Applications are invited for a postdoctoral research position within the Translating Research in Elder Care (TREC) research program. Located at the University of Alberta in Edmonton, Alberta, Canada, TREC (https://trecresearch.ca/) is a multi-disciplinary pan-Canadian and international group of researchers, clinicians, nursing home resident representatives, and healthcare decision makers who conduct research on nursing home quality of care and knowledge translation. TREC maintains a world-class and unique repository of survey, clinical, and administrative healthcare use records that define a range of nursing home work environment, clinical, and broader healthcare system use factors. Data can also be linked to multiple clinical trials designed to enhance nursing home care and resident quality of life.
Working under the direction of Dr. Jennifer Knopp-Sihota, Associate Professor and TREC Investigator, the successful applicant will work on projects associated with improving the quality of life and clinical care of nursing home residents. Current projects include: (1) a CIHR funded pain scale development project in which we aim to improve and evaluate an observational pain assessment scale for nursing home residents with dementias; (2) a polypharmacy and deprescribing intervention study; and (3) a study aimed at reducing dementia behaviours using non-pharmacological approaches. Additional collaborative opportunities are also available through the TREC scientific team (e.g., the fellow will attend bi-annual national scientific meetings and present research findings at academic conferences).
V. Schadewaldt, B. McElduff, C. D’Este, et al.
PLoS One 2019 Apr 9;14(4):e0215153
The organisational context of healthcare settings has an essential role in how research evidence is used in clinical practice. The Alberta Context Tool (ACT) measures 10 concepts of organisational context with higher scores indicating a more positive work environment and potentially better use of research evidence in patient care. We assessed the psychometric properties of the ACT in Emergency Departments (EDs). This validation study was conducted as part of a multi-centre trial of triage, treatment and transfer (T3 Trial) of patients with stroke admitted to EDs. Stratified sampling with proportional allocation was used to recruit ED nurses from 26 participating hospitals at baseline. Nurses completed a survey containing the ACT. Structural validity was investigated by exploratory and confirmatory factor analysis. Reliability was assessed using Cronbach’s alpha and intraclass correlation coefficients. Item-rest correlations and the average inter-item correlations were also assessed. 558 ED nurses completed the survey, comprised of 433 surveys without missing data. Our exploratory factor analysis produced a 14-factor structure, explaining 62% of variance of organisational context. For eight of ten concepts, item loadings matched the factor structure of the original ACT. Confirmatory factor analysis of the 10 ACT concepts showed moderate model fit (p = 0.001, root mean square error of approximation: 0.049, standardised root mean squared residual: 0.048). Cronbach’s alphas showed very good internal consistency for nine of ten ACT concepts (alpha>0.7; 0.45-0.90). Item-rest correlations indicated that most ACT items (50 of 56 items) within any concept related well to the total score of the concept. Average inter-item correlations indicated potential redundant items for three concepts (feedback processes, leadership, staffing) that were above the threshold of 0.5. While identifying a few shortcomings for some ACT concepts in an ED context, the majority of findings confirm reliability and validity of the original ACT in an Australian population of ED nurses.
J. Ploeg, M. Canesi, K. D Fraser, et al.
BMJ Open 2019 Mar 20;9(3):e023345-2018-023345
The aim of the study was to understand the experiences of living with multiple chronic conditions (MCC) from the perspective of community-living older adults with MCC. DESIGN: A qualitative study using an interpretive description approach. SETTING: Participants were recruited from southern Ontario, Canada. PARTICIPANTS: 21 community-living, older adults (>/=65 years) with an average of 7.4 chronic conditions including one of diabetes, dementia or stroke. METHODS: Data were collected through digitally-recorded, in-depth, semi-structured in-person interviews. Interview transcripts were analysed and coded using Thorne’s interpretive description approach. RESULTS: Five themes were identified representing older adults’ experiences of living with MCC: (a) trying to stay healthy while living with MCC, (b) depending on family caregivers for support with just about everything, (c) paying the high costs of living with MCC, (d) making healthcare decisions by proxy and (e) receiving healthcare services that do not address the complex needs of persons living with MCC. CONCLUSIONS: The experience of living with MCC in the community was complex and multi-faceted. The need for a person-centred and family-centred approach to care in the community, which includes the coordination of health and social services that are tailored to the needs of older adults and their informal caregivers, was underscored. Such an approach would facilitate improved information-sharing and discussion of care management options between health professionals and their patients, enable older adults with MCC to actively engage in priority-setting and decision-making and may result in improved health and quality of life for older adults with MCC.
S. M. N. Glegg, E. Jenkins and A. Kothari.
Implement Sci 2019 Mar 27;14(1):34-019-0879-1
To date, implementation science has focused largely on identifying the individual and organizational barriers, processes, and outcomes of knowledge translation (KT) (including implementation efforts). Social network analysis (SNA) has the potential to augment our understanding of KT success by applying a network lens that examines the influence of relationships and social structures on research use and intervention acceptability by health professionals. The purpose of this review was to comprehensively map the ways in which SNA methodologies have been applied to the study of KT with respect to health professional networks. METHODS: Systematic scoping review methodology involved searching five academic databases for primary research on KT that employed quantitative SNA methods, and inclusion screening using predetermined criteria. Data extraction included information on study aim, population, variables, network properties, theory use, and data collection methods. Descriptive statistics and chronology charting preceded theoretical analysis of findings. RESULTS: Twenty-seven retained articles describing 19 cross-sectional and 2 longitudinal studies reported on 28 structural properties, with degree centrality, tie characteristics (e.g., homophily, reciprocity), and whole network density being most frequent. Eleven studies examined physician-only networks, 9 focused on interprofessional networks, and 1 reported on a nurse practitioner network. Diffusion of innovation, social contagion, and social influence theories were most commonly applied. CONCLUSIONS: Emerging interest in SNA for KT- and implementation-related research is evident. The included articles focused on individual level evidence-based decision-making: we recommend also applying SNA to meso- or macro-level KT activities. SNA research that expands the range of professions under study, examines network dynamics over time, extends the depth of analysis of the role of network structure on KT processes and outcomes, and employs mixed methods to triangulate findings, is needed to advance the field. SNA is a valuable approach for evaluating key network characteristics, structures and positions of relevance to KT, implementation, and evidence informed practice. Examining how network structure influences connections and the implications of those holding prominent network positions can provide insights to improve network-based KT processes.
Wednesday 8 May 10:00-11:00 MT
Presenter: Laura Aloisio
This webinar will provide an overview of the differences and similarities of demographic-, individual- and context-level factors affecting job satisfaction among regulated nurses and allied health workers in nursing homes.
G. Parker, T. Rappon and W. Berta.
BMJ Open 2019 Mar 23;9(3):e027370-2018-027370
There is recognition that the overuse of procedures, tests and medications strains the healthcare system financially and can cause unnecessary stress and harm to patients. In recent years, several initiatives have targeted the reduction or elimination of low-value practices in healthcare. Research suggests that passive interventions, such as the publication of guidelines, are often not sufficient to change behaviour and that active change interventions – interventions which actively implement strategies to change practices – are required to effect significant, sustained practice change. The purpose of this scoping review is to identify and characterise studies of active change interventions designed to reduce or eliminate low-value healthcare practices. METHODS: We will conduct a review of MEDLINE, EMBASE, CINAHL and Scopus databases from inception. Building on previous research, 40 key terms will be used to search literature. The screening process will be conducted separately by two researchers, with discrepancies resolved by a third. Empirical studies of active change interventions used to reduce or eliminate low-value practices will be included. Descriptive statistics and thematic analysis will be used to categorise the characteristics of the studies. ETHICS AND DISSEMINATION: Ethics approval is not required for this study. This scoping review will provide insights into the impact of several characteristics of active change interventions, including the number of interventions (single-faceted or multifaceted) and the level of implementation (individual or organisational). These results can provide guidance and direction for future research in de-implementation. The results will be disseminated through presentations at national and international conferences and the publication of a manuscript.
