April 3, 2018

Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers’ work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care. METHODS: We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July-August 2015. RESULTS: HSWs’ work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety. CONCLUSIONS: HSWs’ work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs’ work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.

Complexity thinking is increasingly being embraced in healthcare, which is often described as a complex adaptive system (CAS). Applying CAS to healthcare as an explanatory model for understanding the nature of the system, and to stimulate changes and transformations within the system, is valuable. MAIN TEXT: A seminar series on systems and complexity thinking hosted at the University of Toronto in 2016 offered a number of insights on applications of CAS perspectives to healthcare that we explore here. We synthesized topics from this series into a set of six insights on how complexity thinking fosters a deeper understanding of accepted ideas in healthcare, applications of CAS to actors within the system, and paradoxes in applications of complexity thinking that may require further debate: 1) a complexity lens helps us better understand the nebulous term “context”; 2) concepts of CAS may be applied differently when actors are cognizant of the system in which they operate; 3) actor responses to uncertainty within a CAS is a mechanism for emergent and intentional adaptation; 4) acknowledging complexity supports patient-centred intersectional approaches to patient care; 5) complexity perspectives can support ways that leaders manage change (and transformation) in healthcare; and 6) complexity demands different ways of implementing ideas and assessing the system. To enhance our exploration of key insights, we augmented the knowledge gleaned from the series with key articles on complexity in the literature. CONCLUSIONS: Ultimately, complexity thinking acknowledges the “messiness” that we seek to control in healthcare and encourages us to embrace it. This means seeing challenges as opportunities for adaptation, stimulating innovative solutions to ensure positive adaptation, leveraging the social system to enable ideas to emerge and spread across the system, and even more important, acknowledging that these adaptive actions are part of system behaviour just as much as periods of stability are. By embracing uncertainty and adapting innovatively, complexity thinking enables system actors to engage meaningfully and comfortably in healthcare system transformation.

Integrated knowledge translation (IKT) is a model of collaborative research, where researchers work with knowledge users who identify a problem and have the authority to implement the research recommendations. Knowledge users have unique expertise pertaining to the research topic, including knowledge of the context and the potential for implementation. Researchers bring methodological and content expertise to the collaboration. Implicit in this approach is the sharing of power between researchers and knowledge users. Sometimes referred to as the co-production of knowledge, this new way of working suggests that the synergies derived from the collaboration will result in better science; more relevant and actionable research findings; increased use of the findings in policy or practice; and mutual learning. An evaluation of knowledge translation funding programs at the Canadian Institutes of Health Research demonstrated that researchers and knowledge users co-producing research were more likely to report improving the health of Canadians, creating more effective health services or products and strengthening the Canadian healthcare system than researchers who do not work with knowledge users

Many representations of the movement of healthcare knowledge through society exist, and multiple models for the translation of evidence into policy and practice have been articulated. Most are linear or cyclical and very few come close to reflecting the dense and intricate relationships, systems and politics of organizations and the processes required to enact sustainable improvements. We illustrate how using complexity and network concepts can better inform knowledge translation (KT) and argue that changing the way we think and talk about KT could enhance the creation and movement of knowledge throughout those systems needing to develop and utilise it. From our theoretical refinement, we propose that KT is a complex network composed of five interdependent sub-networks, or clusters, of key processes (problem identification [PI], knowledge creation [KC], knowledge synthesis [KS], implementation [I], and evaluation [E]) that interact dynamically in different ways at different times across one or more sectors (community; health; government; education; research for example). We call this the KT Complexity Network, defined as a network that optimises the effective, appropriate and timely creation and movement of knowledge to those who need it in order to improve what they do. Activation within and throughout any one of these processes and systems depends upon the agents promoting the change, successfully working across and between multiple systems and clusters. The case is presented for moving to a way of thinking about KT using complexity and network concepts. This extends the thinking that is developing around integrated KT approaches. There are a number of policy and practice implications that need to be considered in light of this shift in thinking.

Nursing theories have attempted to shape the everyday practice of clinical nurses and patient care. However, many theories-because of their level of abstraction and distance from everyday caring activity-have failed to help nurses undertake the routine practical aspects of nursing care in a theoretically informed way. OBJECTIVE: The purpose of the paper is to present a point-of-care theoretical framework, called the fundamentals of care (FOC) framework, which explains, guides, and potentially predicts the quality of care nurses provide to patients, their carers, and family members. DISCUSSION: The theoretical framework is presented: person-centered fundamental care (PCFC)-the outcome for the patient and the nurse and the goal of the FOC framework are achieved through the active management of the practice process, which involves the nurse and the patient working together to integrate three core dimensions: establishing the nurse-patient relationship, integrating the FOC into the patient’s care plan, and ensuring that the setting or context where care is transacted and coordinated is conducive to achieving PCFC outcomes. Each dimension has multiple elements and subelements, which require unique assessment for each nurse-patient encounter. IMPLICATIONS: The FOC framework is presented along with two scenarios to demonstrate its usefulness. The dimensions, elements, and subelements are described, and next steps in the development are articulated.

Translational research (TR) can be viewed as a prominent concept that reflects expectations of societal relevance and has become an important issue in science policy. This article analyses the framings of TR in the policy discourse by comparing policy papers in the USA and some European countries. Problem frames in favor of TR are interpreted as expressions of specific conceptions of science, being either organizational or professional. Based on a qualitative content analysis, different policy documents relating to TR between 2003 and 2013 in the USA and Europe are compared. I found that TR in the USA is more strongly framed as a professional problem whereas in Europe, TR is framed as an organizational problem. It is argued that these different framings of TR have consequences for conceptions of societal relevance and steering in TR.

