration of medication to unlicensed personnel in residential care homes. BACKGROUND: The residents in residential care homes have a need for extensive care and nursing, and large amounts of medicines are common practice. Registered nurses’ workload and difficulties in fulfilling their duties, such as administration of medicines, have led to frequent delegation of this task between the registered nurses and unlicensed assisting personnel. It is, of course, a great responsibility to ensure that the care of the older people remains safe while maintaining quality in the prevailing situation. DESIGN: A qualitative inductive descriptive study. METHODS: Data were collected using audio-recorded semistructured interviews with a purposive sample of 18 registered nurses and interpreted using manifest content analysis. The study was approved by the ethical research committee. RESULTS: Registered nurses found the organisation unsupportive with regard to nursing interventions. The delegation context was experienced as a grey zone; the rules and regulations were not in line with the unspoken expectation to delegate the administration of medicine to unlicensed personnel, in order to be able to manage their daily work. CONCLUSIONS: The slimmed organisation of residential care homes relies upon registered nurses’ use of delegation of medicine administration to unlicensed assistant personnel. It becomes an inevitable assignment entailing a challenging responsibility for patient safety and the quality of care. RELEVANCE TO CLINICAL PRACTICE: The results of this study may contribute to a better understanding of the complexity of caring for older people in residential care homes and to improving the work environment of all healthcare personnel.
BACKGROUND: Understanding the structures and processes related to the supervisor performance of regulated nurses (registered nurses [RN] and registered practical nurses [RPN]) is critical in order to discern how administrators of long-term care (LTC) homes can facilitate and better support nurses given their important contribution to nurse assistants’ job satisfaction and resident outcomes. AIMS: The aim of this integrative review is to identify the structures and processes related to supervisory performance of regulated nurses in LTC. METHODS: An electronic search of six databases for studies published in English between 2000 and September 2015 was conducted by a librarian. The inclusion criteria were studies focused on RN or RPN supervisory performance in LTC, which included a structure or process related to supervisory performance of the nurse. Screening, quality assessment using the Mixed Methods Assessment Tool, and data extraction for the included studies were conducted independently by two reviewers. RESULTS: A total of 22 studies were included in the review. Six nurse structures (e.g., nurses’ “perceptions of their supervisory role and authority” as well as their “personal qualities”), and eight organizational structures (e.g., “organizational support (culture) for supervisory and management practices” and “staffing levels”) were identified. Six processes of effective supervisory performance were identified, such as “being flexible, understanding, considerate listeners and encourage staff input” as well as “respect, value, recognize, acknowledge and motivate” nursing assistants they supervise. LINKING EVIDENCE TO ACTION: The results highlight the nuanced and complex nature of nurses’ supervisory performance and the multifaceted approach required to support effective nurse supervisors in LTC. Future research should examine how resident-related structures, as well as other moderators and mediators, may influence supervisory performance. Developing detailed models of effective supervision can inform future interventions targeting modifiable processes related to supervisory performance to thereby change practice and optimize supervisory performance in LTC.
Health Care Innovation and Quality Assurance
The term “wicked problem” describes a difficult, complex, seemingly intractable issue, such as poverty, crime, and climate change.1 In health care, it can refer to stigmatized conditions, such as obesity, substance use disorders, and domestic violence. This Viewpoint discusses how domestic violence (also referred to as intimate partner violence) is being addressed in a large health care organization using an innovative systems model approach, quality improvement methodology, health information technology (IT), and implementation science. The experience from this care delivery innovation may be applicable to other wicked problems and challenging health care issues that contribute disproportionately to reduced quality of life, chronic health conditions, and high health care utilization.
An intervention targeting fundamental values among caregivers at residential facilities: effects of a cluster-randomized controlled trial on residents’ self-reported empowerment, person-centered climate and life satisfaction
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BACKGROUND: In Sweden the national fundamental values for care of older people state that care should ensure that they can live in dignity and with a sense of well-being. Our hypothesis was that a caregiver intervention targeting the national fundamental values would improve perceived empowerment, person-centered climate and life satisfaction among older people living in residential facilities. METHODS: The study was a cluster-randomized controlled trial with a pre- and one post-test design, conducted in 27 units (17 study units) at 12 residential facilities for older people in five municipalities in central Sweden. The units in each municipality were randomly assigned to intervention or control group. The caregiver intervention was carried out using an interpretative approach with eight guided face-to-face seminars, where self-reflection and dialogue were used. Data were collected using questionnaires. The number of residents was 43 (78 %) in the intervention group and 37 (71 %) in the control group. The Chi-square test and Mann-Whitney U-tests were performed to detect differences between groups and Wilcoxon signed rank tests to explore differences in change over time within groups. Furthermore, generalized estimating equation (GEE) models were used to study effects of the intervention controlling for clustering effects. RESULTS: Primary outcome measures were empowerment, person-centered climate and life satisfaction. In the intervention group, improvements at follow-up were found in residents’ self-reported empowerment (n = 42; p = 0.001, Median difference 4.0, 95 % CI 1.5;6.0), person-centered climate (n = 42; p </=0.001, Median difference 8.0, 95 % CI 4.5;11.4) and life satisfaction regarding the factor quality of everyday activities (n = 40; p = 0.033, Median difference 9.7, 95 % CI 1.0;21.9) while disempowerment decreased (n = 43; p = 0.018, Median difference -1.3, 95 % CI -2.0;0.0). In the control group person-centered climate decreased (n = 37; p = 0.002, Median difference -8.5, 95 % CI -13.6;-3.0) and quality of everyday activities (n = 36; p = 0.012, Median difference -11.6, 95 % CI-21.7;-3.4). Change over time between groups was significant for empowerment (p = 0.001, Median difference 6.0, 95 % CI 3.0;9.0), disempowerment (p = 0.006, Median difference -2.0, 95 % CI -4.0;-1.0) and person-centered climate (p </= 0.001, Median difference 16.0, 95 % CI 9.7;23.0) and for life satisfaction regarding the factor quality of everyday activities (p = 0.002, Median difference 22.1, 95 % CI 8.2;37.4). Results of GEE confirmed earlier results; revealed interaction effects for empowerment (parameter estimate -5.0, 95 % CI -8.3;-1.8), person-centered climate (parameter estimate -16.7, 95 % CI -22.4;-10.9) and life satisfaction regarding the factor quality of everyday activities (parameter estimate -25.9, 95 % CI -40.3;-11.5). CONCLUSION: When the Swedish national fundamental values were put into practice increases in empowerment, person-centered climate and quality of everyday activities were found among older people with intact cognitive ability living in residential facilities. Limitations to consider are the differences between the two groups at baseline, drop-outs and that neither the data collector nor the outcome assessors were blinded to group assignment of participants. TRIAL REGISTRATION: The study was registered in ISRCTN92658034 in January 2013.
