November 19, 2018



Blog post by Professor Jo Rycroft-Malone on Nursing Research
Research by Nurses for Nursing and Care Improvement: A funder’s view

Two new articles on Facilitating Implementation of Research Evidence (FIRE)

A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar

Jo Rycroft-Malone, Kate Seers, Ann Catrine Eldh, Karen Cox, Nicola Crichton, Gill Harvey, Claire Hawkes, Alison Kitson, Brendan McCormack, Christel McMullan, Carole Mockford, Theo Niessen, Paul Slater, Angie Titchen, Teatske van der Zijpp, and Lars Wallin
Implementation Science 2018 11/16;13(1):138
Facilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice.

Designing and implementing two facilitation interventions within the ‘Facilitating Implementation of Research Evidence (FIRE)’ study: a qualitative analysis from an external facilitators’ perspective

Gill Harvey, Brendan McCormack, Alison Kitson, Elizabeth Lynch and Angie Titchen.
Implementation Science 2018 11/16;13(1):141
The “Facilitating Implementation of Research Evidence” study found no significant differences between sites that received two types of facilitation support and those that did not on the primary outcome of documented compliance with guideline recommendations. Process evaluation highlighted factors that influenced local, internal facilitators’ ability to enact the roles as envisaged. In this paper, the external facilitators responsible for designing and delivering the two types of facilitation intervention analyse why the interventions proved difficult to implement as expected, including the challenge of balancing fidelity and adaptation.


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


Changing behaviour ‘more or less’-do theories of behaviour inform strategies for implementation and de-implementation? A critical interpretive synthesis.
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A. M. Patey, C. S. Hurt, J. M. Grimshaw and J. J. Francis.
Implement Sci 2018 Oct 29;13(1):134-018-0826-6
Implementing evidence-based care requires healthcare practitioners to do less of some things (de-implementation) and more of others (implementation). Variations in effectiveness of behaviour change interventions may result from failure to consider a distinction between approaches by which behaviour increases and decreases in frequency. The distinction is not well represented in methods for designing interventions. This review aimed to identify whether there is a theoretical rationale to support this distinction. METHODS: Using Critical Interpretative Synthesis, this conceptual review included papers from a broad range of fields (biology, psychology, education, business) likely to report approaches for increasing or decreasing behaviour. Articles were identified from databases using search terms related to theory and behaviour change. Articles reporting changes in frequency of behaviour and explicit use of theory were included. Data extracted were direction of behaviour change, how theory was operationalised, and theory-based recommendations for behaviour change. Analyses of extracted data were conducted iteratively and involved inductive coding and critical exploration of ideas and purposive sampling of additional papers to explore theoretical concepts in greater detail. RESULTS: Critical analysis of 66 papers and their theoretical sources identified three key findings: (1) 9 of the 15 behavioural theories identified do not distinguish between implementation and de-implementation (5 theories were applied to only implementation or de-implementation, not both); (2) a common strategy for decreasing frequency was substituting one behaviour with another. No theoretical basis for this strategy was articulated, nor were methods proposed for selecting appropriate substitute behaviours; (3) Operant Learning Theory makes an explicit distinction between techniques for increasing and decreasing frequency. DISCUSSION: Behavioural theories provide little insight into the distinction between implementation and de-implementation. Operant Learning Theory identified different strategies for implementation and de-implementation, but these strategies may not be acceptable in health systems. Additionally, if behaviour substitution is an approach for de-implementation, further investigation may inform methods or rationale for selecting the substitute behaviour.

Exploring the synergies between focused ethnography and integrated knowledge translation.
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J. Baumbusch, S. Wu, S. B. Lauck, D. Banner, T. O’Shea and L. Achtem.
Health Res Policy Syst 2018 Nov 3;16(1):103-018-0376-z
Issues with the uptake of research findings in applied health services research remain problematic. Part of this disconnect is attributed to the exclusion of knowledge users at the outset of a study, which often results in the generation of knowledge that is not usable at the point of care. Integrated knowledge translation blended with qualitative methodologies has the potential to address this issue by working alongside knowledge users throughout the research process. Nevertheless, there is currently a paucity of literature about how integrated knowledge translation can be integrated into qualitative methodology; herein, we begin to address this gap in methodology discourse. The purpose of this paper is to describe our experience of conducting a focused ethnography with a collaborative integrated knowledge translation approach, including the synergies and potential sources of discord between integrated knowledge translation and focused ethnography. METHODS: We describe the specific characteristics and synergies that exist when using an integrated knowledge translation approach with focused ethnography, using a research exemplar about the experiences of frail, older adults undergoing a transcatheter aortic valve implantation. RESULTS: Embedding integrated knowledge translation within focused ethnography resulted in (1) an increased focus on the culture and values of the context under study, (2) a higher level of engagement among researchers, study participants and knowledge users, and (3) a commitment to partnership between researchers and knowledge users as part of a larger programme of research, resulting in a (4) greater emphasis on the importance of reciprocity and trustworthiness in the research process. CONCLUSIONS: Engaging in integrated knowledge translation from the outset of a study ensures that research findings are relevant for application at the point of care. The integration of integrated knowledge translation within focused ethnography allows for real-time uptake of meaningful and emerging findings, the strengthening of collaborative research teams, and opportunities for sustained programmes of research and relationships in the field of health services research. Further exploration of the integration of knowledge translation approaches with qualitative methodologies is recommended.