R. Feo, L. J. Frensham, T. Conroy and A. Kitson.
Nurse Educ Pract 2019 Mar 9;36:82-84
Fundamental care has come under increased scrutiny due to high-profile reports globally of poor nursing care. The reasons for these documented care failures are widely debated, with some scholars identifying issues with how fundamental care is valued within healthcare systems and by nurses. During focus groups designed to evaluate a fundamental care education intervention, we identified a perception commonly held by first-year pre-registration (pre-licensure) students that appeared indicative of a de-valuing of fundamental care: students routinely described fundamental care as ‘common sense’ and doubted that such care should form a key part of their education. In this paper, we explore this perception and its potential consequences for nursing education, clinical practice, and research. We argue that a perception of fundamental care as ‘common sense’ is a myth; it undermines the inherent complexity of providing such care to a consistently high standard and has negative implications for nursing education and continuing professional development, patient experiences and outcomes, and the advancement of nursing science. It is a perception that must be challenged.
A. Lewis, G. Harvey, M. Hogan and A. Kitson.
Int J Nurs Stud 2018 Dec 31;94:32-41
An intervention ‘Better Oral Health in Home Care’ was introduced (2012-2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people’s oral health. OBJECTIVE: To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project. DESIGN: A Realist Evaluation applying Normalisation Process Theory within a single case study setting. SETTING: Community aged care (home care) provider in South Australia, Australia. PARTICIPANTS: Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated. METHODS: Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012-December 2014) and Time 2 (Post-implementation July 2017-July 2018). RESULTS: At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice. CONCLUSION: Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.
J. Dollard, G. Harvey, E. Dent, et al.
J Frailty Aging 2018;7(3):193-195
Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having >/=4 unplanned emergency department (ED) presentations/ admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.
Poster discussions often enable interesting opportunities for knowledge transfer, exchange and future collaborations and are a wonderful way to get to know other members of the dementia community. The abstract judged best overall will be awarded a certificate of recognition and a $500 cash prize. Five abstracts will also be selected for a ten minute oral presentation.
Natalie F. Douglas and Rebecca H. Affoo.
American Journal of Speech-Language Pathology 2019/04.
The purpose of this study was to assess the self-perceived knowledge and self-efficacy of certified nursing assistants (CNAs) when using external memory aids to enhance the communication and independence of residents with dementia living in skilled nursing facilities (SNFs). One hundred forty-four CNAs completed a measure pertaining to self-perceived knowledge and self-efficacy of external memory aids. CNAs had favorable beliefs about the usefulness of external memory aids to help both conversation and independence in activities of daily living for residents with dementia (M = 4.0, SD = 0.84; M = 3.92, SD = 0.85) on a 5-point Likert scale, with 5 = strongly agree and 1 = strongly disagree. There were no statistically significant differences between CNAs who reported being trained to use external memory aids with residents with dementia and CNAs who reported they were not trained according to items related to self-efficacy (U = 2203.5, z = −1.483, p = .138; U = 2179, z = −1.547, p = .122; U = 2115, z = −1.82, p = .069; U = 2320, z = −0.942, p = .346). Results of this study indicated that the lack of uptake of external memory aids for residents with dementia in SNFs may not solely be due to lack of buy-in or lack of time on the part of the CNA. Speech-language pathologists should provide this training to support the uptake of external memory aids for residents with dementia; however, these data suggest that current training methods may not be considerate of the nuances of implementation. Speech-language pathologists and researchers should consider the finer aspects of theoretically grounded facilitation techniques as next steps to the broader implementation of this intervention for residents with dementia living in SNFs.
C. A. Ottoni, J. Sims-Gould and H. A. McKay.
Can J Aging 2019 Apr 4:1-11
Most older Canadians do not engage in sufficient physical activity. There is an urgent need for outside-the-box strategies that encourage and sustain active lifestyles. Video is a promising knowledge translation (KT) tool to engage diverse audiences in discussion and action around health promoting behaviours. We adopted a KT framework to inform a structured process of video development we have named systematic approach to evidence-informed video (SAEV). This guided the creation and dissemination of a 19-minute documentary video: I’d Rather Stay (https://vimeo.com/80503957). Following screenings, we collected focus group and questionnaire data from 48 participants aged 60 years and older at baseline and 6-month follow-up. The video educated, encouraged, and activated older people around issues such as independence, physical activity and social connectedness. We encourage researchers to adopt KT strategies – and to use evidence-informed video – that older adults can relate to and critically engage with on an accessible, emotional, and intellectual level.
H. L. Gainforth, K. Baxter, J. Baron, E. Michalovic, J. G. Caron and S. N. Sweet.
Health Res Policy Syst 2019 Apr 11;17(1):39-019-0434-1
In April 2016, the Rick Hansen Institute (RHI) hosted an innovative, 2-day conference called Praxis 2016. RHI aimed to bring together a diverse group of stakeholders to develop solutions for overcoming the challenges of translating spinal cord injury (SCI) research into practice. To understand the impact of Praxis, RHI funded an independent team to evaluate Praxis at the individual and setting level using the RE-AIM framework. Individual-level findings are published elsewhere. The aim of this evaluation is to report on the impact of Praxis at the setting level in terms of its adoption, implementation and maintenance. METHODS: Data sources included interviews with attendees (n = 13) and organisers (n = 9), a fidelity assessment conducted at the conference, and observation notes provided by the evaluation team. RESULTS: Main findings indicated that the Praxis model was adopted by organisers and attendees, implemented by RHI as intended, and has the potential for long-term maintenance. Lessons learned highlighted the importance of including SCI community members throughout the entire process from development to post-conference activities as well as in the research process, the value of facilitation and fostering interactive problem solving, and the need to identify leadership and funds to foster long-term efforts. CONCLUSIONS: Developing and implementing a solutions-focused conference that brings together a diverse group of SCI stakeholders was challenging and rewarding for attendees and organisers. Other domains could learn from, adopt and build on the Praxis 2016 approach to address research-to-practice gaps.
