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New book chapter by Dr. Jo Rycroft-Malone
Organising to connect academic knowledge and practice in healthcare
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New article by Dr. Jo Rycroft-Malone
Bringing critical realism to nursing practice: Roy Bhaskar’s contribution
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In the context of modern nursing practice that is embedded within complex social situations, critical discussions about the contribution of major philosophers are relevant and important. Whilst nurse theorists have advanced and shaped nursing as a discipline, other major philosophers can offer much to advance nursing enquiry. In this paper, we focus on philosopher Roy Bhaskar who, amongst others, developed critical realism, a philosophy for social science which connects with how many of us think about the world. Bhaskar’s work focuses our attention on the interplay between structure and agency and on the search for the causative or generative mechanisms that explain the social world. Bhaskar was interested in human emancipation, and we suggest his work is of great importance to advance understanding of complex social situations. Critical realism has already been endorsed by a range of disciplines, especially in research which focuses on real problems and acknowledges the complexities of the social world. In recent evidence from healthcare literature, there has been a surge in research using realist methodology (realist evaluation and realist synthesis), which is underpinned by the philosophy of critical realism and which offers a different perspective to understanding nursing and healthcare problems through the realist lens. However, we suggest that sufficient attention is not always paid to the philosophical roots of this methodology. In this paper, we provide insight into Bhaskar’s work and demonstrate how research positioned within critical realism and realist methodology can advance nursing and healthcare-related knowledge. Through shining a light on Bhaskar, we illustrate how critical realism philosophy is a natural fit with human and health science enquiry, including nursing.
Calls for Abstracts
Expression of Interest materials are now available for Changing CARE
Through Changing CARE, The Change Foundation will fund up to three projects from health care delivery or service organizations in Ontario. Projects will receive initial funding of up to $75,000 for the first four months, and $750,000 to $1,000,000 (amount subject to Change Foundation Board Approval) in each of the next three subsequent years, through to fiscal year 2019-2020.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice and Methodology
Aging
KT
Infusing Science into Politics and Policy: The Importance of Legislators as an Audience in Mental Health Policy Dissemination Research
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Legislators (i.e., elected Senators and House Representatives at the federal- and state-level) are a critically important dissemination audience because they shape the architecture of the US mental health system through budgetary and regulatory decisions. In this Point of View, we argue that legislators are a neglected audience in mental health dissemination research. We synthesize relevant research, discuss its potential implications for dissemination efforts, identify challenges, and outline areas for future study.
The Roles of System and Organizational Leadership in System-Wide Evidence-Based Intervention Sustainment: A Mixed-Method Study
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If evidence-based interventions (EBIs) are not sustained, investments are wasted and public health impact is limited. Leadership has been suggested as a key determinant of implementation and sustainment; however, little empirical work has examined this factor. This mixed-methods study framed using the Exploration, Preparation, Implementation, Sustainment (EPIS) conceptual framework examines leadership in both the outer service system context and inner organizational context in eleven system-wide implementations of the same EBI across two U.S. states and 87 counties. Quantitative data at the outer context (i.e., system) and inner context (i.e., team) levels demonstrated that leadership predicted future sustainment and differentiated between sites with full, partial, or no sustainment. In the outer context positive sustainment leadership was characterized as establishing a project’s mission and vision, early and continued planning for sustainment, realistic project plans, and having alternative strategies for project survival. Inner context frontline transformational leadership predicted sustainment while passive-avoidant leadership predicted non-sustainment. Qualitative results found that sustainment was associated with outer context leadership characterized by engagement in ongoing supportive EBI championing, marketing to stakeholders; persevering in these activities; taking action to institutionalize the EBI with funding, contracting, and system improvement plans; and fostering ongoing collaboration between stakeholders at state and county, and community stakeholder levels. For frontline leadership the most important activities included championing the EBI and providing practical support for service providers. There was both convergence and expansion that identified unique contributions of the quantitative and qualitative methods. Greater attention to leadership in both the outer system and inner organizational contexts is warranted to enhance EBI implementation and sustainment.
The sciences are different and the differences matter
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While biology often has been identified as the field of science where over the past half century progress has been most dramatic, physics continues to be the widely held model of what a field of science should aim to be like. The ideal hallmarks are quantitative characterization of the subject matter studied and mathematical specification of theory. The central argument of this paper is that the subject matter of many important fields of science is very different from that of physics – several of the physical sciences and much of biology, as well as the social sciences, are good examples – and that trying to ape the descriptive and analytic characteristics of physics in these fields hinders the development of understanding. Research on innovation is among this class.
Varieties of scientific knowledge and their contributions to dealing with policy problems: A response to Richard Nelson’s “The sciences are different and the differences matter”
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The substantial differences between the kind of knowledge characteristic of classical mechanics and that found in much 20th century physics, biology and the human sciences have made the belief that there is a single model of scientific knowledge best represented by Newtonian physics increasingly untenable. The more that sciences deal with phenomena that are complex in terms of their internal structures, are partially constituted by their connections to their contexts, and whose causally influential processes are subject to endogenous change, the more important it is to recognise the diversity of the kinds of knowledge they produce and their varied connections to material and social technologies. Theories and models that differ in their contextual independence, complexity of internal structures and specificity of causal processes contribute in different ways and under different conditions to the resolution of policy issues. Applying causal models of what worked in other situations to policy problems often fail because key contingencies not included in such models have changed and/or their success has itself altered actors’ perceptions and preferences.