Clinicians as novice facilitators: a SIMPLE case study
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Adrienne M. Young, Heather H. Keller, Rhiannon Barnes and Jack J. Bell.
J of Health Org and Mgt 2018 10/30; 2018/11
The purpose of this paper is to advance understanding about the facilitation process used in complex implementation projects, by describing the function of novice clinician facilitators, and the barriers and enablers they experience, while implementing a new model of care for managing hospital malnutrition. Design/methodology/approach Semi-structured interviews were undertaken with local facilitators (n=7) involved in implementing The SIMPLE Approach (Systematised Interdisciplinary Malnutrition Pathway Implementation and Evaluation) in six hospitals in Queensland, Australia. Facilitator networks and training supported the clinicians acting as novice facilitators. Findings Key functions of the facilitator role were building relationships and trust; understanding the problem and stimulating change through data; negotiating and implementing the change; and measuring, sharing and reflecting on success. ?Dedicated role, time and support? was identified as a theme encompassing the key barriers and enablers to successful facilitation. Practical implications When implementing complex interventions within short project timelines, it is critical that novice clinician facilitators are given adequate and protected time within their role, and have access to regular support from peers and experienced facilitators. With these structures in place, facilitators can support iterative improvements through building trust and relationships, co-designing strategies with champions and teams and developing internal capacity for change. Originality/value This case study extends the knowledge about how facilitation works in action, the barriers faced by clinicians new to working in facilitator roles, and highlights the need for an adapt-to-fit approach for the facilitation process, as well as the innovation itself.; Purpose The purpose of this paper is to advance understanding about the facilitation process used in complex implementation projects, by describing the function of novice clinician facilitators, and the barriers and enablers they experience, while implementing a new model of care for managing hospital malnutrition. Design/methodology/approach Semi-structured interviews were undertaken with local facilitators (n=7) involved in implementing The SIMPLE Approach (Systematised Interdisciplinary Malnutrition Pathway Implementation and Evaluation) in six hospitals in Queensland, Australia. Facilitator networks and training supported the clinicians acting as novice facilitators. Findings Key functions of the facilitator role were building relationships and trust; understanding the problem and stimulating change through data; negotiating and implementing the change; and measuring, sharing and reflecting on success. ?Dedicated role, time and support? was identified as a theme encompassing the key barriers and enablers to successful facilitation. Practical implications When implementing complex interventions within short project timelines, it is critical that novice clinician facilitators are given adequate and protected time within their role, and have access to regular support from peers and experienced facilitators. With these structures in place, facilitators can support iterative improvements through building trust and relationships, co-designing strategies with champions and teams and developing internal capacity for change. Originality/value This case study extends the knowledge about how facilitation works in action, the barriers faced by clinicians new to working in facilitator roles, and highlights the need for an adapt-to-fit approach for the facilitation process, as well as the innovation itself.

Advancing the evaluation of integrated knowledge translation
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S. A. Kreindler.
Health Res Policy Syst 2018 Nov 6;16(1):104-018-0383-0
Integrated knowledge translation (IKT) flows from the premise that knowledge co-produced with decision-makers is more likely to inform subsequent decisions. However, evaluations of manager/policy-maker-focused IKT often concentrate on intermediate outcomes, stopping short of assessing whether research findings have contributed to identifiable organisational action. Such hesitancy may reflect the difficulty of tracing the causes of this distal, multifactorial outcome. This paper elucidates how an approach based on realistic evaluation could advance the field. MAIN TEXT: Realistic evaluation views outcomes as a joint product of intervention mechanisms and context. Through identification of context-mechanism-outcome configurations, it enables the systematic testing and refinement of ‘mid-range theory’ applicable to diverse interventions that share a similar underlying logic of action. The ‘context-sensitive causal chain’ diagram, a tool adapted from the broader theory-based evaluation literature, offers a useful means of visualising the posited chain from activities to outcomes via mechanisms, and the context factors that facilitate or disrupt each linkage (e.g. activity-mechanism, mechanism-outcome). Drawing on relevant literature, this paper proposes a context-sensitive causal chain by which IKT may generate instrumental use of research findings (i.e. direct use to make a concrete decision) and identifies an existing tool to assess this outcome, then adapts the chain to describe a more subtle, indirect pathway of influence. Key mechanisms include capacity- and relationship-building among researchers and decision-makers, changes in the (perceived) credibility and usability of findings, changes in decision-makers’ beliefs and attitudes, and incorporation of new knowledge in an actual decision. Project-specific context factors may impinge upon each linkage; equally important is the organisation’s absorptive capacity, namely its overall ability to acquire, assimilate and apply knowledge. Given a sufficiently poor decision-making environment, even well-implemented IKT that triggers important mechanisms may fall short of its desired outcomes. Further research may identify additional mechanisms and context factors. CONCLUSION: By investigating ‘what it is about an intervention that works, for whom, under what conditions’, realistic evaluation addresses questions of causality head-on without sacrificing complexity. A realist approach could contribute greatly to our ability to assess – and, ultimately, to increase – the value of IKT.