D. Thomson, S. Brooks, M. Nuspl and L. Hartling.
Health Res Policy Syst 2019 Apr 11;17(1):40-019-0437-y
Research shows a significant gap between healthcare research and evidence-based healthcare policy and practice. Knowledge translation (KT) has an important role in addressing this gap by bolstering evidence-informed healthcare. Canada’s Strategy for Patient-Oriented Research (SPOR) is a nationally mandated and supported initiative developed to respond to the gap between research and practice. One aspect of SPOR is the provincial/territorial SUpport for People and Patient-Oriented Research and Trials (SUPPORT) Units, intended to assist local health researchers and systems to reach the goal of improving the quality and quantity of patient-oriented research in Canada. This article presents the programme theory development and a formative evaluation of the KT Platform in Alberta’s SPOR SUPPORT Unit. METHODS: We used a mixed-methods approach to develop the KT Platform’s programme theory and subsequently conducted the formative evaluation. An extensive needs assessment, comprised of 59 qualitative interviews with researchers and health systems employees in Canada with an interest in KT, served as the basis for our programme theory design. Three years after launching the KT Platform, we hired an evaluation consultant to conduct a formative evaluation of the Platform’s programme theory and operations. The evaluation was performed by conducting nine interviews with KT Platform service users (n = 6) and KT experts acting in advisory capacities to the KT Platform (n = 3). RESULTS: The KT Platform developed a ‘4C Model’ as a summary of the Platform’s programme theory. This model is designed to meet local needs for capacity-building, a community of practice, consultation services, and contributions to KT science. This suite of services was found to help the local health system implement health evidence with measurable positive health outcomes. However, the community remains hesitant about their capacity as individuals to design and perform important KT activities independently. CONCLUSIONS: With the mandate and support provided by SPOR, the KT Platform was able to design a strong programme theory based on evidence from an extensive needs assessment of the local community. The resulting 4C Model has provided a framework for KT work to assist in improving local health outcomes and can be considered by others designing KT programmes as a useful model to follow. Ongoing monitoring and assessment are required to continue to identify and respond to local needs.
M. H. Lovink, A. J. A. H. van Vught, A. Persoon, R. T. C. M. Koopmans, M. G. H. Laurant and L. Schoonhoven.
Nurs Health Sci 2019 Apr
Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.
S. R. Bolt, J. T. van der Steen, J. M. G. A. Schols, S. M. G. Zwakhalen, S. Pieters and J. M. M. Meijers.
Int J Nurs Stud 2019 Jan 3
Nursing staff caring for people with dementia have a crucial role in addressing palliative care needs and identifying changes in health status. Palliative care for people with dementia is complex and requires specific competences. A lack thereof may lead to unnecessary hospitalizations, poor symptom control and undesirable burdensome treatments. Understanding what nursing staff need to provide palliative care specifically for people with dementia facilitates the development of tailored and feasible interventions. OBJECTIVE: To investigate what is known from the literature regarding the needs in providing palliative dementia care as perceived by nursing staff working in home care or in long-term care facilities and to establish an integrated conceptualization of these needs. DESIGN: A scoping review method combined with thematic analysis methods. DATA SOURCES: Bibliographic databases of PubMed, CINAHL and PsycINFO were searched for primary research studies. REVIEW METHODS: Guidelines from the Joanna Briggs Institute were utilized as a framework for setting up and conducting the scoping review. Eligible articles considered nursing staff’s perceived needs in providing palliative dementia care at home or in long-term care facilities. Two authors assessed eligibility based on title and abstract, assessed full texts for selected records and assessed the quality of included articles. Thematic analysis methods were used to identify themes from relevant study findings, which were integrated to form a conceptualization. RESULTS: Of the 15 articles that were included, most used qualitative methods (N = 13) and were conducted in long-term care facilities (N = 14). Themes reflecting nursing staff needs on a direct care-level concern recognizing and addressing palliative care needs (such as comfort), verbal and non-verbal communication, challenging behaviour and familiarity: knowing and understanding the person with dementia. On more distant levels, themes involve a need for interdisciplinary collaboration, training and education and organizational support. CONCLUSION: A comprehensive overview of nursing staff perspectives on providing palliative care for people with dementia demonstrates interdependent needs related to recognizing and addressing palliative care needs, communicating, handling challenging behaviour and building close care relationships. These care-related needs occur within workplace and organizational contexts. Organizational support is considered insufficient. Yet, healthcare organizations have the authority to fulfil a facilitating role in implementing nursing interventions tailored to nursing staff needs. Areas for further research include home care settings, the psychosocial and spiritual domains of palliative dementia care, advance care planning and family involvement.
S. S. Huang and J. R. Bowblis.
Gerontologist 2018 Nov 3;58(6):1136-1146
Ownership of nursing homes (NHs) has primarily focused broadly on differences between for-profit (FP), nonprofit (NFP), and government-operated facilities. Yet, among FPs, the understanding of detailed ownership structures at individual NHs is rather limited. Particularly, NH administrators may hold significant equity interests in their facilities, leading to heterogeneous financial incentives and NH outcomes. Through the principal-agent theory, this article studies how managerial ownership of individual facilities affects NH outcomes. Design and Methods: We use a unique panel dataset of Ohio NHs (2005-2010) to empirically examine the relationship between managerial equity ownership and NH staffing, quality, and financial performance. We identify facility administrators as owner-managers if they have more than 5% of the equity stakes or are relatives of the owners. The statistical analysis is based on the pooled ordinary least squares and NH-fixed effect models. Results: We find that owner-managed NHs are associated with higher nursing staff levels compared to other FP NHs. Surprisingly, despite higher staffing levels, owner-managed NHs are not associated with better quality and we find no statistically significant difference in financial performance between owner-managed and nonowner-managed FP NHs. Our results do not support the principal-agent model and we offer alternative explanations for future research. Implications: Our findings provide empirical evidence that NH ownership structures are more nuanced than simply broadly categorizing facilities as FP or NFP, and our results do not fully align with the standard principal-agent model. The role of managerial ownership should be considered in future NH research and policy discussions.
K. Nordstrom and T. Wangmo.
Nurs Ethics 2018 Dec;25(8):1004-1016
Neglect and abuse of elders in care institutions is a recurring issue in the media. Elders in care institutions are vulnerable due to their physical, cognitive, and verbal limitations. Such vulnerabilities may make them more susceptible to mistreatment by caregivers on whom they are heavily dependent. OBJECTIVES:: The goal was to understand caregivers’ concerns about ensuring correct and proper treatment, as well as their experiences with neglect and abuse of older patients. This article examines resources and challenges of professional ethics within the care setting. RESEARCH DESIGN:: A study was conducted to explore the quality of care provided to older patients in nursing homes, geriatrics institutions, and ambulant care in the northwest region of Switzerland. PARTICIPANTS AND RESEARCH CONTEXT:: A total of 23 semi-structured interviews were conducted with nursing staff of varying experience levels. ETHICAL CONSIDERATIONS:: Ethical approval was granted by the competent regional ethics commission, Ethikkomission Nordwest-und Zentralschweiz EKNZ [Ethics Commission Northwest and Central Switzerland] (2014-015). FINDINGS:: Three themes emerged from our data analysis: professional identity, professional context, and professional relationships. Our findings indicate mutual vulnerabilities within these three themes, characterizing the interactions between nursing staff and older patients. Study participants believe that incidences of error, neglect, and abuse are consequences of their own vulnerability since they are not able to meet the demands of an overstraining work situation. DISCUSSION:: Different aspects of this mutual vulnerability are described and critically discussed as challenges for professional ethics. CONCLUSION:: Early education, continuous training as well as better management and response from the institution are necessary to maintain professionalism while handling mutual vulnerabilities.