Can the Medical-nursing Combined Care Promote the Accessibility of Health Services for the Elderly in Nursing Home? A Study Protocol of Analysis of the Effectiveness Regarding Health Service Utilization, Health Status and Satisfaction with Care
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Background: Currently, segmentation of healthcare and daily care for the elderly living in nursing homes usually results in the elderly not getting medical treatment timely and effectively. The medical-nursing combined care, which has been put into practice in several areas in China, is developed to enhance the accessibility of healthcare for the elderly. The aim of the study is to explore the effectiveness of the new care service, based on Andersen model, regarding health service utilization, health status and service satisfaction. Methods: The effectiveness of medical-nursing combined care will be measured in a cross-sectional study in nine nursing homes in Jianghan District, Wuhan, China, with 1067 old residents expected to participate. The questionnaire containing items of demographics, health service use, service satisfaction and instrument of SF-36 V2 is developed based on the conceptual framework of Andersen behaviour model of health service utilization. Descriptive analysis, variance analysis, multiple factors analysis, and correlation analysis will be performed to compare the sociological characteristics, health service use, health status and service satisfaction of the elderly living in different modes of nursing homes, to explore the influence factors of care effectiveness, as well as to study the relationship between health behaviour and health outcomes. Conclusion: The study design of analysing the effects of medical-nursing combined care and performing the horizontal comparison among the nursing homes under the framework of Andersen model is blazing new trails. Recruitment and design of questionnaire are important issues. Successful data collection and quality control are also necessary. Taking these into account, this study is estimated to provide evidence for the effectiveness of medical-nursing combined care service in China.
This review summarizes current literature pertaining to infection prevention in nursing home population including post-acute care patients and long-term care residents. Approximately 2 million infections occur each year and more than one-third of older adults harbor multidrug-resistant organisms in this setting. Surveillance, hand hygiene, isolation precautions, resident and employee health programs, education, and antibiotic stewardship are essential elements of infection prevention and control programs in nursing homes. This article discusses emerging evidence suggesting the usefulness of interactive multimodal bundles in reducing infections and antimicrobial resistance, thereby enhancing safety and quality of care for older adults in nursing homes.
Over the past three decades, there has been a notable increase in studies of practice change interventions in long-term care (LTC) settings. This review, based on a modified realist approach, addresses the following questions: What practice change intervention characteristics work? And, in what circumstances do they work and why? A modified realist approach was applied to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases and published literature for empirical studies of practice change interventions that (a) were conducted in LTC settings, (b) involved formal care staff members, and (c) reported a formal evaluation. Ninety-four articles met the inclusion criteria. Interventions that included only predisposing factors were least likely to be effective. Interventions that included reinforcing factors were most likely to produce sustained outcomes. We concluded that interventions aimed at practice change in LTC settings should include feasible and effective enabling and reinforcing factors.
BACKGROUND: Common sense suggests and research indicates relationships between staff factors in residential dementia care and quality of life (QOL) for residents, with poor care increasing suffering. However, we do not have a coherent picture of which staff interventions have an impact on quality of care (QOC) or resident QOL. METHODS: A comprehensive search of 20 years’ peer-reviewed literature using Medline, PsycINFO, Embase, PubMed, CINAHL, and the Cochrane, Campbell Collaboration identified 4,760 studies meriting full text review. Forty-six met the inclusion criteria, namely interventions in long-term facilities helping staff develop their capacity to provide better care and/or QOL for residents with dementia. Thirty-five other papers comprised an associated predictor review. RESULTS: Conclusions from these limited data are further compromised because nine studies failed to measure effects on residents and only half assessed effects after the project team withdrew. Of these, excellent studies produced change over the medium (3-4 months) or longer term, including reduction in challenging behavior and restraint use but this applied only to a minority. A number of studies failed to measure effects on QOC, limiting conclusions about mechanisms underlying change. CONCLUSION: In general, level of intervention required depended on the target. For outcomes like restraint use, structured education sessions with some support appear adequate. Programs to reduce pain require more support. For complicated issues like challenging behavior and increasing co-operation in showering, detailed, supportive, on-site interventions are required. Improvements in restraint and staff/resident interactions were the most promising findings. (Review registration number: PROSPERO 2014:CRD42014015224).
AIM: To investigate effects of robot-assisted group activity with Paro on quality of life in older people with dementia. BACKGROUND: Nursing home residents with severe dementia often experience social withdrawal and lower quality of life, which are suggested to be enhanced by non-pharmacological interventions. DESIGN: A cluster-randomized controlled trial. Ten nursing home units were randomized to robot-assisted intervention or control group (treatment as usual). METHODS: Data were collected between March 2013 – September 2014. 27 participants participated in group activity for 30 minutes twice a week over 12 weeks, 26 participated in the control group. Change in quality of life was assessed by local nurses through the Quality of Life in Late-Stage Dementia scale at baseline, after end of intervention and at three months follow-up. The scale and regular psychotropic medication were analyzed stratified by dementia severity. Analysis using mixed model, one-way ANOVA and linear regression were performed. RESULTS: An effect was found among participants with severe dementia from baseline to follow-up showing stable quality of life in the intervention group compared with a decrease in the control group. The intervention explained most of the variance in change in the total scale and in the subscales describing tension and well-being for the group with severe dementia. The intervention group used significantly less psychotropic medication compared with the control group after end of intervention. CONCLUSION: Pleasant and engaging activities facilitated by nursing staff, such as group activity with Paro, could improve quality of life in people with severe dementia.