Health research is conducted with the expectation that it advances knowledge and eventually translates into improved health systems and population health. However, research findings are often caught in the know-do gap: they are not acted upon in a timely way or not applied at all. Integrated knowledge translation (IKT) is advanced as a way to increase the relevance, applicability and impact of research. With IKT, knowledge users work with researchers throughout the research process, starting with identification of the research question. Knowledge users represent those who would be able to use research results to inform their decisions (e.g. clinicians, managers, policy makers, patients/families and others). Stakeholders are increasingly interested in the idea that IKT generates greater and faster societal impact. Stakeholders are all those who are interested in the use of research results but may not necessarily use them for their own decision-making (e.g. governments, funders, researchers, health system managers and policy makers, patients and clinicians). Although IKT is broadly accepted, the actual research supporting it is limited and there is uncertainty about how best to conduct and support IKT. This paper presents a protocol for a programme of research testing the assumption that engaging the users of research in phases of its production leads to (a) greater appreciation of and capacity to use research; (b) the production of more relevant, useful and applicable research that results in greater impact; and (c) conditions under which it is more likely that research results will influence policy, managerial and clinical decision-making.

Knowledge creation forms an integral part of the knowledge-to-action framework aimed at bridging the gap between research and evidence-informed decision making. Although principles of science communication, data visualisation and user-centred design largely impact the effectiveness of communication, their role in knowledge creation is still limited. Hence, this article aims to provide researchers a systematic approach on how knowledge creation can be put into practice. Methods: A systematic two-phased approach towards knowledge creation was formulated and executed. First, during a preparation phase the purpose and audience of the knowledge were defined. Subsequently, a developmental phase facilitated how the content is ‘said’ (language) and communicated (channel). This developmental phase proceeded via two pathways: a translational cycle and design cycle, during which core translational and design components were incorporated. The entire approach was demonstrated by a case study. Results: The case study demonstrated how the phases in this systematic approach can be operationalised. It furthermore illustrated how created knowledge can be delivered. Conclusion: The proposed approach offers researchers a systematic, practical and easy-to-implement tool to facilitate effective knowledge creation towards decision-makers in healthcare. Through the integration of core components of knowledge creation evidence-informed decision making will ultimately be optimized.

To summarise quantitative evaluations of interventions designed to support the careers of women in academia of any discipline.Method A systematic search of English entries in PubMed, CINAHL and Google Scholar was conducted in September 2017. Methodological quality of the studies was independently assessed by two authors using the Joanna Briggs Institute quality appraisal checklists. Meta-analysis was not possible due to heterogeneity in methods and outcomes; results were synthesised and displayed narratively.Results Eighteen eligible studies were identified, mostly evaluating programmes in academic medicine departments. The most common interventions were mentoring, education, professional development and/or networking programmes. All programmes took a {\textquoteleft}bottom-up{\textquoteright} approach in that women were responsible for opting into and devoting time to participation. Study quality was low overall, but all studies reported positive outcomes on at least one indicator. Most often this included improvements in self-rated skills and capabilities, or satisfaction with the programme offered. Results regarding tangible outcomes were mixed; while some studies noted improvements in promotion, retention and remuneration, others did not.Conclusions This review suggests that targeted programmes have the potential to improve some outcomes for women in academia. However, the studies provide limited high-quality evidence to provide information for academic institutions in terms of the best way to improve outcomes for women in academia. The success of an intervention appears to be undermined when it relies on the additional labour of those it is intending to support (ie, {\textquoteleft}bottom-up{\textquoteright} approaches). As such, academic institutions should consider and evaluate the efficacy of {\textquoteleft}top-down{\textquoteright} interventions that start with change in practice of higher management.

This scoping review explored: (i) the role of unregulated care providers in the healthcare system; (ii) their potential role on interprofessional teams; (iii) the impact of unregulated care provider’s role on quality of care and patient safety; and (iv) education and employment standards. BACKGROUND: Unregulated care providers in Canada assist older adults with personal support and activities of daily living in a variety of care settings. As the care needs of an aging population become increasingly complex, the role of unregulated care providers in healthcare delivery has also evolved. Currently, many unregulated care providers are performing tasks previously performed by regulated health professionals, with potential implications for quality of care and patient safety. Information is fragmented on the role, education and employment standards of unregulated care providers. METHODS: A scoping review was conducted following the methods outlined by Arksey and O’Malley (International Journal of Social Research Methodology, 8, 2005, 19) and Levac, Colquhoun, and O’Brien (Implementation Science, 5, 2010, 69). An iterative search of published and grey literature was conducted from January 2000 to September 2016 using Medline, CINAHL, SCOPUS and Google. Inclusion and exclusion criteria were applied to identify relevant studies published in English. RESULTS: The search yielded 63 papers for review. Results highlight the evolving role of unregulated care providers, a lack of recognition and a lack of authority for unregulated care provider decision-making in patient care. Unregulated care providers do not have a defined scope of practice. However, their role has evolved to include activities previously performed by regulated professionals. Variations in education and employment standards have implications for quality of care and patient safety. CONCLUSIONS: Unregulated care providers are part of an important workforce in the long-term care and community sectors in Canada. Their evolving role should be recognised and efforts made to leverage their experience on interprofessional teams and reduce variations in education and employment standards. IMPLICATIONS FOR PRACTICE: This study highlights the evolving role of unregulated care providers in Canada and presents a set of recommendations for implementation at micro, meso, and macro policy levels.