D. E. Berish, J. Bornstein and J. R. Bowblis.
J Am Med Dir Assoc 2019 Mar 25
Each year states are required to survey nursing homes (NHs), including issuing deficiency citations when regulatory standards are not met. These deficiency citations can have substantial consequences for NHs. Because it is imperative that the survey process is conducted consistently across facilities, this study aims to determine whether deficiency outcomes vary with the presence of a long-term care ombudsman at the survey. DESIGN: A retrospective secondary data analysis of facility-level data using panel regression techniques was used to determine whether the presence of an ombudsman at a survey affected deficiency outcomes. Additional analysis assured the results were not due to ombudsmen being more likely to be present at poorer performing facilities. SETTING AND PARTICIPANTS: The data include freestanding NHs in the United States with at least 2 surveys between 2009 and 2015, resulting in 95,237 surveys from 14,996 unique NHs. MEASURES: The number and deficiency score were analyzed for 4 types of deficiencies: all deficiencies and the broad categories of quality of care, quality of life, and administration. The key explanatory variable is the presence of an ombudsman at survey. The regression model controlled for other important facility-level covariates. RESULTS: The presence of an ombudsman varied across states (range: 0.8%-82.0%; mean: 29.9%). Regression analysis found ombudsman presence was associated with a 0.2 increase in the number of deficiencies and 2.2-point increase in deficiency score. These correspond to a 3.9% and 5.9% increase, respectively. On a percentage basis, the largest effects were found for quality of life and administration deficiencies. CONCLUSIONS/IMPLICATIONS: By being present at surveys, ombudsmen may bring issues to the attention of state surveyors, resulting in worse deficiency outcomes during annual surveys. This can have consequences for NHs, and further work is needed to assure that ombudsmen are using their resources where they are most needed.
T. T. Barry, M. Longacre, K. O. Carney and S. Patterson.
Geriatr Nurs 2019 Mar 28
Team-based approaches to long-term care are increasingly part of the landscape in residential care facilities to improve staff performance and resident outcomes vis-a-vis empowering direct care staff. This study characterizes licensed and unlicensed nursing staffs’ (N=95) perceptions of inclusion as care team members by co-workers, supervisors and non-nursing clinicians. Further, we explored whether inclusion was correlated with heightened empowerment and its related dimensions using the Perception of Empowerment Instrument. Linear regression analyses revealed that levels of total empowerment, autonomy, responsibility and participation were associated with how included team members felt and by which members of the care team. These findings shed light on the potential importance of tailoring staff training to target specific team members to increase a sense of empowerment that aligns with the specific dimension(s) for a targeted group.
M. Omori, C. Baker, J. Jayasuriya, et al.
Qual Health Res 2019 Mar 31:1049732319839363
The importance of family’s involvement in care planning has been stressed to cater individualized, person-centered care in residential aged care. However, in reality, there are numerous structural obstacles and barriers that limit opportunities for their involvement. The aim of this article is to explore what they are. The findings based on the 12 focus groups, six groups of care professionals and six groups of family/relatives, reveal that the narrow pathway of communication between staff and families, which is hierarchically structured, one-directional, and clinically driven, enables the former to maintain and control professional boundaries between formal and informal care-giving. Such communication style delimits an opportunity for families to engage in quality discussion about care planning for their loved ones with care staff. Communication within residential aged care facilities embodies complex dynamics of care expectations and responsibilities held by care staff and families.
G. D’Onofrio, D. Sancarlo, M. Raciti, et al.
J Alzheimers Dis 2019 Apr 3
In the EU funded MARIO project, specific technological tools are adopted for the people living with dementia (PLWD). In the final stage of the project, a validation of the MARIO companion robot was performed from August to October 2017. OBJECTIVE: The aims of the present study are: 1) to illustrate the key results and evidence obtained in the final evaluation phase of the project across the three different pilot sites; 2) to assess the engagement dimensions of the PLWD who interacted with the MARIO robot; and 3) to assess the acceptability and efficacy of the MARIO companion robot on clinical, cognitive, neuropsychiatric, affective and social aspects, resilience, quality of life in PLWD, and burden level of the caregivers. METHODS: 38 people (M = 14; F = 24) with Alzheimer’s disease were screened for eligibility and all were included. The following tests were administered Pre and Post interactions with MARIO: Observational Measurement of Engagement (OME), Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Frontal Assessment Battery (FAB), Neuropsychiatric Inventory (NPI), Cornell Scale for Depression in Dementia (CSDD), Multidimensional Scale of Perceived Social Support (MSPSS), 14-item Resilience Scale (RS-14), Quality of Life in Alzheimer’s Disease (QOL-AD), Caregiver Burden Inventory (CBI), Tinetti Balance Assessment (TBA), and Comprehensive Geriatric Assessment (CGA) was carried out. RESULTS: In Post-MARIO interactions, significant improvements were observed in RS-14 (p = 0.020).Considering the age of the people, PLWD with 68-76 years perceived that they had major social support (MSPSS Total: p = 0.016) and friends to support them (MSPSS Fri: p = 0.014). Indeed, the younger people (55-67 years) were less depressed (CSDD: p = 0.033), and more resilient (RS-14: p = 0.003). The people aged 77-85 years perceived they had major family support (MSPSS Fam: p = 0.018). The participants were gender and education matched without any statistically significant difference. CONCLUSION: MARIO may be a useful tool in mitigating depression and loneliness, while enhancing social connectedness, resilience, and overall quality of life for people with dementia.
I. Livingstone, J. Hefele, P. Nadash, D. Barch and N. Leland.
J Am Med Dir Assoc 2019 Apr;20(4):462-469
To understand physical therapy (PT) and occupational therapy (OT) staffing levels in nursing homes and to examine their relationship with quality of care. DESIGN: Observational study that used 4 secondary data sources to perform facility-level panel data analyses. SETTING AND PARTICIPANTS: For-profit and nonprofit US nursing homes participating in Medicare and/or Medicaid. The final analytic sample includes 42,374 observations from 12,352 nursing homes, 2013-2016. METHODS: Three Centers for Medicare & Medicaid Services quality measures, including activities of daily living (ADL), falls, and 5-star quality, were used to examine the association between PT/OT staffing and quality. Bivariate analyses between PT/OT staffing and facility-level characteristics were run to describe the staffing disciplines in this setting. F tests and t tests were used to test for significance of each relationship. The sample was stratified into quintiles to determine if nursing homes with higher PT/OT staffing levels were linked to higher quality. Significance was determined using F tests and chi-squared tests. Finally, multilevel random effects regressions were performed to examine the relationship between PT/OT staffing and quality. RESULTS: Bivariate analyses indicate that PT/OT staffing levels vary across several nursing home characteristics. After stratifying the sample based on staffing levels, this study found that nursing homes that differ in staffing levels also differ in their quality performance. The random effects regression models also estimated a significant, positive relationship between higher staffing levels and quality, evidenced by each quality domain. CONCLUSIONS/IMPLICATIONS: The findings demonstrate that PT/OT staffing may be important components in improving long-stay resident outcomes and overall quality. Evidence was found in support of utilizing a combination of both PT/OT staff and nursing staff to improve resident outcomes, and expanding coverage of these staff/services under Medicaid. Further research should evaluate effective multidisciplinary approaches to care to lend further support to policy makers and progress quality improvement strategies.
