March 19, 2018



New TREC Article
SCOPEOUT: sustainability and spread of quality improvement activities in long-term care- a mixed methods approach.
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L. A. Cranley, M. Hoben, J. Yeung, C. A. Estabrooks, P. G. Norton and A. Wagg.
BMC Health Serv Res 2018 Mar 12;18(1):174-018-2978-0
Interventions to improve quality of care for residents of long-term care facilities, and to examine the sustainability and spread of such initiatives, remain a top research priority. The purpose of this exploratory study was to assess the extent to which activities initiated in a quality improvement (QI) collaborative study using care aide led teams were sustained or spread following cessation of the initial project and to identify factors that led to its success. METHODS: This study used an exploratory mixed methods study design and was conducted in seven residential long-term care facilities in two Canadian provinces. Sustainability and spread of QI activities were assessed by a questionnaire over five time points for 18 months following the collaborative study with staff from both intervention with non-intervention units. Semi-structured interviews were conducted with care managers at six and 12 months. QI team success in applying the QI model was ranked as high, medium, or low using criteria developed by the research team. Descriptive statistics, bivariate analyses, and General Estimating Equations were used to analyze the data. Interview data were analyzed using thematic analysis. RESULTS: In total, 683 surveys were received over the five time periods from 476 unique individuals on a facility unit. Seven managers were interviewed. A total of 533 surveys were analyzed. While both intervention and non-intervention units experienced a decline over time in all outcome measures, this decline was significantly less pronounced on intervention units. Facilities with medium and high success ranking had significantly higher scores in all four outcomes than facilities with a low success ranking. Care aides reported significantly less involvement of others in QI activities, less empowerment and less satisfaction with the quality of their work life than regulated care providers. Manager interviews provided evidence of sustainability of QI activities on the intervention units in four of the seven facilities up to 18 months following the intervention and demonstrated the need for continued staff and leadership engagement. CONCLUSION: Sustainability of a QI project which empowers and engages care aides is possible and achievable, but requires ongoing staff and leadership engagement.

New TREC Newsletter is available

Read it here.
Learn more about the funding of VOICES Committee, how TREC supports evidence informed policy, and what was accomplished in the recent TREC meetings in February.

New Article by Dr. Shannon Scott
Digital storytelling as a method in health research: a systematic review protocol
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K. L. Rieger, C. H. West, A. Kenny, et al.
Syst Rev 2018 Mar 5;7(1):41-018-0704-y
Digital storytelling is an arts-based research method with potential to elucidate complex narratives in a compelling manner, increase participant engagement, and enhance the meaning of research findings. This method involves the creation of a 3- to 5-min video that integrates multimedia materials including photos, participant voices, drawings, and music. Given the significant potential of digital storytelling to meaningfully capture and share participants’ lived experiences, a systematic review of its use in healthcare research is crucial to develop an in-depth understanding of how researchers have used this method, with an aim to refine and further inform future iterations of its use. METHODS: We aim to identify and synthesize evidence on the use, impact, and ethical considerations of using digital storytelling in health research. The review questions are as follows: (1) What is known about the purpose, definition, use (processes), and contexts of digital storytelling as part of the research process in health research? (2) What impact does digital storytelling have upon the research process, knowledge development, and healthcare practice? (3) What are the key ethical considerations when using digital storytelling within qualitative, quantitative, and mixed method research studies? Key databases and the grey literature will be searched from 1990 to the present for qualitative, quantitative, and mixed methods studies that utilized digital storytelling as part of the research process. Two independent reviewers will screen and critically appraise relevant articles with established quality appraisal tools. We will extract narrative data from all studies with a standardized data extraction form and conduct a thematic analysis of the data. To facilitate innovative dissemination through social media, we will develop a visual infographic and three digital stories to illustrate the review findings, as well as methodological and ethical implications. DISCUSSION: In collaboration with national and international experts in digital storytelling, we will synthesize key evidence about digital storytelling that is critical to the development of methodological and ethical expertise about arts-based research methods. We will also develop recommendations for incorporating digital storytelling in a meaningful and ethical manner into the research process. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registry number CRD42017068002 .

New article by Dr. Susan Slaughter
Modified Texture Food Use is Associated With Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project
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V. Vucea, Heather H. Keller, J. M. Morrison, et al.
J Nutr Health Aging 2018 03/08
Modified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered.

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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Culture and Change
Research Practice and Methodology


Agile Implementation: A Blueprint for Implementing Evidence-Based Healthcare Solutions.
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M. Boustani, C. A. Alder and C. A. Solid.
J Am Geriatr Soc 2018 Mar 7
OBJECTIVES: To describe the essential components of an Agile Implementation (AI) process, which rapidly and effectively implements evidence-based healthcare solutions, and present a case study demonstrating its utility. DESIGN: Case demonstration study. SETTING: Integrated, safety net healthcare delivery system in Indianapolis. PARTICIPANTS: Interdisciplinary team of clinicians and administrators. MEASUREMENTS: Reduction in dementia symptoms and caregiver burden; inpatient and outpatient care expenditures. RESULTS: Implementation scientists were able to implement a collaborative care model for dementia care and sustain it for more than 9 years. The model was implemented and sustained by using the elements of the AI process: proactive surveillance and confirmation of clinical opportunities, selection of the right evidence-based healthcare solution, localization (i.e., tailoring to the local environment) of the selected solution, development of an evaluation plan and performance feedback loop, development of a minimally standardized operation manual, and updating such manual annually. CONCLUSION: The AI process provides an effective model to implement and sustain evidence-based healthcare solutions.