BACKGROUND: Nursing homes are important locations for palliative care. High quality palliative care requires an evaluation of the different care needs of the nursing home residents. The interRAI Palliative Care instrument is a comprehensive assessment that evaluates the needs and preferences of adults receiving palliative care. OBJECTIVES: This study aims to evaluate the usefulness, feasibility and face validity of the interRAI Palliative Care instrument. DESIGN: A qualitative study was conducted, based on the abductive reasoning approach. SETTING: Fifteen nursing homes in Flanders (Belgium). PARTICIPANTS: Calls for participation were sent out by four umbrella organizations of Flemish nursing homes (Belgium) and at a national conference for nursing home staff. Nineteen care professionals (nurses, certified nursing assistants, psychologists, physiotherapists, quality coordinators and directors) of 15 nursing homes voluntarily agreed to participate in the study. METHODS: During one year, care professionals evaluated the needs and preferences of all nursing home residents receiving palliative care by means of the interRAI Palliative Care instrument. Data on the usefulness, feasibility and face validity of the interRAI Palliative Care instrument were derived from notes, semi-structured interviews and focus groups with participating care professionals and were thematically analyzed and synthesized. Data were gathered between December 2013 and March 2015. RESULTS: In general, the interRAI Palliative Care (interRAI PC instrument) is a useful instrument according to care professionals in nursing homes. However, care professionals made a series of recommendations in order to optimize the usefulness of the instrument. The interRAI PC instrument is not always feasible to complete because of organizational reasons. Furthermore, the face validity of the instrument could be improved since certain items are incomplete, lacking, redundant or too complex. CONCLUSIONS: Findings highlight the importance of adapting the content of the interRAI Palliative Care instrument for use in nursing homes. Furthermore, the use of the instrument should be integrated in the organization of daily care routines in the nursing homes. Tackling the critical remarks of care professionals will help to optimize the interRAI Palliative Care instrument and hence support palliative care of high quality in nursing homes.
Longstanding concerns about quality care provision, specifically in the area of long-term care, have prompted calls for changing the culture of care to reflect more client-driven and relationship-centred models. Despite an increase in culture change initiatives in both Canada and the United States, there is insufficient information about the theories and approaches that guide culture change. The purpose of this paper is to describe a culture change initiative currently underway in Canada, the Partnerships in Dementia Care Alliance, and the theoretical foundations informing our work. More specifically, we describe how the theoretical and philosophical underpinnings of the Alzheimer Disease and Related Dementias framework, the authentic partnership approach, participatory action research and Appreciative Inquiry have been integrated to guide a culture change process that encourages working collaboratively, thinking and doing differently and re-imagining new possibilities for changing the culture of dementia care.
Research Practice and Methodology
The ways in which social scientists conceptualize the “reflexive” human subject have important consequences for how we go about our research. Whether and how we understand human subjects to be the authors of our own actions helps to structure what we say about health, health care, and the many other topics addressed in qualitative health research. In this article, I critically discuss assumptions of human reflexivity that are built into qualitative social science of health and medicine. I describe three alternative ways of understanding reflexive thought and human action derived from the theoretical works of Pierre Bourdieu, Bruno Latour, and George Lakoff and Mark Johnson, respectively. I then apply these three different ways of thinking about reflexivity and the acting subject to the analysis of an excerpt of participant observation data from a health services research study of transitions from hospital to home, illuminating the different kinds of analyses that arise from each perspective. I conclude with a call for social scientists to commit to the search for better ways of understanding the human subject, resisting the temptation to “settle” on theoretical statements that close down the path to more sophisticated conceptualizations of human thought and action.
An increasing number of family caregivers are seeking services and support due in large part to the dramatic increase in the number of older adults obtaining dementia diagnoses. This paper describes barriers and challenges experienced by our research team in recruiting early-stage dementia caregiving dyads into research studies. Effective recruitment and screening strategies to address these barriers are also discussed. Recruitment and enrollment success depends on these strategies as well as having well-trained recruitment staff who are knowledgeable about the study and have experience working with older adults, and more specifically, persons with dementia.
AIM: To explore how nurses and care-assistants (nursing staff) working in six Flemish nursing homes experience and describe their involvement in grief care. BACKGROUND: Although grief in older people is widely described in literature, less is known about how nursing staff in nursing homes offer and perceive grief care. DESIGN: A qualitative research design with elements of constructivist grounded theory was used. METHODS: Loosely structured face-to-face interviews were done with fourteen nurses and care-assistants. Data were collected from October 2013 – March 2014. Interview transcripts were analysed using the Qualitative Analysis Guide of Leuven (QUAGOL) method with support of NVivo 10. FINDINGS: Grief care in nursing homes is characterized by a complex tension between two care dimensions: (1) being involved while keeping an appropriate distance; and (2) being while doing. Nursing staff described key enablers and influencing factors for grief care at the level of both the individual and the organizational context. CONCLUSION: Findings suggest an established personal sensitivity for grief care considered from the nursing staff points of view. Nevertheless, a common denominator was the necessity to further develop a supportive and multidisciplinary grief care policy ingrained in the existing care culture. Suggested components of this grief care policy are: (a) centring attention on non-death-related loss and the cumulative nature of loss in residents; (b) building capacity by means of reflective practices; and (c) the importance of self-care strategies for nursing staff. Further, the findings from this study point towards a need for education and training.
It is estimated that a population of 12 million receives long-term services and supports. According to Center for Medicare and Medicaid Services (CMS) estimates in 2015, Medicare reimbursed post-acute care for 5.6 million beneficiaries. In 2011, Medicaid funded long-term services and supports for 4.8 million people, with 1.4 million institutionalized [of which 87% were residing in a nursing facility (NF)]. The location of services evolved since 1999, with 13.4% fewer NF residents (approximately 1.6 million) and increased numbers served by home health agency (HHA) (approximately 3.5 million).