L. Zysberg, T. Band-Winterstein, I. Doron, et al.
Int J Nurs Stud 2019 Mar 18;94:98-106
The health care aide position embodies one of the most basic paradoxes of long-term care for older adults: those who have the most contact and most intensive interaction with nursing-home residents are also those having the least training, authority, and status within the system. They therefore hold one of the keys to quality care in many settings, especially nursing homes. In the absence of agreement on the position’s roles, responsibilities, and authority, it is important to examine how the position is perceived by the key members in the long-term-care framework. OBJECTIVES: The current study examined and compared health care aides’ and nurses’ perceptions of the position in nursing-home settings in Israel, using a standardized tool developed for this inquiry. The comparison accounted for potential intervening factors that may help better understand the job requirements and boundaries. DESIGN: A comparative survey design. SETTINGS: 30 nursing homes (of at least 20 beds) in northern Israel. PARTICIPANTS: We used convenience sampling to recruit 369 health care aides and 261 nurses (a total of 630 participants). METHODS: The main instrument of data collection was specially designed and validated for this study. It was based on a qualitative study that defined basic content units representing tasks importance, knowledge, and personal characteristics for the job. RESULTS: Participants found it difficult to prioritize the job components or to differentiate between core tasks and characteristics and the secondary aspects of their job. General care, profession-specific knowledge, and emotional abilities were endorsed the most by participants. Cleaning, communication, and safety were ranked lower (although rankings were still considerably high). However, previous experience as a health care aide undermined incumbents’ perceptions of their own responsibilities and professionalism. Incumbent health care aides rated most factors higher than nurses did, with the exception of the importance of communication. CONCLUSION: Our results may help decision makers understand the complexity around the health care aide position, manage and develop it more effectively while setting standards (training and certification, performance appraisal, and more) for professionalization processes and better defining the division of nursing work between health care aides and nurses.
M. Mileski, M. Brooks, J. B. Topinka, et al.
Healthcare (Basel) 2019 Mar 25;7(1):10.3390/healthcare7010051
Perceptions against the use of alarming devices persist in long-term care environments as they are seen as annoying, costly, and a waste of time to the staff involved. Ascertaining whether these perceptions are true or false via the literature was a focus of this study. Proper information to educate staff and to work past these perceptions can be a positive effector for resident safety. Many facilitators for the use of alarming devices were found, as well as many barriers to their use as well. New technology is changing the perceptions regarding these types of devices as time passes. Education is a key component for staff, residents, and families. There are “traditional” issues with the use of alarms such as alarm fatigue by caregivers, high costs of implementation, and issues with proper implementation of alarms. Alarms are perceived as intrusive and the noise from them can be a potential cause of falls. However, alarming devices can be a key intervention in the safety of those residents who are prone to falls. This requires proper implementation and education for all parties involved, and proper oversight surrounding use of the devices.
J. F. Lavallee, T. A. Gray, J. Dumville and N. Cullum.
Health Soc Care Community 2019 Mar 27
Pressure ulcers can be painful and negatively affect health-related quality of life and healthcare costs. Many people living in nursing homes are at risk of developing a pressure ulcer. Nursing home staff, tissue viability nurses and researchers have co-designed the first theory and evidence-informed care bundle specifically for nursing homes, which consists of three prevention practices (skin inspection, support surfaces, repositioning) and a range of behaviour change techniques to promote these practices. We conducted a mixed methods feasibility study of the use of this care bundle in one nursing home in the North of England using an uncontrolled, before-and-after study design. We collected quantitative data on pressure ulcer prevention behaviours of the nursing home staff and pressure ulcer incidence rates for 5 weeks prior to implementing the bundle. Data collection continued for a further 9 weeks during the bundle implementation phase. We explored adherence to the bundle and participants’ experiences of using it. The Conceptual Framework for Implementation Fidelity and the Theoretical Domains Framework informed the semi-structured interviews. Quantitative and qualitative data were analysed using descriptive statistics and deductive framework analysis respectively. We collected data for 462 resident bed days prior to implementing the bundle; five new pressure ulcers were recorded and repositioning was the only documented pressure ulcer prevention behaviour. We collected data for 1,181 resident bed days during the intervention phase; no new pressure ulcers developed and the documented prevention behaviours included repositioning, skin inspection and checking support surfaces. Participants reported that the bundle enhanced the care they delivered and offered suggestions for future improvements. Our findings have highlighted a number of feasibility issues surrounding recruitment and retention, collecting data and implementation fidelity. A pressure ulcer prevention bundle specifically designed for nursing homes was acceptable. The feasibility work has highlighted the potential for the intervention and the areas that require development and refinement.
M. Kohler, J. Schwarz, M. Burgstaller and S. Saxer.
Z Gerontol Geriatr 2018 Jan;51(1):48-53
Management for people with dementia is complex due to the multifactorial nature of the disease and cognitive impairment. OBJECTIVE: This study explored the effects of an educational program and subsequent nursing case conferences on urinary incontinence and quality of life of nursing home residents with dementia. METHODS: The stepped-wedge trial design was used and seven nursing homes were included. In total 140 people were included in the study. The intervention consisted of an educational program and six case conferences at each ward. Urinary incontinence and quality of life were measured at baseline, after 2 and 6 months as well as at the end of the study. Univariate analysis of variance (ANOVA), repeated measures ANOVA and linear regression were used to compare the groups and the results at different times of measurement. The responsible ethics committees approved the study. RESULTS: After 6 months urinary incontinence decreased or was approximately equal to the initial measurement. At the end of the study urinary incontinence was slightly but not significantly higher. In the whole sample the quality of life increased in seven out of nine categories up to the end of the study. CONCLUSION: Urinary incontinence management for people with dementia is complex and an educational program and case conferences during 6 months proved to be effective in reducing urinary incontinence and improve the quality of life in nursing home residents with dementia.
C. Davidson, S. Loganathan, L. Bishop, et al.
J Am Med Dir Assoc 2019 Apr 3
Pressure ulcers pose an important quality-of-care challenge in nursing homes, with serious consequences for residents’ health. We assessed the scalability of the On-Time Pressure Ulcer Prevention (On-Time) intervention strategy, developed by the Agency for Healthcare Research & Quality, in nursing homes nationwide. INTERVENTION: On-Time uses electronic health record reports to identify changes in resident pressure ulcer risk and facilitate multidisciplinary input into clinical decision making. OBJECTIVE: To assess the scalability and impact of On-Time on pressure ulcer incidence in nursing homes. DESIGN: We used quasi-experimental methods, employing a difference-in-differences design, to compare the pre-post trends in pressure ulcer incidence in the treatment and comparison homes. SETTING AND PARTICIPANTS: The study population included long-stay residents at high risk for developing pressure ulcers in 47 nursing homes and matched comparison homes in 17 states. MEASURES: Stage 2 to 4 pressure ulcer incidence among long-stay residents who met the criteria for high risk, identified using an algorithm adapted from the Minimum Data Set 3.0 Percent of High-Risk Residents with Pressure Ulcers (Long Stay) measure. RESULTS: The overall decline in pressure ulcer rates for treatment relative to matched comparison homes was statistically insignificant (P > .05). A subgroup of heterogeneous homes experienced a statistically significant decline of 3.24 percentage points (61.0% relative decrease) in pressure ulcer rates relative to matched comparison homes, but no uniting characteristic common across homes readily explained their success. CONCLUSIONS/IMPLICATIONS: Scalability of future health information technology-based quality improvement interventions in nursing home settings requires nuanced implementation support, particularly around electronic health record report accessibility and accuracy.