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Health Care Administration and Organization

Determinants of turnover among low wage earners in long term care: the role of manager-employee relationships.
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M. Matthews, M. K. Carsten, D. J. Ayers and N. Menachemi.
Geriatr Nurs 2018 Feb 27
The demand for Long-Term Care (LTC) is steadily increasing as Baby Boomers age and enter retirement. High turnover rates among employees in LTC creates challenges for supervisors and administrators, and can negatively impact quality of care. This study examines manager-subordinate relationship quality using Leader-Member Exchange Theory (LMX) as an antecedent to turnover among low-wage earners in the LTC environment. Survey data measuring LMX, job satisfaction, and demographic information was collected at time 1, and turnover data was collected 18 months later at time 2. The results reveal that all four LMX dimensions were rated significantly different among subordinates who left versus those who stayed, however, only the LMX dimension of supervisor loyalty was a significant predictor of turnover among low wage earners. Our study adds a more nuanced view of the reasons low-wage employees turnover, and presents implications for clinical managers and LTC organizations more broadly.

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Health Care Innovation and Quality Assurance

Data-Driven Diffusion Of Innovations: Successes And Challenges In 3 Large-Scale Innovative Delivery Models
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D. A. Dorr, D. J. Cohen and J. Adler-Milstein.
Health Aff (Millwood) 2018 Feb;37(2):257-265
Failed diffusion of innovations may be linked to an inability to use and apply data, information, and knowledge to change perceptions of current practice and motivate change. Using qualitative and quantitative data from three large-scale health care delivery innovations-accountable care organizations, advanced primary care practice, and EvidenceNOW-we assessed where data-driven innovation is occurring and where challenges lie. We found that implementation of some technological components of innovation (for example, electronic health records) has occurred among health care organizations, but core functions needed to use data to drive innovation are lacking. Deficits include the inability to extract and aggregate data from the records; gaps in sharing data; and challenges in adopting advanced data functions, particularly those related to timely reporting of performance data. The unexpectedly high costs and burden incurred during implementation of the innovations have limited organizations’ ability to address these and other deficits. Solutions that could help speed progress in data-driven innovation include facilitating peer-to-peer technical assistance, providing tailored feedback reports to providers from data aggregators, and using practice facilitators skilled in using data technology for quality improvement to help practices transform. Policy efforts that promote these solutions may enable more rapid uptake of and successful participation in innovative delivery system reforms.

An Action Research to Optimize the Well-Being of Older People in Nursing Homes: Challenges and Strategies for Implementing a Complex Intervention.
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A. Bourbonnais, F. Ducharme, P. Landreville, C. Michaud, M. A. Gauthier and M. H. Lavallee.
J Appl Gerontol 2018 Mar 1:733464818762068
Few studies have been conducted on strategies to promote the implementation of complex interventions in nursing homes (NHs). This article presents a pilot study intended to assess the strategies that would enable the optimal implementation of a complex intervention approach in NHs based on the meanings of screams of older people living with Alzheimer’s disease. An action research approach was used with 19 formal and family caregivers from five NHs. Focus groups and individual interviews were held to assess different implementation strategies. A number of challenges were identified, as were strategies to overcome them. These latter included interactive training, intervention design, and external support. This study shows the feasibility of implementing a complex intervention to optimize older people’s well-being. The article shares strategies that may promote the implementation of these types of interventions in NHs.

Minimum Data Set Changes in Health, End-Stage Disease and Symptoms and Signs Scale: A Revised Measure to Predict Mortality in Nursing Home Residents
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J. A. Ogarek, E. M. McCreedy, K. S. Thomas, J. M. Teno and P. L. Gozalo.
J Am Geriatr Soc 2018 Mar 2
To revise the Minimum Data Set (MDS) Changes in Health, End-stage disease and Symptoms and Signs (CHESS) scale, an MDS 2.0-based measure widely used to predict mortality in institutional settings, in response to the release of MDS 3.0. DESIGN: Development of a predictive scale using observational data from the MDS and Medicare Master Beneficiary Summary File. SETTING: All Centers for Medicare and Medicaid Services (CMS)-certified nursing homes in the United States. PARTICIPANTS: Development cohort of 1.3 million Medicare beneficiaries newly admitted to a CMS-certified nursing home during 2012. Primary validation cohort of 1.2 million Medicare recipients who were newly admitted to a CMS-certified nursing home during 2013. MEASUREMENTS: Items from the MDS 3.0 assessments identified as likely to predict mortality. Death information was obtained from the Medicare Master Beneficiary Summary File. RESULTS: MDS-CHESS 3.0 scores ranges from 0 (most stable) to 5 (least stable). Ninety-two percent of the primary validation sample with a CHESS scale score of 5 and 15% with a CHESS scale of 0 died within 1 year. The risk of dying was 1.63 times as great (95% CI=1.628-1.638) for each unit increase in CHESS scale score. The MDS-CHESS 3.0 is also strongly related to hospitalization within 30 days and successful discharge to the community. The scale predicted death in long-stay residents at 30 days (C=0.759, 95% confidence interval (CI)=0.756-0.761), 60 days (C=0.716, 95% CI=0.714-0.718) and 1 year (C=0.655, 95% CI=0.654-0.657). CONCLUSION: The MDS-CHESS 3.0 predicts mortality in newly admitted and long-stay nursing home populations. The additional relationship to hospitalizations and successful discharges to community increases the utility of this scale as a potential risk adjustment tool.