PURPOSE: Malnutrition is common in residential care environments, primarily due to poor intake. Micronutrient deficiency, although poorly investigated to date, is also reported to be high. Improving the nutrient density of consumed foods is a potential mechanism to promote increased nutrient intake. A scoping review was conducted to: (1) explore the evidence on micronutrient food fortification strategies, (2) identify candidate nutrients and food vehicles for successful food fortification, and (3) identify gaps for future research. METHODS: The scoping review framework of Arksey and O’Malley was used. A comprehensive search strategy of 4 electronic databases (MEDLINE, EMBASE, CINAHL, and Web of Science) was completed. Two reviewers were involved in screening and data extraction for all selected articles. RESULTS: A total of 4394 relevant articles were identified for screening, and application of inclusion/exclusion criteria resulted in 6 food fortification studies (8 citations; 1 study had 3 citations). Overall, vitamin D (n = 5 studies) and calcium (n = 4 studies) were the most common micronutrients fortified; milk products, margarine, bread, and pureed foods were fortification vehicles. Most studies fortified below the RDA recommendation and did not include clinical outcomes. Samples were small and intervention periods were short (3-6 months). CONCLUSIONS: Fortification is a viable strategy for improving the nutrient density of foods consumed in residential care. Although disparate, this literature suggests the potential for further undertaking of fortification to prevent micronutrient deficiencies among residents and future research should consider multinutrient preparations and clinical outcomes.
BACKGROUND: Determining if a transfer of a skilled nursing facility (SNF) patient/resident to an acute hospital is potentially avoidable or preventable is challenging. Most previous research on potentially avoidable or preventable hospitalizations is based on diagnoses without in-depth root cause analysis (RCA), and few studies have examined SNF staff perspective on preventability of transfers. OBJECTIVES: To examine factors associated with hospital transfers rated as potentially preventable versus nonpreventable by SNF staff. 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: Sixty-four of 88 SNFs randomized to the intervention group submitted RCAs with a rating of whether the transfer was determined to be potentially preventable or nonpreventable. INTERVENTIONS: SNFs were implementing the INTERACT Quality Improvement (QI) program. MEASURES: Data were abstracted from the INTERACT QI tool, a structured, retrospective RCA on hospital transfers. RESULTS: A total of 4527 RCAs with a rating of preventability were submitted during the 12-month implementation period, of which 1044 (23%) were rated as potentially preventable by SNF staff. In unadjusted univariate analyses, factors associated with ratings of potentially preventable included acute changes in condition of fever, decreased food or fluid intake, functional decline, shortness of breath, and new urinary incontinence; other factors included the clinician, resident, and/or family insisting on the transfer, transfers that occurred fewer than 30 days from SNF admission and that occurred on weekends, transfers ordered by a covering physician (as opposed to the primary physician), and transfers that resulted in an emergency department (ED) visit with return to the SNF. Factors associated with ratings of nonpreventable included on-site evaluation by a physician or other clinician, and transfers related to falls. Among factors precipitating the transfers, clinician and resident and/or family insistence on transfer, and transfers related to fever and falls remained significant in a multivariate analysis. There were no significant differences among characteristics of SNFs that rated a relatively high versus low proportion of transfers as potentially preventable. CONCLUSION: SNF staff rated a substantial proportion of transfers as potentially preventable on retrospective RCAs. Factors associated with ratings of preventability, as well as illustrative case examples, provide important insights that can assist SNFs in focusing education and care process improvements in order to reduce unnecessary hospital transfers and their associated morbidity and costs.
OBJECTIVE: Physical restraints are associated with severe side effects and suffering. A comprehensive, person-centered, methodology was implemented in 41 Spanish nursing homes to safely eliminate restraints. METHODS: Data were collected in 2 waves: September 2011 (at the beginning of the intervention, n = 4361) and September 2014 (n = 5051). Use of 10 different types of physical restraints was recorded, as well as frequency of psychotropic medication prescription, falls, and mortality. RESULTS: Mean age was 83.4 (SD 8.5) and 63.5% of the residents had dementia. Frequency (95% confidence interval) of people having at least 1 restraint was reduced from 18.1% (17.0-19.3) to 1.6% (1.3-2.0). Use of benzodiazepines was also reduced, with no significant changes in other psychotropic medications and mortality. The rate of total falls increased from 13.1% (12.1-14.1) to 16.1% (15.1-17.1), with no significant increase in injurious falls. CONCLUSION: Physical restraints can almost completely be eliminated with reasonable levels of safety.
Skin failure is an emerging concept that clarifies trends in clinical practice. Its recognition provides common nomenclature, opens research directions, and questions assumptions regarding pressure ulcers as a quality measure. Adoption of the term is a step toward uniform terminology in compliance with a value based payment system.
OBJECTIVES: To determine the rate of inappropriate admissions to emergency departments (EDs) and to identify determinants of these admissions. DESIGN: Prospective multicenter study. SETTING: Burgundy (France), EDs and medical nursing homes (MNHs). PARTICIPANTS: 1000 Burgundy MNH residents admitted to EDs, from April 17 to June 20, 2013. MEASUREMENTS: For each subject, a questionnaire was completed. Data included age, gender, type of health professional who referred the resident to the ED (THP), whether or not a medical dispatcher organized the transfer to the ED, transport mode, reason for admission to the ED, level of independence according to the Groupes Iso-Ressource score (GIRS), and diagnosis made in the ED. The French version of the Appropriateness Evaluation Protocol grid was applied to each admission to the ED, and in some situations, the expert committee ruled on the appropriateness of the admission to the ED. MNH characteristics were also recorded. Two groups were constituted according to the appropriateness or not of admission to the ED. RESULTS: Mean age of the 1000 residents was 87. There were 706 women. Two-thirds were referred to the EDs by a physician, mainly a general practitioner. In 91.7%, the transfer to the ED was organized by a medical dispatcher, and 8.8% were transported by medicalized transport. More than 95% had a GIRS </=4. Among the admissions to EDs, 18.1% were inappropriate. Female gender (P = .017), nonmedicalized transport (P = .002), public MNH (P = .044), and nonaccess to a geriatric opinion in an emergency (P = .043) were determinants of inappropriate admission to EDs. CONCLUSION: In this first study on admissions to EDs of MNH residents using French data, we found a lower rate of admissions to the ED than that reported in the literature. Female gender, nonmedicalized transport, public MNH, and nonaccess to a geriatric opinion in an emergency were associated with inappropriate admission to EDs.