T. Lloyd, S. Conti, F. Santos and A. Steventon.
BMJ Qual Saf 2019 Apr 7
Thirteen residential care homes and 10 nursing homes specialising in older people in Rushcliffe, England, participated in an improvement programme. The enhanced support provided included regular visits from named general practitioners and additional training for care home staff. We assessed and compared the effect on hospital use for residents in residential and nursing homes, respectively. METHODS: Using linked care home and administrative hospital data, we examined people aged 65 years or over who moved to a participating care home between 2014 and 2016 (n=568). We selected matched control residents who had similar characteristics to the residents receiving enhanced support and moved to similar care homes not participating in the enhanced support (n=568). Differences in hospital use were assessed for residents of each type of care home using multivariable regression. RESULTS: Residents of participating residential care homes showed lower rates of potentially avoidable emergency admissions (rate ratio 0.50, 95% CI 0.30 to 0.82), emergency admissions (rate ratio 0.60, 95% CI 0.42 to 0.86) and Accident & Emergency attendances (0.57, 95% CI 0.40 to 0.81) than matched controls. Hospital bed days, outpatient attendances and the proportion of deaths that occurred out of hospital were not statistically different. For nursing home residents, there were no significant differences for any outcome. CONCLUSIONS: The enhanced support was associated with lower emergency hospital use for older people living in residential care homes but not for people living in nursing homes. This might be because there was more potential to reduce emergency care for people in residential care homes. In nursing homes, improvement programmes may need to be more tailored to residents’ needs or the context of providing care in that setting.
V. T. Cotter, M. M. Hasan, J. Ahn, C. Budhathoki and E. Oh.
Am J Hosp Palliat Care 2019 Apr 4:1049909119841544
This study was conducted to enhance the rate of advance care planning (ACP) conversations and documentation in a dementia specialty practice by increasing physician knowledge, attitudes, and skills. We used a pre- and postintervention paired design for physicians and 2 independent groups for patients. The ACP dementia educational program encompassed 3 objectives: (1) to understand the relevance of ACP to the dementia specialty practice, (2) to provide a framework to discuss ACP with patients and caregivers, and (3) to discuss ways to improve ACP documentation and billing in the electronic medical record. A 10-item survey was utilized pre- and posteducational intervention to assess knowledge, attitudes, and skill. The prevalence of ACP documentation was assessed through chart review 3 months pre- and postintervention. The educational intervention was associated with increased confidence in ability to discuss ACP ( P = .033), belief that ACP improves outcomes in dementia ( P = .035), knowledge about ACP Medicare billing codes and requirements ( P = .002), and belief that they have support from other personnel to implement ACP ( P = .017). In 2 independent groups of patients with dementia, documentation rates of an advance directive increased from 13.6% to 19.7% ( P = .045) and the Medical Order for Life-Sustaining Treatment (MOLST) increased from 11.0% to 19.0% ( P = .006). The MOLST documentation in 2 independent groups of patients with nondementia increased from 7.3% to 10.7% ( P = .046). Continuing efforts to initiate educational interventions are warranted to increase the effectiveness ACP documentation and future care of persons with dementia.
B. Stockigt, R. Suhr, D. Sulmann, M. Teut and B. Brinkhaus.
Complement Med Res 2019 Apr 3:1-10
Intentional Touch (InTouch) refers to a soft physical touch with the aim to ease complaints and enhance well-being. Central questions were perception of InTouch by nurses and patients and possible effects on pain perception. PATIENTS AND METHODS: InTouch was developed by stakeholder involvement. Nurses working in geriatric care received expert training in InTouch. Semi-structured interviews and participant observation (including video recording) were conducted with nurses applying and patients with chronic pain receiving InTouch after the beginning of the intervention and after 4 weeks. Interviews were analyzed based on Qualitative Content Analysis and video recordings based on Qualitative Visual Analysis. RESULTS: Six elderly patients with chronic pain and 6 nurses were included. Nurses and patients equally described relaxation, well-being, and a sensation of warmth during the intervention. Patients reported no pain during the intervention. After the intervention, 3 patients each experienced pain relief or no change. Patients described better drive and positive feelings, and nurses felt empowered in their nursing work. Empathetic attention had special importance for improving the therapeutic relationship. CONCLUSION: The results of this study suggest that InTouch promoted relaxation, well-being, and pain relief for elderly people suffering from chronic pain and may contribute positively to the therapeutic relationship.
C. Hugo, M. Dwonczyk, J. Skinner and L. Isenring.
Australas J Ageing 2018 Dec;37(4):300-304
Mealtimes directly impact the quality of life of residents in aged care. The objective of The Lantern Project is to improve the dining experience of aged care residents to reduce malnutrition risk through improving dietary intake, meal. METHODS: A transdisciplinary team of aged care professionals and resident advocates was formed as a collaboration collectively known as The Lantern Project. RESULTS: This paper outlines the journey and timeline of The Lantern Project collaboration since its inception and the interplay between the monthly stakeholder meetings and inter-related research projects demonstrating improved outcomes. CONCLUSION: Transdisciplinary collaboration offers well-grounded benefits and realistic strategies sensitive to the complexity of the aged care setting.
J. L. Sullivan, O. L. Adjognon, R. L. Engle, et al.
Health Care Manage Rev 2018 Jul/Sep;43(3):193-205
From 2010 to 2013, the Department of Veterans Affairs (VA) funded a large pilot initiative to implement noninstitutional long-term services and supports (LTSS) programs to support aging Veterans. Our team evaluated implementation of 59 VA noninstitutional LTSS programs. PURPOSE: The specific objectives of this study are to (a) examine the challenges influencing program implementation comparing active sites that remained open and inactive sites that closed during the funding period and (b) identify ways that active sites overcame the challenges they experienced. METHODOLOGY: Key informant semistructured interviews occurred between 2011 and 2013. We conducted 217 telephone interviews over four time points. Content analysis was used to identify emergent themes. The study team met regularly to define each challenge, review all codes, and discuss discrepancies. For each follow-up interview with the sites, the list of established challenges was used as a priori themes. Emergent data were also coded. RESULTS: The challenges affecting implementation included human resources and staffing issues, infrastructure, resources allocation and geography, referrals and marketing, leadership support, and team dynamics and processes. Programs were able to overcome challenges by communicating with team members and other areas in the organization, utilizing information technology solutions, creative use of staff and flexible schedules, and obtaining additional resources. DISCUSSION: This study highlights several common challenges programs can address during the program implementation. The most often mentioned strategy was effective communication. Strategies also targeted several components of the organization including organizational functions and processes (e.g., importance of coordination within a team and across disciplines to provide good care), infrastructure (e.g., information technology and human resources), and program fit with priorities in the organization (e.g., leadership support). IMPLICATIONS: Anticipating potential pitfalls of program implementation for future noninstitutional LTSS programs can improve implementation efficiency and program sustainability. Staff at multiple levels in the organization must fully support noninstitutional LTSS programs to address these challenges.
Q. Lood, M. Kirkevold, K. Sjogren, A. Bergland, P. O. Sandman and D. Edvardsson.
J Adv Nurs 2019 Apr 2
To explore the extent to which a more person-centred climate could explain the variation in quality of care, as rated by relatives to nursing home residents in three countries. DESIGN: A cross-sectional, correlational, anonymous questionnaire study. METHODS: Questionnaires were administered to 346 relatives to residents in six nursing homes in Australia, Norway and Sweden between April – June 2016. A total of 178 relatives agreed to participate. Data were analysed using descriptive statistics and hierarchical multiple regression. RESULTS: The results showed that the relatives’ experiences of a more person-centred climate was associated with higher ratings of the quality of care. A person-centred climate of safety had the strongest unique association with the quality of care, explaining 14% of the variance in quality of care. In addition, the results indicated that the relatives in general were satisfied the quality of care and that children to the residents rated the quality of care higher than partners or other relatives. CONCLUSION: This study advances the understanding of the relationship between person-centredness in nursing homes and quality of care, showing that person-centred climate aspects of safety and hospitality have a significant role in the quality of care as perceived by relatives. IMPACT: Person-centredness in nursing homes is often mentioned as a quality of care indicator, but the empirical evidence for this suggestion is limited. This study expanded the evidence-base for person-centredness as a significant aspect of relatives’ experiences of the quality of care in nursing homes
M. Villeval, E. Gaborit, F. Berault, T. Lang and M. Kelly-Irving.
Implement Sci 2019 Apr 2;14(1):35-019-0880-8
The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a “key functions/implementation/context” (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their “key functions”) from those associated with their translation within a specific context (their “form”). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications. METHODS: The interventions were independently described by researchers and intervention’s implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar. RESULTS: Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described. CONCLUSIONS: For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.