A Triple Helix Model of Medical Innovation: Supply, Demand, and Technological Capabilities in terms of Medical Subject Headings
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We develop a model of innovation that enables us to trace the interplay among three key dimensions of the innovation process: (i) demand of and (ii) supply for innovation, and (iii) technological capabilities available to generate innovation in the forms of products, processes, and services. Building on triple helix research, we use entropy statistics to elaborate an indicator of mutual information among these dimensions that can provide indication of reduction of uncertainty. To do so, we focus on the medical context, where uncertainty poses significant challenges to the governance of innovation. We use the Medical Subject Headings (MeSH) of MEDLINE/PubMed to identify publications within the categories “Diseases” (C), “Drugs and Chemicals” (D), “Analytic, Diagnostic, and Therapeutic Techniques and Equipment” (E) and use these as knowledge representations of demand, supply, and technological capabilities, respectively. Three case-studies of medical research areas are used as representative ‘entry perspectives’ of the medical innovation process. These are: (i) human papilloma virus, (ii) RNA interference, and (iii) magnetic resonance imaging. We find statistically significant periods of synergy among demand, supply, and technological capabilities (C-D-E) that point to three-dimensional interactions as a fundamental perspective for the understanding and governance of the uncertainty associated with medical innovation. Among the pairwise configurations in these contexts, the demand–technological capabilities (C-E) provided the strongest link, followed by the supply–demand (D-C) and the supply–technological capabilities (D-E) channels.
Implementation and de-implementation: two sides of the same coin?
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Avoiding low value care received increasing attention in many countries, as with the Choosing Wisely campaign and other initiatives to abandon care that wastes resources or delivers no benefit to patients. While an extensive literature characterises approaches to implementing evidence-based care, we have limited understanding of the process of de-implementation, such as abandoning existing low value practices. To learn more about the differences between implementation and de-implementation, we explored the literature and analysed data from two published studies (one implementation and one de-implementation) by the same orthopaedic surgeons. We defined ‘leaders’ as those orthopaedic surgeons who implemented, or de-implemented, the target processes of care and laggards as those who did not. Our findings suggest that leaders in implementation share some characteristics with leaders in de-implementation when comparing them with laggards, such as more open to new evidence, younger and less time in clinical practice. However, leaders in de-implementation and implementation differed in some other characteristics and were not the same persons. Thus, leading in implementation or de-implementation may depend to some degree on the type of intervention rather than entirely reflecting personal characteristics. De-implementation seemed to be hampered by motivational factors such as department priorities, and economic and political factors such as cost-benefit considerations in care delivery, whereas organisational factors were associated only with implementation. The only barrier or facilitator common to both implementation and de-implementation consisted of outcome expectancy (ie, the perceived net benefit to patients). Future studies need to test the hypotheses generated from this study and improve our understanding of differences between the processes of implementation and de-implementation in the people who are most likely to lead (or resist) these efforts.
Exploring the barriers to and facilitators of implementing research into practice
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District and community nursing roles have changed rapidly in recent years. Community nurses are increasingly being tasked with carrying out multiple roles, which require them to put research into practice and use evidence-based tools and interventions. The implementation of interventions and tools needs to be developed from empirical research, requiring evidence, to be translated into practice. However, this process may be compromised or enhanced by a number of factors. This exploratory, descriptive qualitative study sought to identify barriers and facilitators to community nurses implementing research into practice. Four focus groups were conducted with registered community nurses and district nurses (n=22). Analysis identified four main themes: keeping up to date with evidence; using a clinical tool; education/training and implementation. Findings suggest that there are barriers at a personal, professional and organisational level. Strategies are suggested to overcome these obstacles.
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Health Care Administration and Organization
The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study 
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BACKGROUND: Considering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC. OBJECTIVES: This study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices. METHODS: A mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012. RESULTS: Implementing a nurse practitioner-led pain team in LTC significantly reduced residents’ pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC. CONCLUSIONS: The findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.
Current role challenges in New Zealand aged residential care: the potential consequences for healthcare assistant role expansion
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BACKGROUND: Challenges facing healthcare assistants in aged residential care are a focus of global debate. These challenges involve remuneration, education, skill mix, work conditions and organisational structures. OBJECTIVES/AIMS: We enter the discussion by acknowledging current work, education and remuneration for healthcare assistants. We then consider the supervisory relationships between registered nurses (RNs), enrolled nurses (ENs) and healthcare assistants, educational levels for RNs, ENs and healthcare assistants, and the interplay between organisation and practice in aged residential care. We suggest that improving work for the healthcare assistant has the potential to lead change in all role levels. DESIGN: Discussion paper. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: We argue that adjustments to work structures, education and skill advancement of RNs, ENs and healthcare assistants could improve staff working conditions and clarify practice boundaries. The ultimate result is likely to be an improvement to quality of care and the life of residents in aged residential care.