Development and Usability Testing of EPC Evidence Review Dissemination Summaries for Health Systems Decisionmakers

AHRQ November 2018
Objectives. To develop dissemination summaries based on AHRQ EPC evidence reviews, and to evaluate the summaries, and their components, for usability among health systems decisionmakers. Methods. For each of two reviews, we designed a three-page summary with the intent that the first page could potentially be a stand-alone one-page summary. Summaries included various report elements (e.g., key questions, methods, eligibility criteria, analytic framework, summary tables, forest plots) and varied in layout and design (e.g., text only vs. use of images). We conducted ‘think aloud’ telephone interviews with six decisionmakers from Strategic Clinical Networks, which are clinician-led teams that develop and implement evidence-informed health improvement strategies within a province-wide fully integrated health system. We analyzed the data thematically and translated themes into recommendations.


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Health Care Administration and Organization

Exploring factors influencing the work-related morale for certified nursing assistants in hospice care: A structural equation modeling study
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J. Y. Wang, H. L. Zhuang, J. Y. Chiou, C. W. Wang, C. Y. Wang and L. F. Liu.
PLoS One 2018 Oct 26;13(10):e0206281
Certified nursing assistants (CNAs) in palliative care units often encounter the death of patients and undergo emotional burdens because of their altruistic practices. However, the influences of altruism and perceptions of death on the work morale of CNAs remain unclear. The fact that morale can be improved by modifying related factors justifies the necessity of a theoretical model of morale for CNAs. However, such a model is currently absent. Based on relevant literature, factors including altruism, social support, perceptions of death, and job satisfaction are related to morale through the mediation of job stress. AIM: This study was aimed toward determining the influencing factors and developing a structural model of morale with regard to CNAs working in palliative care units. DESIGN: The hypothesized model was tested in a cross-sectional design with structural equation modeling using AMOS 23. SETTING/PARTICIPANTS: A total of 413 CNAs from five hospice units in Taiwan participated in the survey. RESULTS: Goodness-of-fit indexes, including chi2/DF = 2.187, PGFI = 0.461, and PNFI = 0.462, among others, confirmed the modified model fit the data well. Altruism, social support, perceptions of death, and job satisfaction were negatively related to job stress (-0.238, -0.196, -0.204, and -0.131, respectively). Altruism and social support positively affected job satisfaction (0.635 and 0.553). Factors directly affecting morale included altruism, social support, job stress, and job satisfaction (0.837, 0.711, -0.244, and 0.540, respectively). The relationship between altruism and morale was the strongest among all the direct paths toward morale. Job stress was the major mediator in these relationships. CONCLUSION: Altruism is imperative for morale. The confirmed model is called the Five Constructs to Morale (5CM) model. These findings indicate the need to assess the levels of altruism and perceptions of death during the recruitment of CNAs. From the perspective of human resource management and organizational behavior, CNAs with a high level of altruism and a positive attitude toward death assure the well-being of end of life patients because of work involvement and commitment to the challenging work of hospice care. The cultivation of a supportive environment and coping strategies are suggested for the management of CNAs facing patient death. Hospice care decision makers should carefully assess morale levels among health professionals by applying the 5CM model. Identifying modifiable factors that can improve morale among nursing staff in hospice care to ensure work fulfillment and quality care merits emphasis in clinical practice. The establishment of effective strategies to facilitate the work morale of nursing staff is suggested for palliative care units. Morale improvement related task should be a global public health priority.

Healthcare Costs of Frailty: Implications for Long-term Care
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Aarón Salinas-Rodríguez, Betty Manrique-Espinoza, Ileana Heredia-Pi, Ana Rivera-Almaraz, José Alberto Ávila-Funes
Journal of the American Medical Directors Association 2018/11.
In the next few decades, there will be an unprecedented demand for health services required by frail and nonfrail older individuals. This increased demand will have multiple implications for individuals, families, health systems, and larger society. One of the main implications is higher health care costs. Recent evidence has shown that frailty could be associated with higher health care costs.

The Impact of Incomplete Nursing Home Transfer Documentation on Emergency Department Care
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C. J. Gettel, R. C. Merchant, Y. Li, et al.
J Am Med Dir Assoc 2018 Oct 29
Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission. DESIGN: Retrospective study using 2 abstractors blinded to the study aims. SETTING AND PARTICIPANTS: 474 records from NH residents transferred to the 3 EDs of Rhode Island’s largest health care system from September 2015 to September 2016. MEASURES: NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission. RESULTS: Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P = .03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01-1.18). CONCLUSIONS/IMPLICATIONS: Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms.