K. I. Hower, V. Vennedey, H. A. Hillen, et al.
BMJ Open 2019 Apr 1;9(4):e027591-2018-027591
Health and social care systems, organisations and providers are under pressure to organise care around patients’ needs with constrained resources. To implement patient-centred care (PCC) successfully, barriers must be addressed. Up to now, there has been a lack of comprehensive investigations on possible determinants of PCC across various health and social care organisations (HSCOs). Our qualitative study examines determinants of PCC implementation from decision makers’ perspectives across diverse HSCOs. DESIGN: Qualitative study of n=24 participants in n=20 semistructured face-to-face interviews conducted from August 2017 to May 2018. SETTING AND PARTICIPANTS: Decision makers were recruited from multiple HSCOs in the region of the city of Cologne, Germany, based on a maximum variation sampling strategy varying by HSCOs types. OUTCOMES: The qualitative interviews were analysed using an inductive and deductive approach according to qualitative content analysis. The Consolidated Framework for Implementation Research was used to conceptualise determinants of PCC. RESULTS: Decision makers identified similar determinants facilitating or obstructing the implementation of PCC in their organisational contexts. Several determinants at the HSCO’s inner setting and the individual level (eg, communication among staff and well-being of employees) were identified as crucial to overcome constrained financial, human and material resources in order to deliver PCC. CONCLUSIONS: The results can help to foster the implementation of PCC in various HSCOs contexts. We identified possible starting points for initiating the tailoring of interventions and implementation strategies and the redesign of HSCOs towards more patient-centredness.
C. M. Shea, K. Turner, J. Albritton and K. L. Reiter.
Health Care Manage Rev 2018 Jul/Sep;43(3):261-269
Recent emphasis on value-based health care has highlighted the importance of quality improvement (QI) in primary care settings. QI efforts, which require providers and staff to work in cross-functional teams, may be implemented with varying levels of success, with implementation being affected by factors at the organizational, teamwork, and individual levels. PURPOSE: The purpose of our study was to (a) identify contextual factors (organizational, teamwork, and individual) that affect implementation effectiveness of QI interventions in primary care settings and (b) compare perspectives about these factors across roles (health care administrators, physician and nonphysician clinicians, and administrative staff). METHODS/APPROACH: We conducted semistructured interviews with 24 health care administrators, physician and nonphysician primary care providers, and administrative staff representing 10 primary care practices affiliated with one integrated delivery system. RESULTS: Participants across all roles identified similar organizational- and team-level factors that influence QI implementation including organizational capacity to take on new initiatives (e.g., time availability of physicians), technical capability for QI (e.g., data analysis skills), and team climate (e.g., how well staff work together). There was greater variation in terms of individual-level factors, particularly perceived meaning and purpose of QI. Perceptions about value of QI ranged from positive impacts on patient care and practice competitiveness to decreased efficiency and distractions from patient care, but differences did not appear attributable to role. CONCLUSIONS: Successful QI implementation requires effective collaboration within cross-functional teams. Additional research is needed to assess how best to employ implementation strategies that promote cross-understanding of QI among team members and, ultimately, effective implementation of QI programs. PRACTICE IMPLICATIONS: Health care managers in primary care settings should strive to create a strong teamwork climate, reinforced by opportunities for staff in various roles to discuss QI as a collective.
L. D. DiMartino, S. A. Birken, L. C. Hanson, et al.
Health Care Manage Rev 2018 Jul/Sep;43(3):249-260
The implementation science literature has contributed important insights regarding the influence of formal policies and practices on health care innovation implementation, whereas informal implementation policies and practices have garnered little attention. The broader literature suggests that informal implementation policies and practices could also influence innovation use. PURPOSE: We used the Organizational Theory of Innovation Implementation to further understand the role of formal and informal implementation policies and practices as determinants of implementation effectiveness. We examined their role within the context of initiatives to increase palliative care consultation in inpatient oncology. METHODS: We used a case study design in two organizational settings within one academic medical center: medical and gynecologic oncology. We completed semistructured interviews with medical (n = 12) and gynecologic (n = 10) oncology clinicians using questions based on organizational theory. Quantitative data assessed implementation effectiveness, defined as aggregated palliative care consult rates within oncology services from 2010 to 2016. Four palliative care clinicians were interviewed to gain additional implementation context insights. RESULTS: Medical oncology employed multiple formal policies and practices including training and clinician prompting to support palliative care consultation and a top-down approach, yet most clinicians were unaware of the policies and practices, contributing to a weak implementation climate. In contrast, gynecologic oncology employed one formal policy (written guideline of criteria for initiating a consult) but also relied on informal policies and practices, such as spontaneous feedback and communication; they adopted a bottom-up approach, contributing to broader clinician awareness and strong implementation climate. Both services exhibited variable, increasing consult rates over time. PRACTICE IMPLICATIONS: Informal policies and practices may compensate or substitute for formal policies and practices under certain conditions (e.g., smaller health care organizations). Further research is needed to investigate the role of formal and informal policies and practices in shaping a strong and sustainable implementation climate and subsequent effective innovation implementation.
NEJM Catalyst Insights Council, Stephen J. Swensen, Namita Seth Mohta
In that context, it is notable that culture at many health care organizations is changing — and in the right direction, say nearly 60% of respondents to our latest NEJM Catalyst Insights Council survey. Three-quarters of respondents — who are clinical leaders, clinicians, and executives from organizations directly involved in health care delivery — label culture change a high or moderate priority in their organization.
B. Klein and I. Schlomer.
Z Gerontol Geriatr 2018 Jan;51(1):25-31
Being able to maintain personal hygiene plays a crucial role for independent living in old age or when suffering from disabilities. Within the European project ICT Supported Bath Robots (ISUPPORT) an intelligent robotic shower system is being developed, which enables patients to shower independently at home or in institutionalized settings. OBJECTIVE: The aim of this contribution is the identification of ethical issues in the development of a robotic shower system utilizing the model for the ethical evaluation of socio-technical arrangements (MEESTAR). MATERIAL AND METHODS: In ISUPPORT a variety of concepts and methods are implemented in order to achieve technology acceptance such as user-centered requirements analysis, usability-tests and analysis of sociocultural and ethical aspects. This article reports the analysis of focus groups with 14 older adults and 9 professional caregivers utilizing MEESTAR as a heuristic approach for analyzing sociotechnical arrangements and identifying ethical problems. RESULTS AND DISCUSSION: The MEESTAR procedure was adapted to the research question and client groups and implemented as a discursive method. This gave an insight into the meaning and background of ethical aspects and also a deeper insight into nursing processes as well as the requirements which the system should fulfil. Shortcomings are that the ethical dimensions are not everyday language and the time restrictions. In the next step a standardized assessment instrument will be developed and piloted.