BACKGROUND: Dementia often eventually leads to dependency on others and finally to residential care. However, in Norway about half of the dementia population lives at home, due to individual and political wishes. There is scarce and inconclusive knowledge of how living in a nursing home differs from living at home for persons with dementia (PWDs) with regard to their quality of life (QoL). The first aim of the study was therefore to compare QoL, cognitive and physical functions, social contacts, sleep patterns, physical activity levels, exposure to light, and medication of PWDs in nursing homes and home-dwelling PWDs, and whether living in nursing homes was associated with a lower QoL than living at home for PWDs. A second aim was to examine if possible differences between residencies in QoL were consistent over time. METHODS: The cross-sectional study was based on baseline data from two RCT studies of PWDs. A total of 15 nursing homes with adapted units for PWDs and 23 adapted day care centres for home-dwelling PWDs recruited 78 and 115 participants respectively. Trained nurses scored sociodemographic data, level of dementia (on the Clinical Dementia Rating scale), amount of medication, and QoL (QUALID). Sleep patterns, physical activity levels, and light exposure were measured by actigraphy. A multiple regression analysis was used to test the association between residency and QoL. The association between residency and change in QoL over time was investigated by linear regression analysis of a subsample with follow-up data. RESULTS: Home-dwelling PWDs showed significantly higher QoL than PWDs in nursing homes. This difference was maintained even after stratifying on the severity of dementia. Home-dwelling PWDs with moderate dementia showed significantly less use of walking aids, more social contact, higher levels of activity and exposure to daylight, and less use of psychotropic medications. The regression model explained 28 % of the variance in QoL in persons with moderate dementia. However, only residency contributed significantly in the model. Residency also significantly predicted negative change over time in QoL. CONCLUSION: The study indicated that living at home as long as possible is not only desirable for economic or health political reasons but also is associated with higher QoL for persons with moderate dementia. More studies are needed to investigate how QoL could be increased for PWDs in nursing homes.
The psychometric properties of The Consumer Assessment of Healthcare Providers and Systems (CAHPS(R)) Nursing Home survey: Discharged Resident Instrument (NHCAHPS-D) are examined. A random sample of 550 nursing homes was selected from across the United States and 365 agreed to participate (participation rate = 66%). From 7,020 surveys sent to discharged residents, 4,926 were returned (response rate = 70%). The psychometric properties of the resident responses and the survey items were robust. Confirmatory factor analyses model fit statistics met the criterion for good conformance. Five of the initial NHCAHPS-D instrument domains were identified (environment, care, communication and respect, autonomy, and activities), along with a sixth (transitions) added by the authors. The standardization and reliability that NHCAHPS-D provides could facilitate the same benefits we have seen in other industries for the CAHPS family of instruments (i.e., quality improvement, reimbursement, public reporting, and benchmarking) and also become an industry standard.
In England and Wales the two most likely places of death are hospitals (52%) and nursing homes (22%). The Department of Health published its National End of Life Care Strategy in July 2008 (Department of Health. End of Life Care Strategy: Promoting High Quality Care For All Adults at the End of Life. London: Department of Health; 2008) to improve the provision of care, recommending the use of the Liverpool Care Pathway for the Dying Patient (LCP). The original aim was to assess the impact of the LCP on care in two settings: nursing homes and intensive care units (ICUs). Qualitative, matched case study. Data were collected from 12 ICUs and 11 nursing homes in England: (1) documentary analysis of provider end-of-life care policy documents; (2) retrospective analysis of 10 deaths in each location using written case notes; (3) interviews with staff about end-of-life care; (4) observation of the care of dying patients; (5) analysis of the case notes pertaining to the observed patient’s death; (6) interview with a member of staff providing care during the observed period; (7) interview with a bereaved relative present during the observation; (8) economic analysis focused on the observed patients; and (9) strict inclusion and selection criteria for nursing homes and ICUs applied to match sites on LCP use/non-LCP use. It was not possible to meet the stated aims of the study. Although 23 sites were recruited, observations were conducted in only 12 sites (eight using the LCP). A robust comparison on the basis of LCP use could not, therefore, take place. Although nurses in both settings reported that the LCP supported good care, the LCP was interpreted and used differently across sites, with the greatest variation in ICUs. Although not able to address the original research question, this study provides an unprecedented insight into care at the end of life in two different settings. The majority of nursing homes had implemented some kind of ‘pathway’ for dying patients and most homes participating in the observational stage were using the LCP. However, training in care of the dying was variable and specific issues were identified relating to general practitioner involvement, the use of anticipatory drugs and the assessment of consciousness and the swallowing reflex. In ICUs, end-of-life care was inextricably linked with the withdrawal of active treatment and controlling the pace of death. The data highlight how the decision to withdraw was made and, importantly, how relatives were involved in this process. The fact that most patients died soon after the withdrawal of interventions was reported to limit the appropriateness of the LCP in this setting. Although the recruitment of matched sites was achieved, variable site participation resulted in a skewed sample. Issues with the sample size and a blurring of LCP use and non-use limit the extent to which the ambitious aims of the study were achieved. This study makes a unique contribution to understanding the complexity of care at the end of life in two very different settings. More research is needed into the ways in which an organisational culture can be created within which the principles of good end-of-life care become translated into practice. The National Institute for Health Research Health Services and Delivery Research programme.