How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation.
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B. G. Bokhour, G. M. Fix, N. M. Mueller, et al.
BMC Health Serv Res 2018 Mar 7;18(1):168-018-2949-5
Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs. METHODS: We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains. RESULTS: Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges. CONCLUSIONS: Transforming healthcare systems to focus on patient-centered care and better serve the “whole” patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

CFHI Report of the Better Together Policy Roundtable

January 2018
The Better Together Policy Roundtable took place September 25 and 26, 2017 in Ottawa, moderated and co-chaired by the Canadian Foundation for Healthcare Improvement (CFHI). Forty-nine participants convened, representing 12 provinces and territories. They were a diverse mix of patients, patient and family advisors, caregivers, government leaders, and representatives from healthcare organizations and jurisdictions. The roundtable brought together relevant senior government policy leaders responsible for patient and family-centred care (PFCC), key partners, and patient and family advisors to address ways policy can be used to support PFCC practices across regions, provinces and territories.


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Organizational Culture and Change

Developing a workbook to support the contextualisation of global health systems guidance: a case study identifying steps and critical factors for success in this process at WHO
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E. Alvarez, J. N. Lavis, M. Brouwers and L. Schwartz.
Health Res Policy Syst 2018 Mar 2;16(1):19-018-0297-x
BACKGROUND: Global guidance can help countries strengthen their health systems to deliver effective interventions to their populations. However, to have an impact, guidance needs to be contextualised or adapted to local settings; this process includes consideration of health system arrangements and political system factors. To date, methods to support contextualisation do not exist. In response, a workbook was designed to provide specific methods and strategies to enable the contextualisation of WHO’s ‘Optimizing health worker roles to improve maternal and newborn health’ (OptimizeMNH) guidance at the national or subnational level. The objective of this study was to describe the process of developing the workbook and identify key steps of the development process, barriers that arose and facilitators that helped overcome some of these barriers. METHODS: A qualitative single case study design was carried out. Interviews, documents and a reflexive journal were used. Constant comparison and an edit-style of organisation were used during data analysis to develop concepts, themes, subthemes and relationships among them. RESULTS: Thirteen interviews were conducted and 52 documents were reviewed. Three main steps were identified in the process of developing the workbook for health systems guidance contextualisation, namely (1) determining the need for and gaining approval to develop the workbook, (2) developing the workbook (taking on the task, creating the structure of the workbook, operationalising its components, undergoing approval processes and editing it), and (3) implementing the workbook both at the WHO level and at the national/subnational level. Five barriers and/or facilitators emerged relevant to each step, namely (1) having well-placed and credible champions, (2) creating and capitalising on opportunities, (3) finding the right language to engage various actors and obtain buy-in, (4) obtaining and maintaining meaningful buy-in, and (5) ensuring access to resources. CONCLUSIONS: Understanding the key steps and the critical factors involved in the process of developing the workbook could help in the planning of similar and other tools aimed to support the implementation of WHO guidance. A plan for dissemination and implementation needs to be addressed during the preparation of these tools.

Shaping the use of psychotropic medicines in nursing homes: A qualitative study on organisational culture.
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M. Sawan, Y. H. Jeon and T. F. Chen.
Soc Sci Med 2018 Feb 15;202:70-78
Psychotropic medicines have limited efficacy in the management of behavioural and psychological disturbances, yet they are commonly used in nursing homes. Organisational culture is an important consideration influencing use of psychotropic medicines. Schein’s theory elucidates that organisational culture is underpinned by basic assumptions, which are the taken for granted beliefs driving organisational members’ behaviour and practices. By exploring the basic assumptions of culture we are able to find explanations for why psychotropic medicines are prescribed contrary to standards. A qualitative study guided by Schein’s theory was conducted using semi-structured interviews with 40 staff representing a broad range of roles from eight nursing homes. Findings from the study suggest two basic assumptions influenced the use of psychotropic medicines: locus of control and necessity for efficiency or comprehensiveness. Locus of control pertained to whether staff believed they could control decisions when facing negative work experiences. Necessity for efficiency or comprehensiveness concerned how much time and effort was spent on a given task. Participants’ arrived at decisions to use psychotropic medicines that were inconsistent with ideal standards when they believed they were helpless to do the right thing by the resident and it was necessary to restrict time on a given task. Basic assumptions tended to provide the rationale for staff to use psychotropic medicines when it was not compatible with standards. Organisational culture is an important factor that should be addressed to optimise psychotropic medicine use.

Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them – a scoping review.
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I. Scholl, A. LaRussa, P. Hahlweg, S. Kobrin and G. Elwyn.
Implement Sci 2018 Mar 9;13(1):40-018-0731-z
Shared decision-making (SDM) is poorly implemented in routine care, despite being promoted by health policies. No reviews have solely focused on an in-depth synthesis of the literature around organizational- and system-level characteristics (i.e., characteristics of healthcare organizations and of healthcare systems) that may affect SDM implementation. A synthesis would allow exploration of interventions to address these characteristics. The study aim was to compile a comprehensive overview of organizational- and system-level characteristics that are likely to influence the implementation of SDM, and to describe strategies to address those characteristics described in the literature. METHODS: We conducted a scoping review using the Arksey and O’Malley framework. The search strategy included an electronic search and a secondary search including gray literature. We included publications reporting on projects that promoted implementation of SDM or other decision support interventions in routine healthcare. We screened titles and abstracts, and assessed full texts for eligibility. We used qualitative thematic analysis to identify organizational- and system-level characteristics. RESULTS: After screening 7745 records and assessing 354 full texts for eligibility, 48 publications on 32 distinct implementation projects were included. Most projects (N = 22) were conducted in the USA. Several organizational-level characteristics were described as influencing the implementation of SDM, including organizational leadership, culture, resources, and priorities, as well as teams and workflows. Described system-level characteristics included policies, clinical guidelines, incentives, culture, education, and licensing. We identified potential strategies to influence the described characteristics, e.g., examples how to facilitate distribution of decision aids in a healthcare institution. CONCLUSIONS: Although infrequently studied, organizational- and system-level characteristics appear to play a role in the failure to implement SDM in routine care. A wide range of characteristics described as supporting and inhibiting implementation were identified. Future studies should assess the impact of these characteristics on SDM implementation more thoroughly, quantify likely interactions, and assess how characteristics might operate across types of systems and areas of healthcare. Organizations that wish to support the adoption of SDM should carefully consider the role of organizational- and system-level characteristics. Implementation and organizational theory could provide useful guidance for how to address facilitators and barriers to change.

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Research Practice and Methodology

Social Network Analysis: Presenting an Underutilised Method for Nursing Research.
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J. M. Parnell and J. C. Robinson.
J Adv Nurs 2018 Feb 14
This paper introduces social network analysis as a versatile method with many applications in nursing research. BACKGROUND: Social networks have been studied for years in many social science fields. The methods continue to advance but remain unknown to most nursing scholars. DESIGN: Discussion paper. DATA SOURCES: English language and interpreted literature was searched from Ovid Healthstar, CINAHL, PubMed Central, Scopus and hard copy texts from 1965-2017. DISCUSSION: Social network analysis first appeared in nursing literature in 1995 and only minimally through present day. To convey the versatility and applicability of social network analysis in nursing, hypothetical scenarios are presented. The scenarios are illustrative of three approaches to social network analysis and include key elements of social network research design. IMPLICATIONS FOR NURSING: The methods of social network analysis are underused in nursing research, primarily because they are unknown to most scholars. However, there is methodological flexibility and epistemological versatility capable of supporting quantitative and qualitative research. The analytic techniques of social network analysis can add new insight into many areas of nursing inquiry, especially those influenced by cultural norms. Furthermore, visualization techniques associated with social network analysis can be used to generate new hypotheses. CONCLUSION: Social network analysis can potentially uncover findings not accessible through methods commonly used in nursing research. Social networks can be analysed based on individual-level attributes, whole-networks and subgroups within networks. Computations derived from social network analysis may stand alone to answer a research question or incorporated as variables into robust statistical models.

Supporting autonomy of nursing home residents with dementia in the informed consent process.
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E. Beattie, M. O’Reilly, D. Fetherstonhaugh, M. McMaster, W. Moyle and E. Fielding.
Dementia (London) 2018 Jan 1:1471301218761240
In studies involving people with dementia, researchers have historically defaulted to seeking consent from a proxy, the assumption being that people with dementia are unable to provide their own informed consent. This choice denies people with dementia a voice in the consent process, thus disregarding their autonomy and agency. Recently, other options for improving the consent process have been explored. Objective This study aimed to determine whether nursing home residents with dementia could demonstrate an ability to provide their own informed consent as determined by the Evaluation to Sign Consent instrument. Methods As part of a larger study on the quality of life of nursing home residents, the Evaluation to Sign Consent was administered to 392 people diagnosed with dementia. Data on demographic variables, such as gender and age, as well as level of cognitive impairment, were also collected. Results Just over one-fifth (22%) of the residents with dementia were judged as having the capacity to provide their own informed consent to participate in this specific research project. Consistent with existing literature, capacity to consent was significantly, and negatively, associated with cognitive impairment. Conclusion This study demonstrates that assuming all people diagnosed with dementia are unable to provide informed consent for research on the basis of cognitive test scores, or on clinical assessment alone, potentially denies them the autonomy to make a decision that they may be capable of making. Research involving people with mild-to-moderate dementia needs to consider evaluating whether potential participants have the capacity to provide their own consent.