Does Nursing Home Compare Reflect Patient Safety In Nursing Homes?
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D. Brauner, R. M. Werner, T. P. Shippee, J. Cursio, H. Sharma and R. T. Konetzka.
Health Aff (Millwood) 2018 Nov;37(11):1770-1778
The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes’ performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy aimed at improving the quality of nursing home care, to their performance on measures of patient safety in nursing homes such as pressure sores, infections, falls, and medication errors. Although Nursing Home Compare captures some aspects of patient safety, we found the relationship to be weak and somewhat inconsistent, leaving consumers who care about patient safety with little guidance. We recommend that Nursing Home Compare be refined to provide a clearer picture of patient safety and quality of life, allowing consumers to weight these domains according to their preferences and priorities.

A systematic review and meta-analysis of the prevalence and associations of stress and burnout among staff in long-term care facilities for people with dementia
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H. Costello, S. Walsh, C. Cooper and G. Livingston.
Int Psychogeriatr 2018 Nov 13:1-14
Care home staff stress and burnout may be related to high turnover and associated with poorer quality care. We systematically reviewed and meta-analyzed studies reporting stress and burnout and associated factors in staff for people living with dementia in long-term care. METHODS: We searched MEDLINE, PsycINFO, Web of Science databases, and CINAHL database from January 2009 to August 2017. Two raters independently rated study validity using standardized criteria. We meta-analyzed burnout scores across comparable studies using a random effects model. RESULTS: 17/2854 identified studies met inclusion criteria. Eight of the nine studies reporting mean Maslach Burnout Inventory (MBI) scores found low or moderate burnout levels. Meta-analysis of four studies using the 22-item MBI (n = 598) found moderate emotional exhaustion levels (mean 18.34, 95% Confidence Intervals 14.59-22.10), low depersonalization (6.29, 2.39-10.19), and moderate personal accomplishment (33.29, 20.13-46.46). All three studies examining mental health-related quality of life reported lower levels in carer age and sex matched populations. Staff factors associated with higher burnout and stress included: lower job satisfaction, lower perceived adequacy of staffing levels, poor care home environment, feeling unsupported, rating home leadership as poor and caring for residents exhibiting agitated behavior. There was preliminary evidence that speaking English as a first language and working shifts were associated with lower burnout levels. CONCLUSIONS: Most care staff for long-term care residents with dementia experience low or moderate burnout levels. Prospective studies of care staff burnout and stress are required to clarify its relationship to staff turnover and potentially modifiable risk factors.

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Health Care Innovation and Quality Assurance

Ten tips for advancing a culture of improvement in primary care.
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T. Kiran, N. Ramji, M. B. Derocher, G. Rajesh, S. Davie and M. Lam-Antoniades.
BMJ Qual Saf 2018 Oct 31
Embracing practice-based quality improvement (QI) represents one way for clinicians to improve the care they provide to patients while also improving their own professional satisfaction. But engaging in care redesign is challenging for clinicians. In this article, we describe our experience over the last 7 years transforming the care delivered in our large primary care practice. We reflect on our journey and offer 10 tips to healthcare leaders seeking to advance a culture of improvement. Our organisation has developed a cadre of QI leaders, tracks a range of performance measures and has demonstrated sustained improvements in important areas of patient care. Success has required deep engagement with both patients and clinicians, a long-term vision, and requisite patience.

Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care.
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S. Wu, J. M. Morrison, H. Dunn-Ridgeway, V. Vucea, S. Iuglio and H. Keller.
BMC Geriatr 2018 Nov 13;18(1):277-018-0964-3
Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required. METHODS: A mixed methods study conducted between April-November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made. RESULTS: Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff’s creative mealtime initiatives. CONCLUSIONS: This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching.


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Organizational Culture and Change

The impact of inner and outer context on line managers’ implementation leadership
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Rebecca Mosson, Thiele Schwarz von, Anne Richter and Henna Hasson.
The British Journal of Social Work 2018 07/01;48(5):1447-1468
Line managers have an important role in leading implementation of evidence-based practice (EBP). In this task, they are highly influenced by their context. However, little is known about how contextual factors impact managers’ implementation leadership. The aim of the present study is to explore how contextual factors influence line managers’ leadership when implementing EBP. Twenty-eight semi-structured interviews were performed with line managers in social care. A hybrid thematic analysis was carried out. The Consolidated Framework for Implementation Research Framework (CFIR) was used to guide the deductive analysis approach. Findings showed that contextual factors in all of CFIR’s inner setting constructs and in two constructs of the outer-setting domain (Cosmopolitanism and External resources and funding) had a high practical impact on managers’ implementation leadership. However, many of the contextual factors were either not offered to or did not actually reach the managers, which means that they had a limited impact in practice. Moreover, several factors only had a positive practical impact in interaction with other factors, rather than independently. Future research should systematically consider interactions between contextual factors. Identifying factors that have a potential impact in practice may help inform support initiatives to aid managers in developing their implementation leadership.