The Development of the strain in dementia care scale (SDCS)
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BACKGROUND: Though many staff gain satisfaction from working with people with dementia in residential facilities, they also experience significant stress. This is a serious issue because this in turn can affect the quality of care. There is, however, a lack of instruments to measure staff strain in the dementia-specific residential care environment, and the aim of this study, accordingly, was to develop the “Strain in Dementia Care Scale.” METHODS: The instrument was developed in three steps. In the first step, items were derived from six focus group discussions with 35 nurses in the United Kingdom, Australia, and Sweden concerning their experience of strain. In the second step, a preliminary 64-item scale was distributed to 927 dementia care staff in Australia and Sweden, which, based on exploratory factor analysis, resulted in a 29-item scale. In the final step, the 29-item scale was distributed to a new sample of 346 staff in Sweden, and the results were subjected to confirmatory factor analysis. RESULTS: The final scale comprised the following 27 items producing a five-factor solution: Frustrated empathy; difficulties understanding and interpreting; balancing competing needs; balancing emotional involvement; and lack of recognition. CONCLUSIONS: The scale can be used (a) as an outcome measurement in residential care intervention studies; (b) to help residential facilities identify interventions needed to improve staff well-being, and, by extension, those they care for.
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Health Care Innovation and Quality Assurance
Can learning sets help policy managers with their wicked problems?
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This paper reports on an evaluation of a national action learning set for health policy managers from three Australian state/territory health authorities, conducted during 2010–2011. We collected and analysed qualitative data about the major problems the participants encountered in their work, their experiences of the learning set and their perceptions of the outcomes. The predominant concerns of participants were ‘wicked problems’ in four areas: managing the environment, managing the policy process, managing the self and managing the policy team. Participants reported that the learning set had assisted them to gain greater awareness of and ability to navigate their environment, developed their judgement, strategic and problem-solving skills, contributed to empowerment and self-efficacy, and assisted them in providing support for their staff and building capacity in their organisation. Aspects of the method that contributed to learning included engaging with problems experienced by other members and discussing one’s own problems and strategies; and gaining new insight into ways of framing, analysing and responding to problems. The findings suggest that learning sets can be a powerful method for building policy capacity amongst middle-senior policy managers.
Implementation of Telemedicine Consultation to Assess Unplanned Transfers in Rural Long-Term Care Facilities, 2012-2015: A Pilot Study
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INTRODUCTION: Public and private entities in the United States spend billions of dollars each year on potentially avoidable hospitalizations. This is a common occurrence in long-term care (LTC) facilities, especially in rural jurisdictions. This article details the creation of a telemedicine approach to assess residents from rural LTC facilities for potential transfer to hospitals. METHODS: An electronic LTC (eLTC) pilot was conducted in 20 pilot LTC facilities from 2012-2015. Each site underwent technologic assessment and upgrading to ensure that 2-way video communication was possible. A new central “hub” was staffed with advanced practice providers and registered nurses. Long-term care pilot sites were trained and rolled out over 3 years. This article reports development and implementation of the pilot, as well as descriptive statistics associated with provider assessments and averted transfers. RESULTS: Over 3 years, 736 eLTC consultations occurred in pilot sites. One-quarter of consultations occurred between 10 pm and 9 am. Overall, approximately 31% of cases were transferred. This decreased from 54% of cases in 2013 to 17% in 2015. Rural pilot facilities had an average of 23 eLTC consults per site per year. DISCUSSION: Averted transfers represent a dramatic benefit to the residents, as potentially avoidable hospitalizations cause undue stress and allow for nosocomial infections, among other risks. In addition, averting these unnecessary transfers likely saved the taxpayers of the United States over $5 million in admission-related charges to Centers for Medicare and Medicaid Services (511 avoided transfers x $11,000 per average hospitalization from a LTC facility). CONCLUSIONS: Overall, the eLTC pilot showed promise as a proof-of-concept. The pilot’s implementation resulted in increasing utilization and promising reductions in unnecessary transfers to emergency departments and hospitalizations.