Patient engagement in Canada: a scoping review of the ‘how’ and ‘what’ of patient engagement in health research
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E. Manafo, L. Petermann, P. Mason-Lai and V. Vandall-Walker.
Health Res Policy Syst 2018 Feb 7;16(1):5-018-0282-4
Over the last 10 years, patient engagement in health research has emerged as the next evolution in healthcare research. However, limited evidence about the clear role and scope of patient engagement in health research and a lack of evidence about its impact have influenced the uptake, implementation and ongoing evolution of patient engagement. The present study aims to conduct a scoping review to identify methods for and outcomes of patient engagement in health research. METHODS: An adaptation of the scoping review methodology originally described by Arksey and O’Malley and updated by Levac, Colquhoun and O’Brien was applied. Sources from a formal database search and relevant documents from a grey literature search were compiled into data extraction tables. Articles were synthesised into key themes according to the (1) methods and (2) outcomes of patient engagement in health research. RESULTS: The total yield for the scoping review was 55 records from across Canada, the United Kingdom and the United States. While evidence about the methods used to engage patients in health research is increasing, stronger evidence of specific patient and healthcare system outcomes is required. This necessitates further mobilisation of research that explores outcomes and that validates specific tools to evaluate engagement. Additionally, theoretical frameworks that can better inform and sustain patient engagement across the lifecycle of health research are lacking. CONCLUSION: Further increasing the volume and reach of evidence about patient engagement in health research will support the paradigmatic shift needed to normalise the patient’s role in research beyond ‘subject’ or ‘participant’, so as to ultimately improve patient health outcomes and better address healthcare reform in Canada.

Supporting autonomy of nursing home residents with dementia in the informed consent process
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E. Beattie, M. O’Reilly, D. Fetherstonhaugh, M. McMaster, W. Moyle and E. Fielding.
Dementia (London) 2018 Jan 1:1471301218761240
In studies involving people with dementia, researchers have historically defaulted to seeking consent from a proxy, the assumption being that people with dementia are unable to provide their own informed consent. This choice denies people with dementia a voice in the consent process, thus disregarding their autonomy and agency. Recently, other options for improving the consent process have been explored. Objective This study aimed to determine whether nursing home residents with dementia could demonstrate an ability to provide their own informed consent as determined by the Evaluation to Sign Consent instrument. Methods As part of a larger study on the quality of life of nursing home residents, the Evaluation to Sign Consent was administered to 392 people diagnosed with dementia. Data on demographic variables, such as gender and age, as well as level of cognitive impairment, were also collected. Results Just over one-fifth (22%) of the residents with dementia were judged as having the capacity to provide their own informed consent to participate in this specific research project. Consistent with existing literature, capacity to consent was significantly, and negatively, associated with cognitive impairment. Conclusion This study demonstrates that assuming all people diagnosed with dementia are unable to provide informed consent for research on the basis of cognitive test scores, or on clinical assessment alone, potentially denies them the autonomy to make a decision that they may be capable of making. Research involving people with mild-to-moderate dementia needs to consider evaluating whether potential participants have the capacity to provide their own consent.

Factors influencing early stage healthcare-academia partnerships.
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H. Uvhagen, M. von Knorring, H. Hasson, J. Ovretveit and J. Hansson.
Int J Health Care Qual Assur 2018 Feb 12;31(1):28-40
The purpose of this paper is to explore factors influencing early implementation and intermediate outcomes of a healthcare-academia partnership in a primary healthcare setting. Design/methodology/approach The Academic Primary Healthcare Network (APHN) initiative was launched in 2011 in Stockholm County, Sweden and included 201 primary healthcare centres. Semi-structured interviews were conducted in 2013-2014 with all coordinating managers ( n=8) and coordinators ( n=4). A strategic change model framework was used to collect and analyse data. Findings Several factors were identified to aid early implementation: assignment and guidelines that allowed flexibility; supportive management; dedicated staff; facilities that enabled APHN actions to be integrated into healthcare practice; and positive experiences from research and educational activities. Implementation was hindered by: discrepancies between objectives and resources; underspecified guidelines that trigger passivity; limited research and educational activities; a conflicting non-supportive reimbursement system; limited planning; and organisational fragmentation. Intermediate outcomes revealed that various actions, informed by the APHN assignment, were launched in all APHNs. Practical implications The findings can be rendered applicable by preparing stakeholders in healthcare services to optimise early implementation of healthcare-academia partnerships. Originality/value This study increases understanding of interactions between factors that influence early stage partnerships between healthcare services and academia in primary healthcare settings.

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Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process
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N. Ferrah, J. E. Ibrahim, C. Kipsaina and L. Bugeja.
J Aging Health 2018 Apr;30(4):584-604
OBJECTIVE: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. METHOD: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. RESULTS: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. DISCUSSION: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.