Measurement of Nursing Home Culture Change: Systematic Review.
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D. L. Sturdevant, C. A. Mueller and K. C. Buckwalter.
Res Gerontol Nurs 2018 Mar 1;11(2):103-112
Nursing home culture change (NHCC) aims to change the way care is provided in nursing homes. Valid and reliable measures are needed to evaluate the impact of NHCC on outcomes. The current systematic review provides an overview of instruments designed to measure NHCC and criteria for others to evaluate and choose instruments according to their own purpose. Ten instruments were identified that measure NHCC on an organizational level. Lack of development description hindered their assessment, and studies examining the relationship between NHCC and outcomes are rare. A common limitation of the instruments reviewed was the lack of psychometric testing; thus, their validity and reliability need further exploration.

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Research Practice and Methodology

A Qualitative Evidence Synthesis Review of Longitudinal Qualitative Research in Gerontology
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A. L Nevedal, L. Ayalon and S. H. Briller.
Gerontologist 2018 Nov 5
Gerontologists have long been interested in longitudinal qualitative research (LQR), yet ambiguity remains about best practices. The purpose of this review was to conduct a qualitative evidence synthesis to identify strengths and limitations in existing gerontological LQR. Research Design and Methods: We searched for studies published in English before September 2017, using longitudinal qualitative methods and focusing on gerontology. We searched the following databases: PubMed and ProQuest. This was followed up by a snowball search to identify additional LQR articles that were not gerontologically focused but provided conceptual or methodological information to enhance gerontological LQR. Article titles and abstracts were reviewed, and selected articles were independently evaluated by all authors and summarized in a descriptive matrix based on design, analysis, and strengths and limitations. Results: Our literature search resulted in 225 articles, which was then narrowed to 71 articles from 47 different journals based on our inclusion/exclusion criteria. LQR in gerontology varies considerably by study design and analysis approach. LQR design considerations involve number of time points and duration; rapport and retention; and consistent or different sampling, data collection, and measures. LQR analysis considerations involve synchronic and diachronic approaches, consistent or evolving coding, and individual- or group-level analysis. Gerontological LQR articles vary in the extent to which they address special aging considerations. Discussion and Implications: This review indicates that there are areas where gerontological LQR can be strengthened going forward. We provide researchers with strategies to improve LQR rigor in our field and beyond.

AHRQ series on complex intervention systematic reviews-paper 3: adapting frameworks to develop protocols.
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M. Butler, R. A. Epstein, A. Totten, et al.
J Clin Epidemiol 2017 Oct;90:19-27
Once a proposed topic has been identified for a systematic review and has undergone a question formulation stage, a protocol must be developed that specifies the scope and research questions in detail and outlines the methodology for conducting the systematic review. RATIONALE: Framework modifications are often needed to accommodate increased complexity. We describe and give examples of adaptations and alternatives to traditional analytic frameworks. DISCUSSION: This article identifies and describes elements of frameworks and how they can be adapted to inform the protocol and conduct of systematic reviews of complex interventions. Modifications may be needed to adapt the population, intervention, comparators, and outcomes normally used in protocol development to successfully describe complex interventions; in some instances, alternative frameworks may be better suited. Possible approaches to analytic frameworks for complex interventions that illustrate causal and associative linkages are outlined, including time elements, which systematic reviews of complex interventions may need to address. The need for and specifics of the accommodations vary with details of a specific systematic review. This in turn helps determine whether traditional frameworks are sufficient, can be refined, or if alternate frameworks must be adopted.

The Future of Health Services Research: Advancing Health Systems Research and Practice in the United States

National Academy of Medicine, 2018
Health services research is “the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care and the quality and cost of health care.” Since the 1960s, health services research has provided the foundation for progress, effectiveness, and value in health care. Ironically, at a time in which appreciation has never been higher for both the need and potential from health services research, the political and financial support for sustenance and growth appear to be weakening.