How some organizations improve while others remain stagnant is a key question in health care research. Studies identifying how organizations can implement improvement despite barriers are needed, particularly in primary care. PURPOSES: This inductive qualitative study examines primary care clinics implementing improvement efforts in order to identify mechanisms that enable implementation despite common barriers, such as lack of time and fragmentation across stakeholder groups. METHODOLOGY: Using an embedded multiple case study design, we leverage a longitudinal data set of field notes, meeting minutes, and interviews from 16 primary care clinics implementing improvement over 15 months. We segment clinics into those that implemented more versus those that implemented less, comparing similarities and differences. We identify interpersonal mechanisms promoting implementation, develop a conceptual model of our key findings, and test the relationship with performance using patient surveys conducted pre-/post-implementation. FINDINGS: Nine clinics implemented more successfully over the study period, whereas seven implemented less. Successfully implementing clinics exhibited the managerial practice of integrating, which we define as achieving unity of effort among stakeholder groups in the pursuit of a shared and mutually developed goal. We theorize that integrating is critical in improvement implementation because of the fragmentation observed in health care settings, and we extend theory about clinic managers’ role in implementation. We identify four integrating mechanisms that clinic managers enacted: engaging groups, bridging communication, sensemaking, and negotiating. The mean patient survey results for integrating clinics improved by 0.07 units over time, whereas the other clinics’ survey scores declined by 0.08 units on a scale of 5 (p = .02). PRACTICE IMPLICATIONS: Our research explores an understudied element of how clinics can implement improvement despite barriers: integrating stakeholders within and outside the clinic into the process. It provides clinic managers with an actionable path for implementing improvement.

Nursing homes and home care face challenges across different countries as people are living longer, often with chronic conditions. There is a lack of knowledge regarding implementation and impact of quality and safety interventions as most research evidence so far is generated in hospitals. Additionally, there is a lack of effective leadership tools for quality and safety improvement work in this context. METHODS AND ANALYSIS: The aim of the ‘Improving Quality and Safety in Primary Care-Implementing a Leadership Intervention in Nursing Homes and Homecare’ (SAFE-LEAD) study is to develop and evaluate a research-based leadership guide for managers to increase quality and safety competence. The project applies a mixed-methods design and explores the implications of the leadership guide on managers’ and staffs’ knowledge, attitudes and practices. Four nursing homes and four home care services from different Norwegian municipalities will participate in the intervention. Surveys, process evaluation (interviews, observations) and document analyses will be conducted to evaluate the implementation and impact of the leadership intervention. A comparative study of Norway and the Netherlands will establish knowledge of the context dependency of the intervention. ETHICS AND DISSEMINATION: The study is approved by the Norwegian Centre for Research Data (2017/52324 and 54855). The results will be disseminated through scientific articles, two PhD dissertations, an anthology, presentations at national and international conferences, and in social media, newsletters and in the press. The results will generate knowledge to inform leadership practices in nursing homes and home care. Moreover, the study will build new theory on leadership interventions and the role of contextual factors in nursing homes and home care.

Career resilience provided a frame for understanding how Licensed Nursing Facility Administrators (LNFAs) sustain role performance and even thrive in stressful skilled nursing facility work environments. Quantitative and qualitative analyses of in-depth interviews with18 LNFAs, averaging 24 years of experience were conducted by a five-member research team. Analysis was informed by evidence-based frameworks for career resilience in the health professions as well as the National Association of Long-Term Care Administrator Boards’ (NAB) five domains of competent administrative practice. Findings included six sources of work stressors and six sources of professional satisfaction. Also, participants identified seven strategic principles and 10 administrative practices for addressing major sources of stress. Recommendations are provided for research and evidence-based application of the career resilience perspective to LNFA practice aimed at reducing role abandonment and energizing the delivery of the quality of care that each resident deserves.

To explore stakeholders’ understanding of novel integrated approaches to enhancing care in care homes (a care home ‘vanguard’) and identify priorities for evaluation. DESIGN: A qualitative study, using semistructured interviews with commissioners and service providers to/within care homes, and third sector organisations with thematic analysis. SETTING: A Clinical Commissioning Group (CCG) area in England. PARTICIPANTS: Thirty interviewees from care homes, the National Health Service (NHS; England) and local authority, third sector (10 care home managers, 5 general practitioners, 4 CCG employees, 4 local authority employees, 1 national (NHS England) vanguard lead, 2 specialist nurses, 2 geriatricians, 1 third sector and 1 health manager). RESULTS: Four higher level themes emerged from the data: understanding of proposed changes, communication, evaluation of outcome measures of success, and trust and complexity. The vision for the new programme was shared by stakeholders, with importance attached to equitable access to high-quality care. Support for the programme was described as being ‘the right thing to do’, inferring a moral imperative. However, the practical implications of key aspects, such as integrated working, were not clearly understood and the programme was perceived by some as being imposed, top down, from the health service. Barriers and facilitators to change were identified across themes of communication, outcomes, trust and complexity. Importance was attached to the measurement of intangible aspects of success, such as collaboration. Interviewees understood that outcome-based commissioning was one element of the new programme, but discussion of their aspirations and practices revealed values and beliefs more compatible with a system based on trust. CONCLUSIONS: Innovation in service delivery requires organisations to adopt common priorities and share responsibility for success. The vanguard programme is working to ensure health and local authorities have this commitment, but engaging care homes that may feel isolated from the welfare system needs sustained dialogue over the longer term. Evaluation of the programme needs to measure what is important to stakeholders, and not focus too closely on resource consumption.

Assistive technologies are often considered to be passive tools implemented in targeted processes. Our previous study of the implementation of the robot bathtub in a Danish elder center suggested that purposeful rationality was not the only issue at stake. To further explore this, we conducted a constructivist secondary qualitative analysis. Data included interviews, participant observations, working documents, and media coverage. The analysis was carried out in two phases and revealed that the bathing of the older people was constructed as a problem that could be offensive to the users’ integrity, damaging to their well-being, and physically strenuous for the staff. The older users and the nursing staff were constructed as problem carriers. We conclude that technological solutions are not merely neutral and beneficial solutions to existing problems, but are rather part of strategic games contributing to the construction of the very problems they seek to solve.