BACKGROUND: Protein energy malnutrition (PEM) predisposes individuals to disease, delays recovery from illness and reduces quality of life. Care home residents in the United Kingdom are especially vulnerable, with an estimated 30 to 42 % at risk. Evidence for nutritional interventions to address PEM in the care home setting is lacking. Widely used techniques include food-based intervention and/or the use of prescribed oral nutritional supplements. To define outcomes and optimise the design for an adequately powered definitive trial to compare the efficacy of established nutritional interventions in this setting, a cluster randomised feasibility trial with a 6-month intervention was undertaken. METHODS: Care home residents with or at risk of malnutrition were identified across six UK care home sites from September to December 2013. Homes were cluster randomised to standard care (SC), food-based intervention (FB) or oral nutritional supplement intervention (ONS), for 6 months. Key outcomes were trial feasibility and the acceptability of design, allocated interventions and outcome assessments. Anthropometry, dietary intake, healthcare resource usage and participant-reported outcome measures were assessed at baseline and at 3 and 6 months. RESULTS: All six care homes approached were recruited and retained. Of the 110 residents at risk of malnutrition, 85 % entered the trial, and 68 % completed the 6-month intervention. Pre-specified success criteria for feasibility were met for recruitment and retention, intervention acceptability (resident compliance >/=60 %) and measurement of weight, body mass index (BMI), mid-upper arm circumference and dietary intake (data completeness >80 %). Measurement of handgrip strength and triceps skinfold thickness was not found to be feasible in this population. The 95 % confidence interval (CI) data suggested sensitivity to change in dietary intake for weight, BMI and energy intake between baseline and 3 months when each intervention (FB and ONS) was compared with SC. CONCLUSIONS: A definitive trial comparing the efficacy of nutritional support interventions in increasing weight and BMI in malnourished care home residents can be conducted. However, whilst the design was feasible, this trial has highlighted the lack of clinically and patient-relevant outcome measures that are appropriate for use in this setting for both research and clinical practice. In particular, this trial identified a need for a more simple measure of functional status, which considers the limitations of functional tests in the care home population. TRIAL REGISTRATION: Current Controlled Trials ISRCTN38047922 , Date assigned: 22 April 2014.
AIM AND OBJECTIVE: To identify the influence of the culture in Canadian long-term care facilities on the awareness of impending death and initiation of a palliative approach to care for residents aged 85 years and older. BACKGROUND: Many long-term care residents die after long, dwindling dying trajectories, yet palliative care is often not provided until within a few hours or days of death. DESIGN: Focused ethnography. METHODS: Data were collected in three long-term care facilities in south-central Ontario, Canada, through interviews with residents, family members and staff members, observation, artefact review and a focus group. Data were analysed using a constant comparative technique. RESULTS: Four cultural influences on the awareness of impending death and consequent initiation of a palliative approach to care were identified: (i) the care demands in long-term care facilities and the resources available to meet these demands; (ii) the belief that long-term care facilities are for living; (iii) the belief that no one should die in pain; and (iv) the belief that no one should die alone. CONCLUSIONS: Commonly held beliefs about the role of long-term care facilities and what is viewed as acceptable care in them mediated the acknowledgement of dying. Late initiation of palliative care was the consequence. In addition, the contextual factors of a low staff-to-resident ratio and reduced staff preparation for palliative care were also influential for a delayed response to dying. IMPLICATIONS FOR PRACTICE: Because strongly held long-term care cultural beliefs underlie care, more timely palliative care for long-term care residents is likely to require the development of an understanding that living and dying are not dichotomous, but rather unfold together from admission until death. Enhanced staff-to-resident ratios and staff training on palliative care will also be necessary to permit long-term care facility staff to focus beyond the currently expected day-to-day care of living residents to provide high-quality end-of-life care throughout the often protracted decline to death for residents of long-term care facilities.
BACKGROUND: Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. METHODS: We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. RESULTS: Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. CONCLUSION: How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.
Inpatient transfer to a care home for end-of-life care: What are the views and experiences of patients and their relatives? A systematic review and narrative synthesis of the UK literature
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BACKGROUND: Transfers from hospital or ‘hospice palliative care units’ to care homes for end-of-life care are an increasingly common part of clinical practice but are a source of anxiety and distress for patients, relatives and healthcare professionals. AIM: To understand the experiences of patients discharged to care homes for end-of-life care. DESIGN: Systematic review and narrative synthesis of the UK literature concerning inpatient transfer from a hospital or hospice palliative care unit to a care home for end-of-life care. RESULTS: The published literature is very limited: only three papers and one conference abstract were identified, all of low quality using Gough’s weight of evidence assessment. No papers examined transfer from hospital: all were of transfers from hospices and were retrospective case note reviews. Many patients were reported to have been negative or ambivalent about moving and experienced feelings of anxiety or abandonment when transferred. Relatives were often either vehemently opposed or ambivalent. Although some came to accept transfer, others reported the transfer to have seriously affected their loved one’s quality of life and that the process of finding a care home had been traumatic. No studies investigated patients’ views prospectively, the views of staff or the processes of decision-making. CONCLUSION: The UK literature is very limited, despite such transfers being an increasingly common part of clinical practice and a source of concern to patients, relatives and staff alike. Further research is urgently needed in this area, especially studies of patients themselves, in order to understand their experiences and views.
PURPOSE: The purpose of this study was to determine whether stage 3, 4, and unstageable pressure injuries develop despite consistently good quality care (CGQC); ascertain whether these wounds occur without prior recognition of a lower-stage pressure injury; and to describe and analyze characteristics of nursing home residents and their higher-stage pressure injuries. DESIGN: Descriptive, nonexperimental, prospective analysis. SUBJECTS AND SETTING: A convenience sample of 20 residents from facilities participated in the study; research sites were located in 7 counties in Western Washington and Orange County, along with a single site in Wisconsin. METHODS: CGQC facilities were identified using a 3-step incremental approach. Research assistants verified CGQC at the facility level. After data collection was complete, a Longitudinal, Expert, All-Data Panel reviewed cases for a final resident-level validity check for CGQC. Remaining cases were submitted to analysis. RESULTS: Residents who developed advanced stage pressure injuries despite CGQC were older, had limited mobility, dementia, comorbid conditions, urinary or fecal incontinence, and infections. The pressure injuries were relatively small and had little-to-no undermining, exudate, or edema. CONCLUSIONS: Stage 3, 4, and unstageable pressure injuries were observed in nursing home residents despite CGQC. Results from this study may serve as a baseline for further research to evaluate characteristics of these wounds when they develop under settings of poor-quality care. Findings also may be useful in creating evidence-based practice guidelines to support decision making around mandatory reporting, diagnosis, and prosecution.