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Prevalence and Associated Factors of Sarcopenia in Nursing Home Residents: A Systematic Review and Meta-analysis
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Y. Shen, J. Chen, X. Chen, L. Hou, X. Lin and M. Yang.
J Am Med Dir Assoc 2018 Nov 5
To review the prevalence and associated factors of sarcopenia in nursing homes. DESIGN: A systematic review and meta-analysis of published studies in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. SETTING: Nursing homes. PARTICIPANTS: Older adults aged >/=60 years. MEASUREMENTS: Sarcopenia was defined according to various validated diagnostic criteria, such as the European Working Group on Sarcopenia in Older People (EWGSOP) criteria and skeletal muscle index (SMI). We performed meta-analyses with random effects models to calculate the pooled prevalence of sarcopenia. The risk of bias of the included studies was evaluated using a 10-item tool explicitly designed for prevalence studies. RESULTS: We included 16 studies with a total of 3585 participants from 129 nursing homes. The included studies were of low to moderate risk of bias. The pooled prevalences of EWGSOP-defined sarcopenia and SMI-defined sarcopenia were 41% [95% confidence interval (CI) 32%-51%, 12 studies, 2685 cases] and 59% (95% CI 24%-93%, 3 studies, 643 cases), respectively. The pooled prevalences of EWGSOP-defined sarcopenia in women and men were 46% (8 studies, 1332 cases) and 43% (8 studies, 739 cases), respectively. The pooled data showed that malnutrition was an independent associated factor of EWGSOP-defined sarcopenia (odds ratio [OR] 1.74, 95% CI 1.36-2.24; 3 studies, 718 cases), but malnutrition risk (OR 1.01, 95% CI 0.53-1.94; 2 studies, 379 cases) and female gender were not (OR 1.14, 95% CI 0.11-11.66; 3 studies, 827 cases). The association between age and body mass index with sarcopenia was inconsistent across studies. Limited evidence indicated that smoking might be related to sarcopenia. CONCLUSIONS/IMPLICATIONS: Sarcopenia is highly prevalent in older nursing home residents. Malnutrition may be an associated factor of sarcopenia. More prospective studies are needed to clarify the association between age, gender, malnutrition, and smoking with sarcopenia.

Aggressive Behaviors Among Nursing Home Residents: Association With Dementia and Behavioral Health Disorders
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X. Cen, Y. Li, M. Hasselberg, T. Caprio, Y. Conwell and H. Temkin-Greener.
J Am Med Dir Assoc 2018 Nov 5
We measured the prevalence and severity of aggressive behaviors (ABs) among nursing home (NH) residents and examined whether individuals with behavioral health disorders were more likely to exhibit aggressive behaviors than others. SETTING AND PARTICIPANTS: The analytical sample included 3,270,713 first Minimum Data Set (MDS) assessments for residents in 15,706 NHs in 2015. MEASURES: Individuals were identified as having (1) behavioral health disorders only (hierarchically categorized as schizophrenia/psychosis, bipolar disorder, personality disorder, substance abuse, depression/anxiety); (2) dementia only; (3) behavioral health disorders and dementia; or (4) neither. The Aggressive Behavior Scale (ABS) measured the degree of aggressive behaviors exhibited, based on 4 MDS items (verbal, physical, other behavioral symptoms, and rejection of care). The ABS scores ranged from 0 to 12 reflecting symptom severity as none (ABS score = 0), mild (ABS score = 1-2), moderate (ABS score = 3-5), and severe (ABS score = 6-12). Bivariate comparisons and multinomial logistic regressions were performed. RESULTS: Residents with behavioral health disorders and dementia had the highest prevalence of ABs (23.1%), followed by dementia only (15.3%), behavioral health disorders only (9.3%), and neither (5.3%). After controlling for individual risk factors and facility covariates, the relative risk of exhibiting severe ABs was 2.47, 5.50, and 9.42 for residents with behavioral health disorders only, dementia only, and behavioral health disorders and dementia, respectively, with a similar pattern for moderate or mild ABs. CONCLUSIONS: Residents with behavioral health disorders were less likely than residents with dementia to exhibit aggressive behaviors in nursing homes. Thus, anecdotally reported concerns that aggressive behaviors are primarily an issue for residents with behavioral health disorders, rather than those with dementia, were not empirically justified.

Minimum Data Set for Incontinence-Associated Dermatitis (MDS-IAD) in adults: Design and pilot study in nursing home residents.
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K. Van den Bussche, S. Verhaeghe, A. Van Hecke and D. Beeckman.
J Tissue Viability 2018 Oct 25
The aim of this study was to develop a Minimum Data Set for Incontinence-Associated Dermatitis (MDS-IAD), to psychometrically evaluate and pilot test the instrument in nursing homes. Comparable to the MDS for pressure ulcers, the MDS-IAD aims to collect epidemiological data and evaluate the quality of care. MATERIALS AND METHODS: After designing and content/face validation by experts and clinicians, staff nurses assessed 108 residents (75.9% female, 77.8% double incontinent) in a convenience sample of five wards. A second nurse independently assessed fifteen residents to calculate inter-rater agreement (p0) and reliability [Cohen’s Kappa (k)]. RESULTS: The k-value for ‘urinary incontinence’ was 0.68 [95% confidence interval (CI) 0.37-0.99] and 0.55 (95% CI 0.27-0.82) for ‘faecal incontinence’. The p0 for severity categorisation according to the Ghent Global IAD Categorisation Tool (GLOBIAD) was 0.60. IAD was diagnosed in 21.3% of the residents. IAD management mainly involved the application of a leave-on product (66.7%), no-rinse foams (49.1%), toilet paper (47.9%), and water and soap (38.8%). Fully adequate prevention or treatment was provided to respectively 3.6% and 8.7% of the residents. CONCLUSION: This instrument provides valuable insights in IAD prevalence at organisational level, will allow benchmarking between organisations, and will support policy makers. Future testing in other healthcare settings is recommended.