To summarize studies that used the international Resident Assessment home care instrument (interRAI HC) to examine study outcomes for older people. METHODS: A comprehensive systematic search was performed to identify relevant studies, using five databases from 1990 until October 2016. The Cochrane Risk-Bias assessment tool and Newcastle-Ottawa Scale was used to assess the quality of RCTs and non-RCTs, respectively. RESULTS: Based on the full-text analysis, 40 studies met the inclusion criteria out of 506 total records. The review included 6 RCTs, 2 quasi-experimental, 17 prospective and retrospective studies, 13 cross-sectional and 2 longitudinal studies. A series of interventions and/or applications were identified from this review that employed the use of interRAI HC instrument: (a) in health services, (b) as a new integrated care model and for implementing machine learning algorithm, (c) as a comprehensive geriatric assessment tool, (d) in case management, (e) for care planning and screening, (f) in drug therapy assessment, (g) to assess caregiver burden, and (h) for various risk assessments. Studies that employed the interRAI HC instrument reported an array of health-outcome measures mostly related to functional, cognition, hospitalization and mortality. CONCLUSIONS: Application of the interRAI HC tool varied markedly across all studies, and the outcomes measures were heterogeneous. Future research directions are discussed. CLINICAL IMPLICATIONS: The results from this study facilitate the use of interRAI HC as a tool to measure an intervention’s effect that leads to improvements in specific geriatric-related health outcome measures emphasizes on functional status and quality of life and ascertain its utility as a quality indicator for the care of older individuals.

There are calls for policymakers to make greater use of research when formulating policies. Therefore, it is important that policy organisations have a range of tools and systems to support their staff in using research in their work. The aim of the present study was to measure the extent to which a range of tools and systems to support research use were available within six Australian agencies with a role in health policy, and examine whether this was related to the extent of engagement with, and use of research in policymaking by their staff. The presence of relevant systems and tools was assessed via a structured interview called ORACLe which is conducted with a senior executive from the agency. To measure research use, four policymakers from each agency undertook a structured interview called SAGE, which assesses and scores the extent to which policymakers engaged with (i.e., searched for, appraised, and generated) research, and used research in the development of a specific policy document. The results showed that all agencies had at least a moderate range of tools and systems in place, in particular policy development processes; resources to access and use research (such as journals, databases, libraries, and access to research experts); processes to generate new research; and mechanisms to establish relationships with researchers. Agencies were less likely, however, to provide research training for staff and leaders, or to have evidence-based processes for evaluating existing policies. For the majority of agencies, the availability of tools and systems was related to the extent to which policymakers engaged with, and used research when developing policy documents. However, some agencies did not display this relationship, suggesting that other factors, namely the organisation’s culture towards research use, must also be considered.

Physician and nursing shortages in acute and critical care settings require research on factors which might drive their commitment, an important predictor of absenteeism and turnover. However, the degree to which the commitment of a physician or a nurse is driven by individual or organizational characteristics in hospitals remains unclear. In addition, there is a need for a greater understanding of how antecedent-commitment relationships differ between both occupational groups. Based on recent findings in the literature and the results of a pilot study, we investigate the degree to which selected individual and organizational characteristics might enhance an employee’s affective commitment working in the field of neonatal intensive care. Moreover, our aim is to examine the different antecedent-commitment relationships across the occupational groups of nurses and physicians. METHODS: Information about individual factors affecting organizational commitment was derived from self-administered staff questionnaires, while additional information about organizational structures was taken from hospital quality reports and a self-administered survey completed by hospital department heads. Overall, 1486 nurses and 540 physicians from 66 Neonatal Intensive Care Units participated in the study. We used multilevel modeling to account for different levels of analysis. RESULTS: Although organizational characteristics can explain differences in an employee’s commitment, the differences can be largely explained by his or her individual characteristics and work experiences. Regarding occupational differences, individual support by leaders and colleagues was shown to influence organizational commitment more strongly in the physicians’ group. In contrast, the degree of autonomy in the units and perceived quality of care had a larger impact on the nurses’ organizational commitment. CONCLUSIONS: With the growing number of hospitals facing an acute shortage of highly-skilled labor, effective strategies on the individual and organizational levels have to be considered to enhance an employee’s commitment to his or her organization. Regarding occupational differences in antecedent-commitment relationships, more specific management actions should be undertaken to correspond to different needs and aspirations of nurses and physicians. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00004589 , date of trial registration: 15.05.2013).

Psychotropic medicines are commonly used in nursing homes, despite marginal clinical benefits and association with harm in the elderly. Organizational culture is proposed as a factor explaining the high-level use of psychotropic medicines. Schein describes three levels of culture: artifacts, espoused values, and basic assumptions. OBJECTIVE: This integrative review aimed to investigate the facets and role of organizational culture in the use of psychotropic medicines in nursing homes. METHOD: Five databases were searched for qualitative, quantitative, and mixed method empirical studies up to 13 February 2017. Articles were included if they examined an aspect of organizational culture according to Schein’s theory and the use of psychotropic medicines in nursing homes for the management of behavioral and sleep disturbances in residents. Article screening and data extraction were performed independently by one reviewer and checked by the research team. The integrative review method, an approach similar to the method of constant comparison analysis was utilized for data analysis. RESULTS: Twenty-four studies met the inclusion criteria: 13 used quantitative methods, 9 used qualitative methods, 1 was quasi-qualitative, and 1 used mixed methods. Included studies were found to only address two aspects of organizational culture in relation to the use of psychotropic medicines: artifacts and espoused values. No studies addressed the basic assumptions, the unsaid taken-for-granted beliefs, which provide explanations for in/consistencies between the ideal use of psychotropic medicines and the actual use of psychotropic medicines. CONCLUSIONS: Previous studies suggest that organizational culture influences the use of psychotropic medicines in nursing homes; however, what is known is descriptive of culture only at the surface level, that is the artifacts and espoused values. Hence, future research that explains the impact of the basic assumptions of culture on the use of psychotropic medicines is important.

Scientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR). METHODS: We searched the literature for existing measures for the 7 Inner Setting domain constructs (Culture Overall, Culture Stress, Culture Effort, Implementation Climate, Learning Climate, Leadership Engagement, and Available Resources). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states (N = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity). RESULTS: CFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR /= 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level. CONCLUSIONS: Our findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.

Proper implementation of evidence-based interventions is necessary for their full impact to be realized. However, the majority of research to date has overlooked facilitators and barriers existing outside the boundaries of the implementing organization(s). Better understanding and measurement of the external implementation context would be particularly beneficial in light of complex health interventions that extend into and interact with the larger environment they are embedded within. We conducted a integrative systematic literature review to identify external context constructs likely to impact implementation of complex evidence-based interventions. METHODS: The review process was iterative due to our goal to inductively develop the identified constructs. Data collection occurred in four primary stages: (1) an initial set of key literature across disciplines was identified and used to inform (2) journal and (3) author searches that, in turn, informed the design of the final (4) database search. Additionally, (5) we conducted citation searches of relevant literature reviews identified in each stage. We carried out an inductive thematic content analysis with the goal of developing homogenous, well-defined, and mutually exclusive categories. RESULTS: We identified eight external context constructs: (1) professional influences, (2) political support, (3) social climate, (4) local infrastructure, (5) policy and legal climate, (6) relational climate, (7) target population, and (8) funding and economic climate. CONCLUSIONS: This is the first study to our knowledge to use a systematic review process to identify empirically observed external context factors documented to impact implementation. Comparison with four widely-utilized implementation frameworks supports the exhaustiveness of our review process. Future work should focus on the development of more stringent operationalization and measurement of these external constructs.

To summarise quantitative evaluations of interventions designed to support the careers of women in academia of any discipline. METHOD: A systematic search of English entries in PubMed, CINAHL and Google Scholar was conducted in September 2017. Methodological quality of the studies was independently assessed by two authors using the Joanna Briggs Institute quality appraisal checklists. Meta-analysis was not possible due to heterogeneity in methods and outcomes; results were synthesised and displayed narratively. RESULTS: Eighteen eligible studies were identified, mostly evaluating programmes in academic medicine departments. The most common interventions were mentoring, education, professional development and/or networking programmes. All programmes took a ‘bottom-up’ approach in that women were responsible for opting into and devoting time to participation. Study quality was low overall, but all studies reported positive outcomes on at least one indicator. Most often this included improvements in self-rated skills and capabilities, or satisfaction with the programme offered. Results regarding tangible outcomes were mixed; while some studies noted improvements in promotion, retention and remuneration, others did not. CONCLUSIONS: This review suggests that targeted programmes have the potential to improve some outcomes for women in academia. However, the studies provide limited high-quality evidence to provide information for academic institutions in terms of the best way to improve outcomes for women in academia. The success of an intervention appears to be undermined when it relies on the additional labour of those it is intending to support (ie, ‘bottom-up’ approaches). As such, academic institutions should consider and evaluate the efficacy of ‘top-down’ interventions that start with change in practice of higher management.

Although allied health clinicians play a key role in the provision of healthcare, embedding a culture of research within public and private health systems remains a challenge. In this rapid review we critically evaluate frameworks for embedding research into routine allied health practice, as the basis for high quality, safe, efficient and consumer-focused care. METHODS: A rapid review (PROSPERO: CRD42017075699) was conducted to evaluate frameworks designed to create and embed research in the health sector. Included were full-text, English-language, peer-reviewed publications or Government reports of frameworks that could inform the implementation of an allied health research framework. Eight electronic databases and four government websites were searched, using search terms such as models, frameworks and research capacity-building. Two independent researchers conducted all review stages and used content and thematic analysis to interpret the results. RESULTS: Sixteen framework papers were finally included. Content analysis identified 44 system and regulatory level items that informed the research frameworks, 125 healthcare organisation items and 76 items relating to individual clinicians. Thematic analysis identified four major themes. Firstly, sustainable change requires allied health research policies, regulation, governance and organisational structures that support and value evidence-based practice. Secondly, research capability, receptivity, advocacy and literacy of healthcare leaders and managers are key to successful research implementation. Third, organisational factors that facilitate a research culture include dedicated staff research positions, time allocated to research, mentoring, professional education and research infrastructure. When healthcare agencies had strong partnerships with universities and co-located research leaders, research implementation was strengthened. Finally, individual attributes of clinicians, such as their research skills and capabilities, motivation, and participation in research teams, are essential to embedding research into practice. CONCLUSION: Theoretical frameworks were identified that informed processes to embed a culture of allied health research into healthcare services. Research-led and evidence-informed allied health practice enables optimisation of workforce capability and high-quality care.