Implementing Dementia Care Mapping to Develop Person-Centred Care: Results of a Process Evaluation within the Leben-QD II Trial
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AIMS AND OBJECTIVE: To evaluate Dementia Care Mapping (DCM) implementation in nursing homes. BACKGROUND: DCM, an internationally applied method for supporting and enhancing person-centred care (PCC) for people with dementia, must be successfully implemented into care practice for its effective use. Various factors influence the implementation of complex interventions such as DCM; few studies have examined specific factors influencing DCM implementation. DESIGN: A convergent parallel mixed methods design embedded in a quasi-experimental trial was used to assess DCM implementation success and influential factors. METHODS: From 2011 to 2013, nine nursing units in nine different nursing homes implemented either DCM (n=6) or a periodic quality of life measurement using the dementia-specific instrument QUALIDEM (n=3). Diverse data (interviews, n=27; questionnaires, n=112; resident records, n=81; and process documents) were collected. Each data set was separately analysed and then merged to comprehensively portray the implementation process. RESULTS: Four nursing units implemented the particular intervention without deviating from the pre-planned intervention. Translating DCM results into practice was challenging. Necessary organisational preconditions for DCM implementation included well-functioning networks, a dementia-friendly culture, and flexible organisational structures. Involved individuals’ positive attitudes towards DCM also facilitated implementation. Precisely planning the intervention and its implementation, recruiting champions who supported DCM implementation, and having well-qualified, experienced project coordinators were essential to the implementation process. CONCLUSIONS: For successful DCM implementation, it must be embedded in a systematic implementation strategy considering the specific setting. Organisational preconditions may need to be developed before DCM implementation. Necessary steps may include team building, developing and realising a PCC-based mission statement, or educating staff regarding general dementia care. The implementation strategy may include attracting and involving individuals on different hierarchical levels in DCM implementation and supporting staff to translate DCM results into practice. RELEVANCE TO PRACTICE: The identified facilitating factors can guide DCM implementation strategy development.
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Research Practice and Methodology
Portraying Reflexivity in Health Services Research
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A model is proposed for supporting reflexivity in qualitative health research, informed by arguments from Bourdieu and Finlay. Bourdieu refers to mastering the subjective relation to the object at three levels-the overall social space, the field of specialists, and the scholastic universe. The model overlays Bourdieu’s levels of objectivation with Finlay’s three stages of research (pre-research, data collection, and data analysis). The intersections of these two ways of considering reflexivity, displayed as cells of a matrix, pose questions and offer prompts to productively challenge health researchers’ reflexivity. Portraiture is used to show how these challenges and prompts can facilitate such reflexivity, as illustrated in a research project.
Strengthening Research through Data Sharing
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Data sharing has incredible potential to strengthen academic research, the practice of medicine, and the integrity of the clinical trial system. Some benefits are obvious: when researchers have access to complete data, they can answer new questions, explore different lines of analysis, and more efficiently conduct large-scale analyses across trials.
Understanding Research Impact: A Review of Existing and Emerging Tools for Nursing
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Researchers and educators are required to show the impact they have in their field when they apply for promotion or extramural funding. There are several tools available for nursing faculty to consult as they build a research impact profile. This article highlights both traditional and more novel tools, the impact metrics they calculate, and why the tools are particularly relevant to the field of nursing.
A Guide to Writing a Qualitative Systematic Review Protocol to Enhance Evidence-Based Practice in Nursing and Health Care
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BACKGROUND: The qualitative systematic review is a rapidly developing area of nursing research. In order to present trustworthy, high-quality recommendations, such reviews should be based on a review protocol to minimize bias and enhance transparency and reproducibility. Although there are a number of resources available to guide researchers in developing a quantitative review protocol, very few resources exist for qualitative reviews. AIMS: To guide researchers through the process of developing a qualitative systematic review protocol, using an example review question. METHODOLOGY: The key elements required in a systematic review protocol are discussed, with a focus on application to qualitative reviews: Development of a research question; formulation of key search terms and strategies; designing a multistage review process; critical appraisal of qualitative literature; development of data extraction techniques; and data synthesis. The paper highlights important considerations during the protocol development process, and uses a previously developed review question as a working example. IMPLICATIONS FOR RESEARCH: This paper will assist novice researchers in developing a qualitative systematic review protocol. By providing a worked example of a protocol, the paper encourages the development of review protocols, enhancing the trustworthiness and value of the completed qualitative systematic review findings. LINKING EVIDENCE TO ACTION: Qualitative systematic reviews should be based on well planned, peer reviewed protocols to enhance the trustworthiness of results and thus their usefulness in clinical practice. Protocols should outline, in detail, the processes which will be used to undertake the review, including key search terms, inclusion and exclusion criteria, and the methods used for critical appraisal, data extraction and data analysis to facilitate transparency of the review process. Additionally, journals should encourage and support the publication of review protocols, and should require reference to a protocol prior to publication of the review results.
Measuring Use of Research Evidence: The Structured Interview for Evidence Use
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Objectives: This article describes the Standard Interview for Evidence Use (SIEU), a measure to assess the level of engagement in acquiring, evaluating, and applying research evidence in health and social service settings. Method: Three scales measuring input, process, and output of research evidence and eight subscales were identified using principal axis factor analysis and parallel analysis of data collected from 202 state and county child welfare, mental health, and juvenile justice systems leaders. Results: The SIEU scales and subscales demonstrate strong internal consistency as well as convergent and discriminant validity. Conclusions: The SIEU is easy to use and can be administered as a complete scale or as three smaller scales to separately examine evidence in acquisition, evaluation, or application. The measure demonstrates potential in understanding the role of research evidence in service settings and in monitoring the process of evidence-based practice and application of scientific principles in social work practice.