BACKGROUND: Litter is known about the well-being of nursing home (NH) residents in Singapore. This study aimed to identify predictors of self-reported quality of life (QOL) of NH residents in Singapore. METHODS: In face-to-face interviews, trained medical students assessed each consenting resident recruited from 6 local NHs using a modified Minnesota QOL questionnaire, and rating scales and questions assessing independence, cognitive function, depression, and communication. Predictors of residents’ QOL in five aspects (comfort, dignity, food enjoyment, autonomy, and security) were identified using the censored least absolute deviations (CLAD) models. RESULTS: A total of 375 residents completed the interviews. A higher score on comfort was negatively associated with major depression while a higher score on dignity was positively associated with no difficulty in communication with staff. Higher scores in food enjoyment were negatively associated with major depression and poorer cognitive function. Higher scores in autonomy were negatively associated with major depression, greater dependence, and difficulty in communication with staff. A higher score on security were negatively associated with major depression. CONCLUSION: It appears that depression and difficulty in communication with staff are the two main modifiable risk factors of poor quality of life of local NH residents.
Older adults are a growing demographic group in the United States, and a range of physical, social, financial, and cultural factors affect their nutritional status. Metabolic and physiologic changes that accompany normal aging modify the nutritional requirements of older adults. An examination of evidence is needed to better understand how nutritional status is associated with aging and risk of mortality or chronic disease among older adults. On October 28-29, 2015, the Food and Nutrition Board convened a workshop, Meeting the Dietary Needs of Older Adults. The workshop was designed to examine factors in the physical, social, and cultural environment that affect the ability of older adults to meet their daily dietary needs. This document summarizes the presentations and discussions from the workshop.
Preparing a CIHR Stage 1 Foundation Application
We will have the opportunity to hear Dr. Michelle Graham (CIHR Foundation Stage 1 Virtual Chair), Dr. Paul Melançon (CIHR Stage 1 Foundation Reviewer), and Dr. Lonnie Zwaigenbaum (CIHR Foundation Awardee) share their insights into the CIHR Stage 1 Foundation application and review process.
The AIC 2016 aims to advance implementation science – the integration of research findings and evidence into policy and practice – to ensure more effective implementation will result in better health, education and wellbeing for individuals, families, and communities.
The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse event incidence over time in SNFs. Identifying adverse events in SNFs, and the types of harm resulting from such events, can lead to opportunities to improve patient and resident safety.
The event will present an overview of the activities and results of the three Learning Communities (LCs); provide insights about factors that influenced innovation adoption and implementation; and share lessons learned in using LCs as a method to implement innovations to improve quality. A leader, or “champion,” from each LC will present highlights about the learning community experience.
In May 2016, the Trans-NIH Funding Announcements for Dissemination and Implementation Research in Health (PAR-16-238 (R01); PAR-16-236 (R21); and PAR-16-237 (R03)) were re-issued. Webinar(s) were hosted as an opportunity for potential applicants interested in learning more about the re-issued announcements.
The Centre for Evidence and Implementation invites you to join Ms Justine Harris, Senior Advisor Evidence in Practice & Policy at the Centre for Evidence and Implementation (CEI), and Dr Ashli Sheidow, Senior Research Scientist at Oregon Social Learning Center, USA. Together they will present a powerful case study illustrating how evidence has directly informed policy design, program selection, and the program adaptation for emerging adults with mental health conditions in New South Wales, Australia.
This webinar presents some of the core competencies most fundamental to understanding and managing behavioral symptoms associated with the diagnosis of Alzheimer’s disease and related dementias. Practical non-pharmacologic interventions for specific behavioral symptoms will be described and the evidence for the risks and benefits of pharmacological interventions will also be reviewed. Most dementias are associated with a range of neuropsychiatric and behavioral disturbances, with as many as 80% to 90% of older adults developing at least one distressing symptom over the course of their illness. The behavioral disturbances in dementia require evaluation of the specific symptoms, including the person’s comfort, the care environment, the caregiver’s needs, and the degree of distress of all those involved in the life of the adult with dementia.
The MSc is specifically designed for individuals who want to improve health services, equipping you with the methodological and theoretical knowledge to bring about sustainable and large-scale change. The course is practical, yet informed by the latest academic research, and is taught by international experts in the field. The research element of the course provides you with an opportunity to conduct your own improvement or implementation project, or to evaluate an existing project.
Cochrane Author Training Workshop
Are you thinking of undertaking a Cochrane review? Have you recently registered a review title with a Cochrane group? If so, you are invited to join the Cochrane author training workshop at the University of Alberta in November, 2016. This workshop is suitable if you: (1) Have registered a review title about interventions, and are ready to begin writing your protocol; OR (2) Have little or no experience in systematic reviews. For more information, please contact Sherrill Johnson (firstname.lastname@example.org), KT Platform Program Coordinator, Training and Professional Development.
Want to be at the leading edge of a fast moving field in terms of how to bring the best evidence to bear in support of policy development and health-system strengthening? Register now for the McMaster Health Forum’s one-day workshop, where you will: develop your knowledge about tools and resources available to help health system policymakers and stakeholders in order to support their use of research evidence; examine the attitudes that are supportive of using research evidence in health system decision-making; and, begin to develop your skills in acquiring, assessing, adapting and applying research evidence.
The Australian-based research found that one-third of patients with advanced, irreversible chronic conditions were given treatments that didn’t necessarily benefit them — including admission to intensive care or chemotherapy — in the last two weeks of their life. The study also revealed that one-quarter of older patients who had Do-Not-Resuscitate orders were still given cardiopulmonary resuscitation (CPR).
“The number of delayed transfers has been increasing at an alarming rate but does not capture the true extent of older people who should not be in hospital. While there is a clear awareness of the need to discharge older people from hospital sooner, there are currently far too many older people in hospitals who do not need to be there. Without radical action, this problem will worsen and add further strain to the financial sustainability of the NHS and local government.”
Ms. Davison is among a number of older Americans who are having intimate relationships well into their 70s and 80s, helped in some cases by Viagra and more tolerant societal attitudes toward sex outside marriage. These aging lovers have challenged traditional notions of growing old and, in some cases, raised logistical and legal issues for their families, caretakers and the institutions they call home.
A University of Alberta psychology professor was named Thursday as the province’s new seniors advocate, ending a wait of more than two years for the government to fill the role.
If your loved one goes missing, you want them to be found fast. Heather Stephen learns about the Herbert Protocol, which is speeding up searches for vulnerable people, including those with dementia.