Healthy Aging: American Geriatrics Society White Paper Executive Summary.
Non UofA Access

S. M. Friedman, P. Mulhausen, M. L. Cleveland, et al.
J Am Geriatr Soc 2018 Nov 1
In July 2015, the Journal of the American Geriatrics Society published a manuscript titled, “Failing to Focus on Healthy Aging: A Frailty of Our Discipline?” In response, the American Geriatrics Society (AGS) Clinical Practice and Models of Care Committee and Public Education Committee developed a white paper calling on the AGS and its members to play a more active role in promoting healthy aging. The executive summary presented here summarizes the recommendations from that white paper. The full version is published online at Life expectancy has increased dramatically over the last century. Longer life provides opportunity for personal fulfillment and contributions to community but is often associated with illness, discomfort, disability, and dependency at the end of life. Geriatrics has focused on optimizing function and quality of life as we age and reducing morbidity and frailty, but there is evidence of earlier onset of chronic disease that is likely to affect the health of future generations of older adults. The AGS is committed to promoting the health, independence, and engagement of all older adults as they age. Geriatrics as an interprofessional specialty is well positioned to promote healthy aging. We draw from decades of accumulated knowledge, skills, and experience in areas that are central to geriatric medicine, including expertise in complexity and the biopsychosocial model; attention to function and quality of life; the ability to provide culturally competent, person-centered care; the ability to assess people’s preferences and values; and understanding the importance of systems in optimizing outcomes.

Sleep Duration and Sleep Quality Are Associated with Physical Activity in Elderly People Living in Nursing Homes.
Non UofA Access

L. Stefan, G. Vrgoc, T. Rupcic, G. Sporis and D. Sekulic.
Int J Environ Res Public Health 2018 Nov 9;15(11):10.3390/ijerph15112512
The main purpose of the study was to explore the associations of sleep duration and sleep quality with physical activity (PA). In this cross-sectional study, participants were 894 elderly individuals (mean age 80 +/- 3 years; 56.0% women) living in nursing homes. PA, sleep duration, and sleep quality (based on the Pittsburgh Sleep Quality Index (PSQI)) were self-reported. The associations of sleep duration and sleep quality with PA at the nursing home level were analyzed using generalized estimating equations with clustering. Participants reporting short sleep duration (9 h; OR = 2.61; 95% CI 1.35(-)5.02) and good sleep quality (<5 points; OR = 1.59; 95% CI 1.19(-)2.12) were more likely to report sufficient PA. When sleep duration and sleep quality were entered into the same model, the same associations remained. This study shows that elderly individuals who report short sleep duration are less likely to meet PA guidelines, while those who report long sleep duration and good sleep quality are more likely to meet PA guidelines. Strategies aiming to improve sleep duration and sleep quality are warranted.

Investigating Barriers to Family Visitation of Nursing Home Residents: A Systematic Review.
Non UofA Access

V. J. Miller.
J Gerontol Soc Work 2018 Nov 9:1-18
Families are integral in helping nursing home residents maintain feelings of social inclusion and an overall sense of belonging, thus reducing consequences of social exclusion. Preliminary research, particularly of the culture change movement in long-term care, shows there are barriers to family engagement and visitation of residents. The objective of this study is to: (1) identify and summarize the barriers most reported to family visitation and (2) synthesize the findings to determine which barriers are most often reported in literature, and which may pose the greatest challenges to family involvement. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a final sample of 15 articles across 11 databases report seven barriers to visitation: psychological, health, staff to family member relationship, employment/finances, travel time, access to transportation, and other. Findings suggest barriers to family visitation and point toward a need for further research as relationships between resident and family member is complex and warrants attention across professions. Interprofessional efforts between social work, allied professionals, and transportation planners are necessary to address this pressing concern experienced by residents in nursing homes, with the ultimate goal of lessening such barriers.

Apathy and health-related quality of life in nursing home residents.
Non UofA Access