Going beyond systematic reviews: Realist and meta-narrative reviews
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Health information technologies are complex interventions whose effects differ across contexts. To improve our understanding of the effects of health information technologies, approaches are needed that utilize evidence beyond experimental results in order to provide explanatory answers to how and why a given technology works. The relatively new realist and meta-narrative review approaches are introduced as important methods in synthesising and analysing evidence in the field of health informatics. A common purpose of these two review approaches is to help create a sense of evidence about complex interventions that enables an understanding of how and why they work. A detailed description of the principles and objectives of the two types of reviews is presented. Key steps required to conduct each of the reviews are summarized, and examples of how the review approaches have been applied to topics related to health informatics are provided. Limitations of the two review approaches are discussed.
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Aging
Repeated Hospital Transfers and Associated Outcomes by Residency Time Among Nursing Home Residents in Taiwan
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BACKGROUND: Nursing home residents’ repeated transfers to hospital are costly and can lead to in-hospital complications and high mortality for frail residents. However, no research has examined the trajectory of residents’ symptoms over their nursing home residency and its relationship to hospital transfer. AIM: The purpose of this retrospective chart-review study was to examine associations between nursing home residents’ characteristics, including length of residency, and repeated hospital transfers as well as the trajectory of transfers during residency. DESIGN: For this retrospective study, we reviewed 583 residents’ charts in 6 randomly selected nursing homes from northern Taiwan. Data were analyzed by descriptive statistics, chi-squared tests, and 1-way analysis of variance. RESULTS: About half of nursing home residents who had been transferred to hospital (n = 320) were transferred more than twice during their residency (50.97%). Residents who had been transferred 1, 2, 3, or >/=4 times differed significantly in length of residency (F = 3.85, P = .01), physical status (F = 2.65, P = .05), medical history of pneumonia (chi2 = 13.03, P = .01), and fractures (chi2 = 8.52, P = .04). Residents with different numbers of transfers differed significantly in their reasons for transfer, that is, falls (chi2 = 13.01, P = .01) and tube problems (chi2 = 8.87, P = .03). Among 705 total transfers, fever was the top reason for transfer, and transfer prevalence increased with nursing home residency. CONCLUSION: To decrease the chance of residents’ hospital transfer, nursing home staff should be educated about recognizing and managing fever symptoms, infection-control programs such as influenza vaccination should be initiated, and fall-prevention/education programs should be started when residents first relocate to nursing homes.
Normalising and planning for death in residential care: findings from a qualitative focus group study of a specialist palliative care intervention
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BACKGROUND: Improving access to palliative care for older adults living in residential care is recognised internationally as a pressing clinical need. The integration of specialist palliative care in residential care for older adults is not yet standard practice. OBJECTIVE: This study aimed to understand the experience and impact of integrating a specialist palliative care model on residents, relatives and staff. METHODS: Focus groups were held with staff (n=40) and relatives (n=17). Thematic analysis was applied to the data. RESULTS: Three major themes were identified. The intervention led to (1) normalising death and dying in these settings, (2) timely access to a palliative care specialist who was able to prescribe anticipatory medications aiding symptom management and unnecessary hospitalisations and (3) better decision-making and planned care for residents, which meant that staff and relatives were better informed about, and prepared for, the resident’s likely trajectory. CONCLUSIONS: The intervention normalised death and dying and also underlined the important role that specialists play in providing staff education, timely access to medicines and advance care planning. The findings from our study, and the growing wealth of evidence integrating specialist palliative care in residential care for older adults, indicate a number of priorities for care providers, academics and policymakers. Further work on determining the role of primary and specialist palliative care services in residential care settings is needed to inform service delivery models.
Quality of life assessments in nursing homes revealed a tendency of proxies to moderate patients’ self-reports
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OBJECTIVE: Research into different patient populations suggests that, on average, proxies report poorer health-related quality of life (HRQoL) compared to self-reports. . We aimed to investigate whether the difference between proxy-reports and self-reports (inter-rater gap) varies across the whole range of self-reports from low to high HRQoL scores, . STUDY DESIGN AND SETTING: A cross-sectional study in 16 Dutch nursing home dementia special care (DSC) units (n=256) and 17 somatic units (n=326). Professional carers, blinded to self-reports, provided Euroqol-5D scores from two perspectives: their own perspective (proxy-proxy) of the patients’ HRQoL, and the estimation of the patient’s view (proxy-patient). RESULTS: The inter-rater gap varied linearly in both DSC and somatic patients from proxy-scores overestimating low self-reports to proxy-scores underestimating high self-reports. This attenuation tendency existed for both proxy-proxy and proxy-patient perspectives. The inter-rater gap tended to be smaller for the proxy-patient perspective. CONCLUSIONS: Proxies (professional carers) tend to attenuate self-reports in NH patients with and without dementia towards moderate scores rather than report systematically poorer HRQoL. A proxy-patient perspective may be preferable to a proxy-proxy perspective for the purpose of estimating self-reports. Further research into other populations is needed to understand whether the attenuation tendency is a general phenomenon.