Development of a complex intervention to improve participation of nursing home residents with joint contractures: a mixed-method study.
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S. Saal, G. Meyer, K. Beutner, et al.
BMC Geriatr 2018 Feb 28;18(1):61-018-0745-z
Joint contractures in nursing home residents limit the capacity to perform daily activities and restrict social participation. The purpose of this study was to develop a complex intervention to improve participation in nursing home residents with joint contractures. METHODS: The development followed the UK Medical Research Council framework using a mixed-methods design with re-analysis of existing interview data using a graphic modelling approach, group discussions with nursing home residents, systematic review of intervention studies, structured 2-day workshop with experts in geriatric, nursing, and rehabilitation, and group discussion with professionals in nursing homes. RESULTS: Graphic modelling identified restrictions in the use of transportation, walking within buildings, memory functions, and using the hands and arms as the central target points for the intervention. Seven group discussions with 33 residents revealed various aspects related to functioning and disability according the International Classification of Functioning, Disability and Health domains body functions, body structures, activities and participation, environmental factors, and personal factors. The systematic review included 17 studies with 992 participants: 16 randomised controlled trials and one controlled trial. The findings could not demonstrate any evidence in favour of an intervention. The structured 2-day expert workshop resulted in a variety of potential intervention components and implementation strategies. The group discussion with the professionals in nursing homes verified the feasibility of the components and the overall concept. The resulting intervention, Participation Enabling CAre in Nursing (PECAN), will be implemented during a 1-day workshop for nurses, a mentoring approach, and supportive material. The intervention addresses nurses and other staff, residents, their informal caregivers, therapists, and general practitioners. CONCLUSIONS: In view of the absence of any robust evidence, the decision to use mixed methods and to closely involve both health professionals and residents proved to be an appropriate means to develop a complex intervention to improve participation of and quality of life in nursing home residents. We will now evaluate the PECAN intervention for its impact and feasibility in a pilot study in preparation for an evaluation of its effectiveness in a definitive trial. TRIAL REGISTRATION: German clinical trials register, reference number DRKS00010037 (12 February 2016).

Video-calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research.
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S. Zamir, C. H. Hennessy, A. H. Taylor and R. B. Jones.
BMC Geriatr 2018 Mar 2;18(1):62-018-0746-y
Older people in care may be lonely with insufficient contact if families are unable to visit. Face-to-face contact through video-calls may help reduce loneliness, but little is known about the processes of engaging people in care environments in using video-calls. We aimed to identify the barriers to and facilitators of implementing video-calls for older people in care environments. METHODS: A collaborative action research (CAR) approach was taken to implement a video-call intervention in care environments. We undertook five steps of recruitment, planning, implementation, reflection and re-evaluation, in seven care homes and one hospital in the UK. The video-call intervention ‘Skype on Wheels’ (SoW) comprised a wheeled device that could hold an iPad and handset, and used Skype to provide a free video-call service. Care staff were collaborators who implemented the intervention within the care-setting by agreeing the intervention, recruiting older people and their family, and setting up video-calls. Field notes and reflective diaries on observations and conversations with staff, older people and family were maintained over 15 months, and analysed using thematic analysis. RESULTS: Four care homes implemented the intervention. Eight older people with their respective social contacts made use of video-calls. Older people were able to use SoW with assistance from staff, and enjoyed the use of video-calls to stay better connected with family. However five barriers towards implementation included staff turnover, risk averseness, the SoW design, lack of family commitment and staff attitudes regarding technology. CONCLUSIONS: The SoW intervention, or something similar, could aid older people to stay better connected with their families in care environments, but if implemented as part of a rigorous evaluation, then co-production of the intervention at each recruitment site may be needed to overcome barriers and maximise engagement.

Pain and pharmacologic pain management in long-stay nursing home residents.
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J. N. Hunnicutt, C. M. Ulbricht, J. Tjia and K. L. Lapane.
Pain 2017 Jun;158(6):1091-1099
Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Representation in the Care Planning Process for Nursing Home Residents With Dementia.
Non UofA Access

E. McCreedy, L. Loomer, J. A. Palmer, S. L. Mitchell, A. Volandes and V. Mor.
J Am Med Dir Assoc 2018 Mar 10
Federally mandated assessments of nursing home (NH) residents drive individualized care planning. Residents with cognitive impairment may not be able to meaningfully communicate their care needs and preferences during this process-a gap that may be partially addressed by involving surrogates. We describe the prevalence of family participation in the care planning process for long-stay NH residents with varying degrees of cognitive impairment. DESIGN: Retrospective study using administrative data made available as part of an ongoing pragmatic cluster randomized controlled trial. SETTING: A total of 292 NHs from 1 large for-profit NH system. PARTICIPANTS: Long-stay NH residents in 2016. MEASUREMENTS: We identified all care planning assessments conducted in 2016 for long-stay NH residents. Cognitive functioning was defined using the Cognitive Function Scale. The Minimum Data Set was used to determine whether a resident, family member, and/or legal guardian participated in the assessment process. Certification and Survey Provider Enhance Reporting system data was used to identify facility-level correlates of family participation. Bivariate and multivariable hierarchical regression results are presented. RESULTS: The analytic sample included 18,552 long-stay NH residents. Family member/representative participation varied by degree of resident cognitive impairment; 8% of residents with no cognitive impairment had family or representative participation in care planning during 2016, compared with 26% of residents with severe impairment. NHs with more social workers had greater family participation in care planning. Available NH characteristics do not explain most of the variation in family participation between NHs (residual intraclass correlation = .57). CONCLUSIONS: Only a minority of family members and surrogates participate in NH care planning, even for residents with severe cognitive impairment. The association between social work staffing and participation suggests family involvement may be a measure of quality improvement capacity. Our findings suggest a lack of voice for a vulnerable population that may have implications on the quality of care received at the end of life.