There have been over 430 publications using the RE-AIM model for planning and evaluation of health programs and policies, as well as numerous applications of the model in grant proposals and national programs. Full use of the model includes use of qualitative methods to understand why and how results were obtained on different RE-AIM dimensions, however, recent reviews have revealed that qualitative methods have been used infrequently. Having quantitative and qualitative methods and results iteratively inform each other should enhance understanding and lessons learned. METHODS: Because there have been few published examples of qualitative approaches and methods using RE-AIM for planning or assessment and no guidance on how qualitative approaches can inform these processes, we provide guidance on qualitative methods to address the RE-AIM model and its various dimensions. The intended audience is researchers interested in applying RE-AIM or similar implementation models, but the methods discussed should also be relevant to those in community or clinical settings. RESULTS: We present directions for, examples of, and guidance on how qualitative methods can be used to address each of the five RE-AIM dimensions. Formative qualitative methods can be helpful in planning interventions and designing for dissemination. Summative qualitative methods are useful when used in an iterative, mixed methods approach for understanding how and why different patterns of results occur. CONCLUSIONS: In summary, qualitative and mixed methods approaches to RE-AIM help understand complex situations and results, why and how outcomes were obtained, and contextual factors not easily assessed using quantitative measures.

Theoretical models propose the environment as a factor influencing the quality of life (QoL) of nursing home residents with dementia. This study investigates whether the observed QoL differs depending on the type of care unit. Research Design and Methods: DemenzMonitor is an exploratory, observational study involving annual data collection in German nursing homes (2012-2014). For this analysis, we selected residents with a recorded diagnosis of dementia and severe cognitive impairment. QoL was measured with the proxy assessment QUALIDEM. Four care unit types were investigated: large integrated, large segregated, small integrated, and small segregated. Results: We did not find a significant difference between the care units. During the 2 years, the observed QoL was not affected by any of the care unit types in a statistically significant or clinically relevant manner. However, a significant interaction effect between time and care unit types was found. Discussion and Implications: Structural and organizational characteristics of care units, which in turn have implications for residents characteristics and the quality of care, may influence the QoL of residents. This may explain the interaction we observed.

This paper is a humanities-based inquiry, applying Huizinga’s framework of homo ludens (“man the player”) to consider “play” in the context of two participatory arts programs (TimeSlips and the Alzheimer’s Poetry Project) for people living with dementia. “Play,” according to this Dutch historian, is at the heart of human activity and what gives meaning to life. Despite empirical research on play across the life course, play in dementia care is a relatively new idea. In addition, there is a dearth of reports based on humanistic inquiry which has slightly different goals than the growing body of qualitative and quantitative studies of participatory arts interventions. Play is not used to infantilize and trivialize people living with dementia but as a way to explore potential for expression, meaning-making, and relationship-building in later life. The arts programs were conducted at two residential care facilities, Scharwyerveld and De Beyart, in the Netherlands over 10 weeks. Close readings of the transcripts and notes from the programs resulted in three observations: people learned to play again, there is power in playing together, and play often led to expressions of joy. Overall, the notion of play may be a helpful framework for future research into innovative arts-based approaches to dementia care.

Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations. OBJECTIVE: Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs. METHODS: We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools. RESULTS: Three randomized controlled trials (RCTs), 22 cohort studies, five case-control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88-0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74-1.20) or emergency department visits (OR 1.05; 95% CI 0.76-1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or beta-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use. CONCLUSION: High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.

Few studies have simultaneously examined changes in physical, cognitive and emotional performance throughout the aging process. METHODS: Baseline data from an ongoing experimental randomized study were analyzed. Physical activity, handgrip, the Senior Fitness Test, Trail Making Test A, Rey Auditory-Verbal Learning Test, Quality of Life-Alzheimer’s Disease Scale (QoL-AD) and the Goldberg Depression Scale were used to assess study participants. Logistic regression models were applied. TRIAL REGISTRATION: ACTRN12616001044415 (04/08/2016). RESULTS: The study enrolled 114 participants with a mean age of 84.9 (standard deviation 6.9) years from ten different nursing homes. After adjusting for age, gender and education level, upper limb muscle strength was found to be associated with Rey Auditory-Verbal Learning Test [EXP(B): 1.16, 95% confidence interval (CI): 1.04-1.30] and QoL-AD [EXP(B): 1.18, 95% CI: 1.06-1.31]. Similarly, the number of steps taken per day was negatively associated with the risk of depression according to the Goldberg Depression Scale [EXP(B): 1.14, 95% CI: 1.000-1.003]. Additional analyses suggest that the factors associated with these variables are different according to the need for using an assistive device for walking. In those participants who used it, upper limb muscle strength remained associated with Rey Auditory-Verbal Learning Test [EXP(B): 1.21, 95% CI: 1.01-1.44] and QoL-AD tests [EXP(B): 1.19, 95% CI: 1.02-1.40]. In those individuals who did not need an assistive device for walking, lower limb muscle strength was associated with Rey Auditory-Verbal Learning Test [EXP(B): 1.35, 95% CI: 1.07-1.69], time spent in light physical activity was associated with QoL-AD test [EXP(B): 1.13, 95% CI: 1.00-1.02], and the number of steps walked per day was negatively associated with the risk of depression according to the Goldberg Depression Scale [EXP(B): 1.27, 95% CI: 1.000-1.004]. CONCLUSIONS: Muscle strength and physical activity are factors positively associated with a better performance on the Rey Auditory-Verbal Learning Test, QoL-AD and Goldberg Depression Scale in older adults with mild to moderate cognitive impairment living in nursing homes. These associations appeared to differ according to the use of an assistive device for walking. Our findings support the need for the implementation of interventions directed to increase the strength and physical activity of individuals living in nursing homes to promote physical, cognitive and emotional benefits. TRIAL REGISTRATION: ACTRN12616001044415 (04/08/2016).