Improving quality of care and reducing unnecessary hospital admissions: a literature review
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As the UK population lives to older ages, with more complex health and social care needs, there comes a time when going to live in a care home might be essential for a frail, older person. Residents and their families expect high-quality care in return for the costs of their placements, but often find this is not the case ( Help the Aged, 2006 ). In order to improve quality in care homes, the Lincolnshire Community Health Services NHS Trust are piloting a care home support team. The new service aims to provide education and training to an unpredictable workforce, with the addition of regular ward rounds in care homes to ensure more proactive care for residents, in order to reduce unnecessary hospital admissions and improve the quality of care offered. This article looks at the literature relating to education and training for staff in care homes to support this service. It also aims to use the reviewed articles to identify specific training and education needed to improve quality of care for residents and reduce avoidable hospital admissions.
Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them
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OBJECTIVES: To examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions. DESIGN: Population-based 10-year retrospective cohort study from 2000 to 2011. SETTING: General community. PARTICIPANTS: All individuals aged 65 and older newly diagnosed with dementia in British Columbia, Canada. MEASUREMENTS: The frequency and timing of transitions over 10 years, participant characteristics associated with greater number of transitions, and the influence of recommended dementia care and high-quality primary care on number of transitions. RESULTS: Individuals experience a spike in transitions during the year of diagnosis, driven primarily by hospitalizations, despite accounting for end of life or newly moving to a long-term care facility (LTCF). This occurs regardless of survival time or care location. Regardless of survival time, individuals not in LTCFs experience a marked increase in hospitalizations in the year before and the year of death, often exceeding hospitalizations in the year of diagnosis. Receipt of recommended dementia care and receipt of high-quality primary care were independently associated with fewer transitions across care settings. CONCLUSION: The spike in transitions in the year of diagnosis highlights a distressing period for individuals with dementia during which unwanted or unnecessary transitions might occur and suggests a useful target for interventions. There is an association between recommended dementia care and outcomes and evidence of the continued value of high-quality primary care in a complex population at a critical point when gaps in continuity are especially likely.
“It Can’t Happen Soon Enough.” The Role of Readiness in Residential Moves by Older Parents
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My father moved from his home of 92 years to a care community in a distant location. This is the story of his move, from the perspective of a gerontologist and soon-to-be young-old daughter. I describe the events that prompted my father’s decision to make the move, how I chose the care community, the transition arrangements, and the outcomes. I discuss key factors that contributed to the successful transition, all with a focus on readiness. Other factors included drawing on my knowledge as a gerontologist, using informal networks to identify a care community, visiting the care community repeatedly, and communicating openly and often with family. I briefly describe my father’s quality of life after the move. I examine my experiences in the context of relevant research in gerontology, recommend how gerontologists can manage transitions to care communities for their aging parents, and offer suggestions for research.
Relationship between frailty, physical performance and quality of life among nursing home residents: the SENIOR cohort
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BACKGROUND: The aim of this study was to assess the relationship between frailty and a large number of indicators related to physical and muscular performance as well as quality of life. METHODS: This is an analysis of data collected at baseline in the Sample of Elderly Nursing home Individuals: an Observational Research (SENIOR) cohort including nursing home residents. Subjects are volunteer, oriented and able to walk (walking assistance allowed) nursing home residents in Belgium. A large number of demographic and clinical characteristics, including physical and muscular performance, were collected from each patient. The prevalence of frailty in this population was assessed using Fried’s definition. RESULTS: In total, 662 subjects are included in this analysis. The mean age of the sample is 83.2 +/- 8.99 years, and 484 (73.1 %) are women. In this population of nursing home residents, the prevalence of frailty is 25.1 %, pre-frailty, 59.8 % and robustness, 15.1 %. Compared to non-frail subjects, frail subjects have lower physical and muscular performances and a lower quality of life. CONCLUSION: Frailty, according to Fried’s definition, seems to be associated with several clinical indicators suggesting a higher level of disability and an increased propensity to develop major clinical consequences. Follow-up data of the SENIOR cohort will be helpful in confirming these findings, establishing cause-effect relationships and identifying the most predictive components of physical frailty for adverse outcomes in nursing homes.
A cross-sectional survey to investigate the quality of care in Tuscan (Italy) nursing homes: the structural, process and outcome indicators of nutritional care
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BACKGROUND: Previous studies have investigated process and structure indicators of nutritional care as well as their use in nursing homes (NHs), but the relative weight of these indicators in predicting the risk of malnutrition remains unclear. Aims of the present study are to describe the quality indicators of nutritional care in older residents in a sample of NHs in Tuscany, Italy, and to evaluate the predictors of protein-energy malnutrition risk. METHODS: A cross-sectional survey was conducted in 67 NHs. Information was collected to evaluate quality indicators of nutritional care and the individual risk factors for malnutrition, which was assessed using the Malnutrition Universal Screening Tool. A multilevel model was used to analyse the association between risk and predictors. RESULTS: Out of 2395 participants, 23.7 % were at high, 11 % at medium, and 65.3 % at low risk for malnutrition. Forty-two percent of the NHs had only a personal scale to weigh residents; 88 % did not routinely use a screening test/tool for malnutrition; 60 % used some standardized approach for weight measurement; 43 % did not assess the severity of dysphagia; 12 % were not staffed with dietitians. Patients living in NHs where a chair or platform scale was available had a significantly lower risk of malnutrition (OR = 0.73; 95 % CI = 0.56-0.94). None of the other structural or process quality indicators showed a statistically significant association with malnutrition risk. CONCLUSIONS: Of all the process and structural indicators considered, only the absence of an adequate scale to weigh residents predicted the risk of malnutrition, after adjusting for case mix. These findings prompt the conduction of further investigations on the effectiveness of structural and process indicators that are used to describe quality of nutritional care in NHs.