Lost and misplaced items and assistive devices in nursing homes: Identifying problems and technological opportunities through participatory design research.
Non UofA Access

C. E. Oude Weernink, L. Sweegers, L. Relou, T. J. van der Zijpp and J. van Hoof.
Technol Disabil 2018 Feb 6;29(3):129-140
Modern healthcare, including nursing home care, goes together with the use of technologies to support treatment, the provision of care and daily activities. The challenges concerning the implementation of such technologies are numerous. One of these emerging technologies are location technologies (RTLS or Real-Time Location Systems). that can be utilized in the nursing home for monitoring the use and location of assets. METHODOLOGY: This paper describes a participatory design study of RTLS based on context mapping, conducted in two nursing home organizations. Rather than investigating the technological possibilities, this study investigates the needs and wishes from the perspective of the care professional. RESULTS: The study identified semantic themes that relate to the practicalities of lost and misplaced items in the nursing home, as well as latent themes that cover the wishes regarding technology in the nursing homes. The organizational culture and building typology may play a role in losing items. CONCLUSION: The participants in this study indicated that RTLS can provide a solution to some of the challenges that they encounter in the workplace. However, the implementation of new technologies should be done with care and should be integrated into existing ICT systems in order to minimize additional training and posing a burden on the workload.

Media Portrayal of the Nursing Homes Sector: A Longitudinal Analysis of 51 U.S. Newspapers.
Non UofA Access

E. A. Miller, I. Livingstone and C. R. Ronneberg.
Gerontologist 2017 Jun 1;57(3):487-500
Most Americans’ low opinion of the nursing home (NH) sector could derive, in part, from the way in which it is portrayed in the media. This study furthers understanding of media portrayal of the NH sector by identifying how NHs were depicted in 51U.S. newspapers from 1999 to 2008. Design and methods: Keyword searches of the LexisNexis database were performed to identify 16,280 NH-related articles. Article content was analyzed, and tone, themes, prominence, and central actor were assessed. Basic frequencies and descriptive statistics were used to examine article content across regions, market type, and over time. Results: Findings reveal considerably less NH coverage in the Western United States and a steady decline in NH coverage nationally over time. Most articles were news stories; more than one third were located on the front page of the newspaper or section. Most articles focused on NH industry and government interests, very few on residents/family and community concerns. Most articles were neutral or negative in tone; very few were positive or mixed. Common themes included quality, financing, and legal concerns. Tone, themes, and other article attributes varied across region, market type, and over time. Implications: Overall, findings reveal changes in how newspapers framed NH coverage, not only with respect to tone but also with respect to what dimensions of this complex issue have been emphasized during the time period analyzed. Variation in media coverage may contribute to differences in government and public views toward the NH sector across regions and over time.

Scripted-IMPROV: Interactive Improvisational Drama With Persons With Dementia—Effects on Engagement, Affect, Depression, and Quality of Life

Non UofA Access

J. Zeisel, M. J. Skrajner, E. B. Zeisel, M. N. Wilson and C. Gage.
Am J Alzheimers Dis Other Demen 2018 Jan 1:1533317518755994
Scripted-IMPROV (SI) is a nonpharmacological (ecopsychosocial) intervention that consists of semi-improvised drama performances specifically designed for persons with dementia (PWD). In this 12-site study, 178 PWD took part in the SI intervention. Levels of engagement/affect were assessed at baseline and again during SI performances; quality of life (via the Dementia Quality of Life scale) and depression (via the Geriatric Depression Scale-Short Form [GDS-SF]) were assessed at baseline and post-treatment. Positive forms of engagement/affect increased, while negative forms of engagement decreased. Regarding depression, for a subsample of 29 participants who scored in the depressed range on the GDS-SF at baseline, depressive symptoms were reduced at post-treatment. Although overall quality of life did not change, the increase in positive affect during SI suggests that quality of life was higher during the intervention itself. In conclusion, SI possesses the characteristics of a high-quality intervention for PWD and seems worthy of further investigation in future research.


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Implementation Science How do we implement evidence to advance practice?

Thursday 5 April 14:00–15:00 WMC Classroom D (2F1.04)
Presenter: Dr. Denise Campbell-Scherer
Why does new evidence so often NOT turn into better practice? Dr. Denise Campbell-Scherer (Associate Professor, Department of Family Medicine & Associate Dean, Physician Learning Program) will reflect on different approaches to implementing evidence. She will use examples from the literature and her own research to demonstrate how to improve our ability to advance practice.