States have a huge stake in where aging seniors and disabled people end up getting long-term care because many of them won’t be able to afford to pay for their care and will have to rely on Medicaid, the health care program for the poor and disabled. Each state has its own Medicaid program, funded jointly by the state and the federal government.
Over time, a patient can end up on a growing list of medications. About two-thirds of seniors living in their own homes take five or more drugs, according to data collected by the Canadian Institute for Health Information. One-quarter of seniors are prescribed 10 or more medications. Each new drug that’s added to the mix increases the risk of adverse side effects and medication interactions.
The case of too much medication in Canadian seniors is finally starting to be recognized for the serious problem it has become. Seniors are particularly vulnerable to the adverse effects of too many prescription drugs, because aging affects their ability to process medications. Working aggressively to reduce their daily medication burden might be the single best thing we can do to improve their quality of life.
Doctors need to focus more on using existing prescription drugs now to treat symptoms of Alzheimer’s disease, rather than waiting for the next generation of medicines, say leading researchers.
They are proposing the creation of a new diagnosis: mild behavioral impairment. The idea is to recognize and measure something that some experts say is often overlooked: Sharp changes in mood and behavior may precede the memory and thinking problems of dementia.
Two studies released at an international Alzheimer’s meeting Tuesday suggest doctors may eventually be able to screen people for this form of dementia by testing the ability to identify familiar odors, like smoke, coffee and raspberry.
Publishing one’s research is a cornerstone of the academic life I have chosen, and I want to share three lessons I’ve learned. (I learned these lessons the hard way, as evidenced by the 18 months it took me to publish my first medical article.) I hope they will both guide and encourage the many really smart people I’ve met in my health care journey who have something important to say but have yet to say it in print.
Canada’s three federal research granting agencies—the CIHR, NSERC and SSHRC—have adopted the Tri-Agency Statement of Principles on Digital Data Management as an important step towards strengthening research data management in Canada and maintaining Canada’s research excellence.
The federal government has announced an independent review of federal funding of the basic sciences. This will assess the program machinery that is currently in place to support science and scientists in Canada. The scope of the review will include the three funding agencies (CIHR, NSERC and SSHRC), as well as additional agencies such as the Canada Foundation for Innovation. Outputs from this review will be core components of the federal government’s Innovation Agenda.
This measure is used to assess the percent of long-stay, high-risk residents with Stage II-IV pressure ulcers.
This measure is used to assess the percent of long-stay residents who have/had an indwelling catheter in the last 7 days.
This measure is used to assess the percent of long-stay residents who self-report report either (1) almost constant or frequent moderate to severe pain in the last 5 days or (2) any very severe/horrible pain in the last 5 days.
This measure is used to assess the percent of long-stay nursing facility residents who were physically restrained on a daily basis.
The “Quality Assessment Tool for Quantitative Studies” developed by the Effective Public Health Practice Project (EPHPP) is a tool for doing knowledge synthesis. This instrument, along with a user manual, provides a standardized means to assess study quality and develop recommendations for study findings. The quality appraisal tool was developed by the Effective Public Health Practice Project (EPHPP) as a discrete step within the systematic review process.
The postdoctoral scholar will be responsible for knowledge mobilization (KM) activities and evaluation related to the VEGA project. S/he will coordinate and support all stages of the knowledge mobilization plan, act as liaison between Research Staff involved in the consultation work and the Project (Faculty) supports and play a key role in the knowledge mobilization evaluation. In addition, the postdoctoral scholar will participate in both project and national-level committee meetings and other key activities, conduct project evaluation tasks, support knowledge mobilization activities, and coordinate the integration of findings across various data sources.
Seniors – Adding Life to Years (SALTY) is a multi-disciplinary, multi-sectoral, pan-Canadian research team aiming to contribute measurably to improving the experience of the final years in long term care (LTC) for older adults, their families, and the workers who care for them. The team is utilizing an integrated knowledge translation (iKT) model to challenge current thinking and practice and undertake robust multi-method health services research. The project consists of 4 integrated research streams.
The Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) has an immediate opening for an Assistant professor, Health Services Research in implementation research involving large-scale health systems. This individual will play a key role in developing health care delivery science research programs and federally funded research grants. The recruit will develop their own research agenda as well as be a scientific resource and mentor faculty and trainees wishing to develop health services research across the AMC campus.
As part of the Section of Early Detection and Prevention (EDP), the goals of the Prevention and Implementation Group (PRI) are to evaluate new preventive strategies, with particular emphasis on the use of new technologies, including molecular markers; to engage in research on methods to implement existing strategies taking into account the social, economic and cultural differences; to collaborate with decision makers to implement already available preventive interventions against cancer, particularly in developing countries where the need is highest and to foster technology transfer and generate educational processes for clinicians, public health decision makers and the public, to make sure the available technology is put in place where it is needed most.
Implementation Scientist, Center for Clinical Quality and Implementation Research
Opportunities are available for tenure or non-tenure track positions, and for junior or senior faculty. We also seek senior research staff and post-doctoral applicants. Successful candidates will be expected to lead interdisciplinary research teams, teach and mentor trainees, perform quantitative and qualitative program evaluations, author scientific manuscripts, and develop grant applications. Experience in statistical analysis, program evaluation, and scientific writing is necessary. The ideal candidate will also have excellent written and verbal communication skills, organizational skills, and experience in quality assessment/improvement or implementation science. For More Information Contact: Sunil Kripalani (MD, MSc, SFHM) Director, Center for Clinical Quality and Implementation Research, email@example.com
This exciting position offers the opportunity for multidisciplinary research on dissemination and implementation with a focus on women’s health and special interest in adolescent reproductive health and family planning.
Dr. Aarons’ lab focuses on the implementation and sustainment of evidence-based practices in community-based settings including the development and testing of implementation strategies and the development of pragmatic measures to assess key implementation constructs. Dr. Aarons’ lab is also known for examination of system and organizational level evidence-based practice sustainment and the advancement and integration of quantitative and qualitative methods in implementation research.
The Department of Health Systems, Management and Policy (HSMP) within the Colorado School of Public Health and The Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) have an immediate opening for a Postdoctoral Fellow/Trainee in health dissemination research involving large-scale health systems. This is a 1-year fellowship with the opportunity for a second-year renewal.