Mini-Nutritional Assessment, Malnutrition Universal Screening Tool, and Nutrition Risk Screening Tool for the Nutritional Evaluation of Older Nursing Home Residents
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Introduction: Malnutrition plays a major role in clinical and functional impairment in older adults. The use of validated, user-friendly and rapid screening tools for malnutrition in the elderly may improve the diagnosis and, possibly, the prognosis. The aim of this study was to assess the agreement between Mini-Nutritional Assessment (MNA), considered as a reference tool, MNA short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), and Nutrition Risk Screening (NRS-2002) in elderly institutionalized participants.
End-of-Life Care in Nursing Homes: From Care Processes to Quality
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BACKGROUND/OBJECTIVE: Nursing homes (NHs) are an important setting for the provision of palliative and end-of-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use. DESIGN AND METHODS: We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics. RESULTS: Better communication with residents/family members was statistically significantly (p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly (p = 0.006) associated with lower use of hospice. CONCLUSIONS: Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents’ EOL care quality needs to be better understood.
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Events
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McMaster Health Forum Fall Workshops
Want to be at the leading edge of the fast paced field of how to bring the best evidence to bear on pressing policy issues in support of health-system strengthening? Don’t miss your chance to attend one of the McMaster Health Forum’s Health Systems Learning fall workshops – Sept 15: one-day workshop; Oct 17-21: five-day workshop.
Online
The McMaster Optimal Aging Portal is a free and easy-to-use website that gives you access to high-quality information to help you age well. Many other online resources offer healthy aging information. What sets the Portal apart from the crowd is its emphasis on providing only the best evidence, and telling you why it’s considered the best. The Portal filters out the noise and makes it easy to understand how evidence-based information can help you — whether you’re a citizen, a clinician, a public health professional or a policymaker.
Advancing Implementation Science Efficiently – the Role of Implementation Laboratories
The presentation will propose implementation laboratories as a potential solution to address this. Implementation laboratories involve close collaboration between health systems delivering implementation strategies at scale and research teams to can address health systems’ priorities and produce generalizable knowledge about factors—context, intervention design, and delivery—that could influence effectiveness of the implementation initiative.
KT Canada Rounds: KT Canada National Seminar Series
Title: Increasing value and reducing waste in knowledge translation and implementation research. This session is offered by Webex from St. Michael’s Hospital in Toronto. All registration requests should be sent to Gail Klein: kleing@smh.ca by Wednesday, September 7th at 12:00 PM ET.
News
HRA stakeholders survey: Updating IRAS Question A51 (UK)
We are part of the EQUATOR Network and are conducting a project that aims to increase the transparency and completeness of future published research. We would like to invite you to help us in this effort by completing this short online survey.
University of Saskatchewan researcher aims to improve dementia care
“Rural regions have fewer resources, (but) they have proportionally more older people – and age is the main risk factor for dementia,” said Debra Morgan, who is professor and chair of rural health care delivery at the Canadian Centre of Health and Safety in Agriculture. “But there are fewer supports in rural and remote communities, specialists are not easily accessible, and physicians have less access to education to help them diagnose and manage.”
Improper Medication Use Rising Among Older Adults (US)
Many older adults take medications that treat health conditions like pain and heart disease. Most take their medications properly, but some older adults have problems taking them the way they should. This includes unintentionally taking a medication the wrong way, as well as intentional abuse.
Special practices surround end of life care at care home
Namaste Care™, created by Joyce Simard, emphasizes programming for residents with advanced dementia, who are no longer able to participate in traditional recreation activities and are no longer able to tell us who they are or who they were. These residents are involved in a group program that emphasizes caring touch, meaningful activities and “honours the spirit within” as defined by the Hindu word Namaste.
Underweight Seniors May Have Added Alzheimer’s Risk (US)
Having a lower weight may increase older adults’ risk of the memory-robbing disorder Alzheimer’s disease, new research suggests.
Surrey senior’s dignity suffering with low staffing in nursing home
The family of an 87-year-old Surrey woman living in a nursing home says she is not getting the help she needs, particularly in the evenings when there are fewer staff.