Improving health guidelines: Evidence-based strategies for writing

Thursday 3 May 08:30-15:00 ECHA 4-099 Cost $300
Presenter: Dr. Karen Schriver
The purpose of this workshop is to provide guideline producers and users with evidence-based writing principles to enhance their writing. Quality writing can help healthcare providers and patients understand, use, and act upon the recommendations, increasing the chances for the adoption of knowledge.

Non UofA

Knowledge Translation Workshop

March 21 (Saskatoon) and March 22 (Regina)
Presenter: Dr Gabrielle Zimmermann
The Saskatchewan Centre for Patient-Oriented Research (SCPOR) is pleased to invite Dr Gabrielle Zimmermann to Regina and Saskatoon to conduct this informative workshop where participants are encouraged to bring their own knowledge translation projects to work on, or just come ready to learn about knowledge translation, both end of grant and integrated. Gabrielle is SPOR Program Coordinator, Knowledge Translation and Implementation Science at the Alberta SPOR SUPPORT Unit Knowledge Translation Platform. She has wide-ranging experience in research and Knowledge Translation (KT) that encompasses the knowledge to action cycle; from creating and synthesizing evidence to facilitating the implementation of evidence into practice. Her experience includes critical appraisal of evidence, integrated KT proposals and end-of-grant KT plans.


Cultural Safety: Ethical and Equitable Health Care for Indigenous Patients, Families, and Communities

Tuesday 24 April 10:00-11:00 MT
Presenter: Meaghan Fullerton
This webinar will introduce participants to the concept of cultural safety in Indigenous Health Care, an orientation that imperative for members of settler society to offer ethical care to Indigenous clients, patients, families, and communities. Consistent with the Truth and Reconciliation’s Calls to Action, cultural safety asks members of settler society to critically reflect on personal and collective culture, history, colonial context, dominant historical narratives, as well as Indigenous voice and experience.

Knowledge Brokers – are they the answer to knowledge translation challenges in healthcare?

Thursday 12 April 10:00-11:00 MT
Presenter: Alison Hoens
Learning Objectives:
Be aware of key messages from the literature with respect to:
-the knowledge broker(s) in healthcare
-the evidence regarding the effect and effectiveness of knowledge brokers in healthcare
-key issues related to the training, recruitment and evaluation of knowledge brokers
Reflect upon if and how knowledge brokers could be incorporated within their own organization

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Culture Change Toolbox

The Culture Change Toolbox is a collection of tools and interventions for changing culture. It’s full of ideas, examples, and exercises. For each tool there are tips on how to apply it and a description of which components of culture it helps to improve.

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Reflecting on the journey of patient engagement

As CFHI has supported the work of engagement as a catalyst for improvement, we recognize that organizations are at different points along the journey to fully embed the perspectives of patients and families in these efforts.

Putting Humans at the Center of Health Care Innovation

Harvard Business Review examines three innovation models that put patients at the centre: The Helix Centre at Imperial College London, the Center for Innovation at the Mayo Clinic, and the Consortium for Medical Technologies at Massachusetts General Hospital.

Poor-quality, predatory conferences prey on academics

“When we noticed that people were using university or grant money for these conferences, we had to put a stop to it,” said one department chair.

Respect, relationships and responsibility are foundational
to academic success

The careers of our most inspiring institutional leaders are marked by a lived commitment to these principles.

The Secret to Becoming a Nurse Quality Leader: Do What’s Good for Patients and Families

Nurses play a pivotal role in quality and safety, but chief quality leaders are often physicians. Petrina McGrath, RN, is an exception. Petrina, who is teaching in IHI’s upcoming professional development program, Chief Quality Officer, is the Executive Transition Lead for People, Practice, and Quality for the Saskatchewan Health Authority. In the following post, she answered some questions about how she got started in quality leadership, and offers advice to aspiring nurse leaders.

Meeting The Needs Of Aging Native Americans (US)

Today, American Indians and Alaska Natives are living longer, with more functional disabilities than the rest of the population, suggesting that the population needing long-term care will balloon in the coming years.

Why some pharma companies have given up on finding Alzheimer’s treatments, even as the need rises

Alzheimer’s remains the sole major cause of death in industrialized countries that lacks a disease-modifying treatment — despite billions invested in trying to find one.

Dementia care advice for transgender patients drawn up (UK)

New guidance for staff caring for transgender people with dementia has been drawn up to ensure patients get dignified and compassionate health care in north Wales.

Pharmacists ordered to do checks on care homes amid fears elderly are being harmed by drugs cocktail (UK)

Pharmacists are to carry out checks on every care home in the country amid fears that thousands of elderly people are being subjected to the ‘chemical cosh’. Simon Stevens, the head of the NHS, will order the deployment of hundreds of pharmacists to review medication being routinely doled out.

Quality of care homes got worse in 1 in 5 local authorities in the last year (UK)

The proportion of care homes rated “inadequate” or “requires improvement” increased in 1 in 5 local authority areas in 2017, according to new analysis by older people’s charity Independent Age.

Robot seal pup one step closer to helping people with dementia

Hygiene and cleaning tests were carried out over nine months on a 10-bed dementia ward and the results, just published, show that PARO was maintained within acceptable limits for NHS Infection Control.

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