J. M. H. Nijsten, R. Leontjevas, M. Smalbrugge, R. T. C. M. Koopmans and D. L. Gerritsen.
Qual Life Res 2018 Nov 7
To explore the association between apathy and health-related quality of life (HRQoL) from resident and proxy perspectives and whether cognition and depression moderate this relationship. METHODS: Secondary analyses with baseline data from a cluster randomized trial on the effects of a care program for depression in Nursing Homes (NHs) were conducted. For HRQoL, the Visual Analogue Scale (VAS) and the Dutch version of the European Quality of Life (EQ-5D) were administered to 521 NH residents, and to professional caregivers reporting from the perspective of the NH resident (Resident-Proxy) and from their own perspective (Proxy-Proxy). Utility scores (U) were calculated for the three perspectives. Apathy, depression, and cognition were measured using the 10-item Apathy Evaluation Scale, the Cornell Scale for Depression in Dementia, and the standardized Mini-Mental State Examination, respectively. RESULTS: Mixed models adjusted for clustering within NH units revealed that apathy was negatively associated with HRQoL both from the Resident-Proxy perspective (EQ-5D VAS: estimated effect, – 0.31, P < 0.001; EQ-5D Utility: – 0.30, P < 0.001) and from the Proxy-Proxy perspective (VAS: – 0.29, P < 0.001; U: – 0.03, P < 0.001), but not from the Resident-Resident perspective (VAS: – 0.05, P = 0.423; Utility: – 0.08, P = 0.161). Controlling for depression and cognition and their interaction terms with apathy did not change the results. CONCLUSION: Apathy is negatively associated with NH resident HRQoL as reported by proxies. Depression and cognitive functioning do not moderate this association. NH residents do not self-report a relationship between apathy and HRQoL. More research is needed to understand caregiver and NH resident attitudes and underlying assumptions regarding apathy and HRQoL.


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Top Ten lessons we built into a new initiative to support evidence-informed policymaking about the non-health SDGs

Tuesday 27 November 10:00-11:00 MT
McMaster Health Forum

The Sustainable Development Goals (SDGs) are an ambitious agenda aiming to improve global outcomes across a range of social and economic development issues. While evidence-informed policymaking approaches have helped drive progress on a number of health issues, a new partnership among the Forum, its peers in 14 countries, International Development Research Centre (Canada’s premier development-research funding body) and the Hewlett Foundation aims to focus on social systems. Join our webinar as John Lavis and Kaelan Moat (Director and Managing Director, respectively, of the McMaster Health Forum), Marie-Gloriose Ingabire (Senior Program Specialist, IDRC), Cristián Mansilla A. (Director of the Evidence-Informed Health Policymaking Unit, Ministry of Health, Government of Chile), and Laurenz Langer (Evidence Synthesis Specialist, Africa Centre for Evidence) share insights from this exciting collaborative venture.

brainXchange webinar The Changing Definitions of Alzheimer’s disease and the Role of Biomarkers

Thursday 6 December 10:00-11:00
Presenter: Dr. Sharon Cohen
Alzheimer’s disease is no longer simply a state of dementia. It is a disease that creeps up gradually in the brain for more than 20 years before the earliest symptoms. Diagnosing and treating the disease before it affects one’s mental abilities is paramount. In this Webinar, you will learn about the biomarkers that are shaping our thinking about how we diagnosis Alzheimer’s disease and how we should be approaching treatment opportunities through clinical trials.

The Challenge Of Being Ethical As A Nurse

Friday 7 December 12:00-13:00 Dvorkin Centre (2G2.07 WMC)
Presenter: Dr. Wendy Austin

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“What They Had” writer-director discusses Alzheimer’s-inspired film

Could fake grants help clean up the peer review process?

HQCA 2017-18 A Year in Review: Inspiring Improvement

What We Know So Far About Evaluating Efforts To Scale Social Innovation

Dementia Is Getting Some Very Public Faces

Caring creatively for an aging population

What Your Clinical Training Didn’t Teach You About Leading Improvement

Dispelling the common myths about dementia

Familiar music could give Alzheimer’s patients a cognitive boost, study suggests

Laughing over spilled Jell-O: a radical prescription for loneliness in seniors

Science Is Getting Less Bang for Its Buck

Engaging with theory: from theoretically informed to theoretically informative improvement research

The future of academic freedom and the curious, the disturbing case of Derek Pyne

Five ways academics can contribute to Wikipedia

Research waste is still a scandal—an essay by Paul Glasziou and Iain Chalmers
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Call for Editor: Nursing History Review

DEADLINE: 15 December
he American Association for the History of Nursing has announced a search for Nursing History Review. Candidates should have the following qualifications:
-Must be able to demonstrate sustained evidence of world-class/leading publications in the history of nursing. Publications can be in the form of books, book chapters and peer-reviewed journal articles. Preference will be given to candidates who can demonstrate publication in all modes. We particularly welcome applications from those members who have previously published in Nursing History Review.
-Should be a tenured associate or full professor or professor emerita.
-Should be an experienced academic in the history of nursing, with a history of post-graduate research supervision and support for new historians.
-Should be prepared to hold the editor position for a 5-year term.

Call for Editor-in-Chief: Journal of Emergency Nursing

DEADLINE: 31 December
-The Emergency Nurses Association (ENA) is seeking an Editor-in-Chief (EIC)to help shape the editorial content of the association’s official scholarly journal, the Journal of Emergency Nursing (JEN).
-The EIC is responsible for the quality and professionalism of editorial content, design and production of JEN. The EIC will collaborate closely with the Journal publisher, ENA staff and association leadership to ensure JEN content aligns with ENA’s mission, vision, strategic plan and publications strategy.
-ENA is the premier association devoted to patient safety and excellence in emergency nursing practice. ENA and its 43,000 members help shape the future of emergency nursing and advocate for safe practice and safe care.

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