We measured the proportion of new post-acute nursing home admissions with behavioral health diagnoses and examined whether patients with these disorders (schizophrenia/psychosis, bipolar, depression/anxiety, personality disorder, and substance abuse) faced disparities in access to high quality facilities. SETTING/PARTICIPANTS: The analytical sample included 3,729,282 admissions to 15,600 facilities nationwide for 2012-2014. MEASUREMENT: Quality was measured for overall and staffing domains reported by the Centers for Medicare and Medicaid Services in the Five-Star Quality Rating System. Multinomial logistic regression models were used. The base model included the diagnostic groups of interest and state dummies. Patient sociodemographics, functional and cognitive status, and comorbid conditions were sequentially added to the base model to determine the independent effect of having a behavioral health diagnosis at admission. RESULTS: Patients with these conditions experienced disparities accessing to high-quality homes compared to patients without. For example, patients with depression/anxiety had lower access to five-star homes, for the staffing quality domain (Model 3 ORs = 0.88, 0.93, 0.92 in years 1 through 3, respectively) compared to patients with no behavioral health diagnosis. Access disparities were faced not only by patients with serious mental illness, as previously demonstrated, but also patients with substance abuse and with depression/anxiety who account for one-third of all new admissions. CONCLUSIONS: Our findings demonstrate persistence of disparities in access to high quality facilities over time and for patients with a broad range of behavioral health conditions. Further research is needed to understand the impact of these disparities on outcomes of patients with behavioral disorders.

It is the position of the Academy of Nutrition and Dietetics that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered dietitian nutritionists assess, evaluate, and recommend appropriate nutrition interventions according to each individual’s medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered dietitian nutritionists in the implementation of individualized nutrition care, including the use of least restrictive diets. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life.

The predicted demographic changes internationally have implications for the nature of care that older people receive and place of care as they age. Healthcare policy now promotes the implementation of end-of-life care interventions to improve care delivery within different settings. The Gold Standards Framework in Care Homes (GSFCH) programme is one end-of-life care initiative recommended by the English Department of Health. Only a small number of care homes that start the programme complete it, which raises questions about the implementation process. AIM: To identify the type, role, impact and cost of facilitation when implementing the GSFCH programme into nursing care home practice. DESIGN: A mixed-methods study. SETTING: Nursing care homes in south-east England. PARTICIPANTS: Staff from 38 nursing care homes undertaking the GSFCH programme. Staff in 24 nursing care homes received high facilitation. Of those, 12 also received action learning. The remaining 14 nursing care homes received usual local facilitation of the GSFCH programme. METHODS: Study data were collected from staff employed within nursing care homes (home managers and GSFCH coordinators) and external facilitators associated with the homes. Data collection included interviews, surveys and facilitator activity logs. Following separate quantitative (descriptive statistics) and qualitative (template) data analysis the data sets were integrated by ‘following a thread’. This paper reports study data in relation to facilitation. RESULTS: Three facilitation approaches were provided to nursing home staff when implementing the GSFCH programme: ‘fitting it in’ facilitation; ‘as requested’ facilitation; and ‘being present’ facilitation. ‘Being present’ facilitation most effectively enabled the completion of the programme, through to accreditation. However, it was not sufficient to just be present. Without mastery and commitment, from all participants, including the external facilitator, learning and initiation of change failed to occur. Implementation of the programme required an external facilitator who could mediate multi-layered learning at an individual, organisational and appreciative system level. The cost savings in the study outweighed the cost of providing a ‘being present’ approach to facilitation. CONCLUSIONS: Different types of facilitation are offered to support the implementation of end-of-life care initiatives. However, in this study ‘being present’ facilitation, when supported by multi-layered learning, was the only approach that initiated the change required.

Ageing societies and a rising prevalence of dementia are associated with increasing demand for care home places. Monitoring technologies (e.g. bed-monitoring systems; wearable location-tracking devices) are appealing to care homes as they may enhance safety, increase resident freedom, and reduce staff burden. However, there are ethical concerns about the use of such technologies, and it is unclear how they might be implemented to deliver their full range of potential benefits. OBJECTIVE: This study explored facilitators and barriers to the implementation of monitoring technologies in care homes. DESIGN: Embedded multiple-case study with qualitative methods. SETTING: Three dementia-specialist care homes in North-West England. PARTICIPANTS: Purposive sample of 24 staff (including registered nurses, clinical specialists, senior managers and care workers), 9 relatives and 9 residents. METHODS: 36 semi-structured interviews with staff, relatives and residents; 175h of observation; resident care record review. Data collection informed by Normalization Process Theory, which seeks to account for how novel interventions become routine practice. Data analysed using Framework Analysis. RESULTS: Findings are presented under three main themes: 1. Reasons for using technologies: The primary reason for using monitoring technologies was to enhance safety. This often seemed to override consideration of other potential benefits (e.g. increased resident freedom) or ethical concerns (e.g. resident privacy); 2. Ways in which technologies were implemented: Some staff, relatives and residents were not involved in discussions and decision-making, which seemed to limit understandings of the potential benefits and challenges from the technologies. Involvement of residents appeared particularly challenging. Staff highlighted the importance of training, but staff training appeared mainly informal which did not seem sufficient to ensure that staff fully understood the technologies; 3. Use of technologies in practice: Technologies generated frequent alarms that placed a burden upon staff, but staff were able to use their contextual knowledge to help to counter some of this burden. Some technologies offered a range of data-gathering capabilities, but were not always perceived as useful complements to practice. CONCLUSION: Implementation of monitoring technologies may be facilitated by the extent to which the technologies are perceived to enhance safety. Implementation may be further facilitated through greater involvement of all stakeholders in discussions and decision-making in order to deepen understandings about the range of potential benefits and challenges from the use of monitoring technologies. Staff training might need to move beyond functional instruction to include deeper exploration of anticipated benefits and the underlying rationale for using monitoring technologies.