Evidence-based Policymaking in Health Systems is a Myth
Knowledge translation begins where research endeavours are often at their most vague. Research often determines the magnitude or mechanisms underlying health system challenges and problems. It sometimes compares intervention approaches to each other. But the question is most often, what ought to be done in this case? This is precisely where evidence can inform, but cannot serve as a base. With this in mind, knowledge translation is about other processes, institutions, disciplines even, converging in the service of better informed decision-making.
Answering the same questions over and over: how to talk to people with dementia
Anyone asked the same question over and over will eventually respond impatiently, which is not good for the person with dementia, or their carer’s stress levels.
Construction gets underway on Ireland’s first village for people with dementia (UK)
Construction work has begun on Ireland’s first purpose built village for people diagnosed with dementia, in the town of Bruff, Co Limerick.
The company behind the development, CareBright Community, stated it will “change the face of dementia care in Ireland”.
A whole genre of advice — known as quit lit— looks at why and when to leave. But little is written about how to quit a faculty post or exit the profession. Leaving an academic job is different than vacating a nonacademic one. A professor can’t just give two weeks’ notice and walk out the door. I’ve submitted my share of resignation letters and watched others leave their posts, so I’ve gleaned a few tips on how to depart a faculty position gracefully.There is no good time to resign. But there are ways to make the process go more smoothly for everyone.
The Baby-Before-Tenure Question
Young women — and young men, increasingly — continue to seek me out with questions about work-life balance, STEM careers, and parenthood, especially during the pretenure years. So this seems as good a time as any to attempt to answer one of our era’s defining questions: As a woman, how do you balance an academic career with the realities of a biological clock?
The Professor Is In: Preparing for the Job Market
I’m gearing up to go on the academic job market this fall. What should I do to get ready?
Resources
The Dementia Evidence Toolkit (UK)
The aim is to make all this information publicly available in a form that is clear and easy to understand for dementia patients, their families and unpaid carers as well as for staff working in health and social care. It will also benefit academics and those involved in decision-making both locally and nationally.
New film puts spotlight on person centred dementia care (UK)
In a new film released August 16, 2016, Health Education England highlights the importance of person-centred care in enabling people in care homes to live well with dementia.
Changing the Landscape: Meeting the Dietary Needs of Older Adults
Interactive infographic to examine factors that affect the ability of older adults to meet their daily dietary needs.
The Canadian Institutes of Health Research (CIHR) Institute of Gender and Health has designed three interactive online modules that will help researchers, reviewers and writers discover best practices for integrating sex- and gender-based analysis across health research disciplines.
Opportunities
Postdoctoral Fellowship in Mental Health and Substance Use Treatment and Implementation Research for Vulnerable Populations
Fellowship Aims: To provide the fellow with broad post-doctoral training in the area of mental health and substance use treatment and implementation research. To provide the fellow with a strong working knowledge of issues involved in research with vulnerable and/or disenfranchised populations, including pregnant women, justice-involved individuals, individuals from minority groups, and individuals living in poverty. To provide the fellow will strategies and experiences in increasing the real-world health and policy impact of his or her research, especially as it relates to poverty, race, health equity, and social justice. To provide the fellow with research training and experience that will provide a foundation for entrance into a clinical research or public health research career. Interested candidates should contact Jennifer Johnson, Ph.D. at Jennifer.Johnson@hc.msu.edu or 810-600-5669.
Postdoctoral Fellowship in Implementation Research for Health Equity
Fellowship Aims: 1) To provide the fellow with broad post-doctoral training in dissemination and implementation research. 2) To provide the fellow with broad training in community-based participatory research. 3) To provide the fellow will strategies and experiences in increasing the real-world health and policy impact of his or her research, especially as it relates to poverty, race, health equity, and social justice. 4) To provide the fellow with local, state, and national connections and experience relevant to policy change to improve health equity. 5) To provide the fellow with research training and experience that will provide a foundation for entrance into a public health research career. Interested candidates should contact Jennifer Johnson, Ph.D. at Jennifer.Johnson@hc.msu.edu or 810-600-5669.
Postdoctoral Fellowship Opportunity – Women’s College Research Institute
A Postdoctoral Research Fellowship in the area of Aging is available at the Women’s College Research Institute, Women’s College Hospital, at the University of Toronto. This position is supported by the Retired Teachers of Ontario (RTO/ERO) Chair, and will provide a researcher with the opportunity to join an established multidisciplinary group of health services researchers. The position will be supervised by Dr. Paula Rochon, Professor, Department of Medicine and the Institute of Health Policy and Management at the University of Toronto, and the Retired Teachers of Ontario (RTO/ERO) Chair in Geriatric Medicine.
Knowledge Broker Mentoring Program: 2nd cohort
The National Collaborating Centre for Methods and Tools (NCCMT) has developed and successfully piloted a 16-month mentorship program to provide public health professionals with the knowledge, skills and tools needed to act as knowledge brokers within their Health Department and advance the uptake and use of research evidence in public health practice. Organizational assessments will be conducted in fall 2016. Mentorship participants will begin their training in January 2017, continuing to April 2018. If your organization is interested in learning more about the Knowledge Broker Mentoring Program, please contact us at nccmt@mcmaster.ca.