Dementia is a syndrome that is progressive, degenerative, and terminal. The palliative care philosophy aims to maximize quality of life for the dying individual and is both beneficial for and underused with persons dying with dementia. OBJECTIVES: The purpose of this study was to investigate the experiences of long-term care staff delivering palliative care to individuals with dementia to determine how care was delivered, to learn which guidelines were used, and whether policies affected the delivery of palliative care. METHODS: Twenty-two staff participants were interviewed. Their experiences were interpreted using phenomenological methodology. RESULTS: Findings yielded 3 key themes: confusion, resource shortages, and communication difficulties. CONCLUSION: Implications for practice include clarification of terminology surrounding palliative care, education of families about dementia and palliative care, better resource management, and the need to address when palliative care best fits within the dementia process.

Nursing home (NH) administrators need tools to measure the effectiveness of care delivered at the end of life so that they have objective data on which to evaluate current practices, and identify areas of resident care in need of improvement. METHODS: A three-phase mixed methods study was used to develop and test an empirically derived chart audit tool aimed at assessing the care delivered along the entire dying trajectory. RESULTS: The Auditing Care at the End of Life (ACE) instrument contains 27 questions captured across 6 domains, which are indicative of quality end-of-life care for nursing home residents. CONCLUSIONS: By developing a brief chart audit tool that captures best practices derived from expert consensus and the research literature, NH facilities will be equipped with one means for monitoring and assessing the care delivered to dying residents.

“I’m Still Me: The Lived Experiences of Residents in Designated Supportive Living” document is the first report of its kind to be released in Alberta. This report contains details of an HQCA pilot project conducted in 2017 involving interviews with a small sample of residents in designated supportive living. The purpose was to gain a deeper understanding of their experiences. Specifically, this report identifies, from residents’ perspectives, themes of what is working well and what could be done to improve residents’ experiences in designated supportive living.

Following the session attendees will be able to:
1. be aware of key messages from the literature with respect to:
a. the knowledge broker role(s) in healthcare
b. the evidence regarding the effect and effectiveness of knowledge brokers in healthcare
c. key issues related to the training, recruitment and evaluation of knowledge brokers
2. reflect upon if and how knowledge brokers could be incorporated within their own organization

Given advances in dental care over the last half century, Canadians are no longer aging with the inevitable loss of their teeth. While this is a welcome trend, it also results in more and more older adults in residential care who require assistance with daily mouth care. On the surface, brushing and flossing seem to be simple mundane tasks. But when providing this care for others, it requires skill, the right resources and the commitment to ensure it is done well. In this webinar we will review the basics of oral disease and its impact on general health and wellness. We will also explore ways to manage daily mouth care for those living in residential care with an overview of the Brushing Up on Mouth Care suite of online, open access resources that were developed in partnership with front-line care staff from long-term care.

Who is this course for? Students and researchers interested in drawing upon cognitive and behaviour change theories to promote changing practice to improve healthcare delivery (no prior experience required). For more information and to register your interest, please contact Zack van Allen (zvanallen@ohri.ca).

The number of students starting nursing degree courses is likely to fall again this year unless the Government takes urgent action, an RCN report has said.

Alzheimer’s is the 6th leading cause of death in the US.

This Common Statement of Principles focuses on two priority areas (home and community care, and mental health and addictions) where federal funding will be provided to PTs in response to increased demands.

Male professors are paid more than female professors even when they get the same grant funding.

A growing chorus of geriatricians, cancer specialists and health system analysts are coming forth with a host of reasons against screening: Such testing in the nation’s oldest patients is highly unlikely to detect lethal disease, hugely expensive and more likely to harm than help since any follow-up testing and treatment is often invasive.

Jonathan O’Donnell sets out some practical advice for early-career researchers competing for grant funding; starting with what can be learnt by serving as a reviewer of applications, how collaborating with others can help, and finally considering what the options are outside of the peer review system.

Instead of a health care system ruled by efficiencies, we need one that treats patients as people, not health care consumers.

Bike uses Google Street View projections

Between 1988 and 2007, the federal government created a number of arm’s-length agencies to address various health policy issues – among them, developing a mental-health strategy, collecting national data, reviewing the effectiveness of drugs and devices. But a new report says the eight agencies, known collectively as the pan-Canadian health organizations (PCHOs), need a fundamental revamp to eliminate duplication and address yawning policy gaps.

Carers looking after older people should be given statutory LGBT training to help tackle homophobia in the sector, the charity Stonewall has said. Discrimination is “alive and kicking,” with many older people fearing abuse from care workers, one man told the Victoria Derbyshire programme.

Cristin Lind and Kyle Knox discuss their experience of co-producing a conference with patients.

Sion Jair, 68, has climbed the Old Man of Coniston at least 5,000 times and the emerging science backs him up that regular, vigorous exercise is beneficial for those with the disease.

It is widely acknowledged that submitting a paper to a journal is a fraught activity for authors. But why should this still be the case? James Hartley and Guillaume Cabanac argue that the process has always been complicated but can, with a few improvements, be less so. By adopting standardised templates and no longer insisting on articles being reformatted, the submission process can quickly be simplified.

In this interview, Dr. Aiken discusses how nurse staffing and the work environment can affect patient safety and outcomes.

Having more nurses with at least a bachelor’s nursing degree at the bedside improved the likelihood of good outcomes for all patients, but it had a much greater effect for patients with dementia.

Going to an academic conference is an exciting opportunity to connect with like-minded individuals and exchange stimulating ideas. However, to make the most of a conference requires a lot of hard work before, during, and after the meeting itself.

Shared reading has a significant impact on mood, concentration and social interaction. A Liverpool charity is running sessions in care homes.

Are you highly skilled in program design, evaluation and performance measurement? Join the Economic Analysis and Evaluation Unit of the Research, Analysis and Evaluation Branch and provide your expertise in evaluation design, planning and management service for policy and program clients from across the health system.