J. D. Chase, K. B. Hirschman, A. L. Hanlon, L. Huang, K. H. Bowles and M. D. Naylor.
Gerontologist 2018 Nov 3;58(6):1147-1155
To identify determinants of self-reported physical functioning (PF) among older adults new to long-term services and supports (LTSS). Research Design and Method: Using the International Classification of Function, Disability, and Health (ICF) framework, we conducted a secondary analysis of self-reported data on symptoms, basic/instrumental activities of daily living, quality of life, assistive devices, physical therapy needs, prior healthcare utilization, health status, and demographics from 470 older adults new to LTSS (Home/Community-Based n = 156; Assisted Living n = 156; Nursing Home n = 158). Multiple linear regression was used to identify associations between ICF constructs and self-reported PF (SF-12 Physical Composite Summary score [SF12PCS], lower scores indicate worse PF). Results: LTSS recipients were mostly female (71%) and over age 80 (Mean: 80.9 years, SD: 8.7). LTSS recipients’ mean SF12PCS score was 37.3 (SD 11.0), indicating overall low self-reported PF. LTSS recipients living in their homes (b = -3.35, p = .003) or assisted living facilities (b = -2.93, p = .012) had significantly lower mean scores compared to recipients in nursing homes. Higher SF12PCS scores were associated with fewer activities of daily living deficits (p < .001), and better quality of life (p < .001). Lower scores were associated with more symptoms (p < .001), poorer nutrition (p = .013), ambulation aid use (p < .001), and physical therapy (p < .026). Discussion and Implications: Diverse health, activity, and environmental factors may facilitate early identification of new LTSS recipients most in need of interventions to optimize self-reported PF. Several health conditions may be targets for such interventions. Additional research is needed to evaluate and compare PF trajectories among older adults receiving LTSS in diverse settings.
Housing Design for an Increasingly Older Population looks at a trio of options for housing the “oldest-old:” the Dutch Apartment/Condo for Life Model (AFL); decentralized Small/Green Houses; and the provision of enhanced personal and health care for people who want to stay in their own home. It offers unique and eye-opening chapters covering: what older people want; what age changes affect independence; demographics and living arrangements; how long-term care is defined; concepts and objectives for housing the frail; care giving and management practices that avoid an institutional lifestyle; innovative case studies; programs that encourage staying at home with service assistance; therapeutic use of outdoor spaces; how technology will help people stay independent; and more.
-Based on the author’s numerous conversations with other experts, as well as his examinations of high quality settings from -Northern Europe and the US
-Building case study examples showcase innovative and compassionate solutions
-In-depth coverage of three major systems that work
-Examines successful programs such as PACE, Friendly Cities, NORC, and the “Village to Village Network” to demonstrate the progress made in helping older, frail people stay in their own homes for as long as possible.
Housing Design for an Increasingly Older Population: Redefining Assisted Living for the Mentally and Physically Frail is an important book for those who create, design, and manage assisted living and skilled nursing facilities, as well as for those who set policies regarding health, and personal care for our world’s aging society.
J. P. Hirdes, G. A. Heckman, A. Morinville, et al.
J Am Med Dir Assoc 2019 Apr 4
To understand how the odds of both adverse and positive transitions vary over the course of episodes of care in nursing homes. DESIGN: Retrospective cohort study of individuals admitted to nursing homes using clinical and administrative Canadian Resident Assessment Instrument version 2 data linked to emergency department and hospital records. SETTING AND PARTICIPANTS: Adults aged 65 years and older, admitted to nursing homes in Ontario, Alberta, British Columbia, and Yukon Territories in Canada, from 2010 to 2015. The sample involved 163,176 individuals with 1,088,336 RAI 2.0 assessments. MEASURES: Data on mortality and hospitalization were obtained from nursing home and hospital records. Multistate Markov models were employed to estimate odds ratios characterizing covariate effects on transitions to different states of health, hospitalization, and death, stratified by day of stay beginning with the initial 90-day period after admission to a nursing home. RESULTS: The first 90 days of stay after admission were characterized by higher odds of both adverse and positive outcomes after adjusting for numerous covariates. Newly admitted residents had greater odds of becoming worse in health instability, being hospitalized, or dying. However, they also had greater odds of being discharged home or improving in health compared with later stages of the episode of care. These associations varied by the resident’s Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) scores at the start of each 90-day follow-up period, and CHESS was associated with differential rates of death, hospitalization, and discharge home. CONCLUSIONS/IMPLICATIONS: The initial 90-day period after nursing home placement is one in which the likelihood of both adverse and positive changes is elevated for nursing home residents. Special efforts must be taken after admission to identify and respond to risk factors that may increase the resident’s odds of negative outcomes. At the same time, there may be a window of opportunity for the person’s transition back to the community after a brief nursing home stay.
V. Critten and N. Kucirkova.
Dementia (London) 2017 Jan 1:1471301217691162
The purpose of these three case studies was to analyse and theoretically explain the contribution of digital multimedia personalisation to stimulate and share long-term memories of people who live with mild to moderate dementia. We investigated how the use of a freely available iPad app can, in a supporting context, facilitate the creation of personalised multimedia stories, including the participants’ audio recordings, texts and photos of items, places or people important to them. Three people who were recruited from a club for people living with dementia created personalised multimedia stories using their own photographs and/or pictures downloaded from the internet, with written captions and audio-recorded voiceovers. Our analysis focuses on the themes and symbols across the three final stories of the participants and the process of creating stories with the Our Story iPad app. The discussion concerns the theoretical value of multimedia and the practical value of story-making apps for people with dementia. We conclude that the multimedia features available with the Our Story app offer a unique opportunity for people living with dementia to store, access and generate memories, capture them in writing and audio; and the ability to continue adding to the original stories.
T. Nakashima, Y. Young and W. H. Hsu.
Am J Alzheimers Dis Other Demen 2019 May;34(3):193-198
This study compares pain interventions received by nursing home residents with and without dementia. Secondary data analyses of cross-sectional data from 50,673 nursing home residents in New York State were collected by the Minimum Data Set 3.0. Frequency distributions and bivariate analyses with chi(2) tests were used to organize and summarize the data. Logistic regression analyses were performed to quantify the relationship between dementia and pain interventions. Our results show that residents with dementia had significantly fewer pain assessments and less reported pain presence than their counterparts. After adjusting for covariates, the results indicate that residents with dementia were significantly less likely to receive pro re nata and nonmedication pain intervention. However, there were no significant differences in scheduled pain medication between the 2 groups. To address the gap, we need more research to design a pain assessment tool that can differentiate severity of pain so that appropriate interventions can be applied.
N. H. Chadborn, C. Goodman, M. Zubair, et al.
BMJ Open 2019 Apr 8;9(4):e026921-2018-02692
Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes. DESIGN: Realist review. SETTING: Care homes. METHODS: The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute. RESULTS: 130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care. CONCLUSION: The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings. TRIAL REGISTRATION NUMBER: CRD42017062601.
I. De-Rosende-Celeiro, G. Torres, M. Seoane-Bouzas and A. Avila.
PLoS One 2019 Apr 8;14(4):e0215002
In homes, problems in daily functioning of older people often occur in the bathroom, especially in the transfers to the toilet and/or shower/bath. Assistive products have the potential to maximise functional independence (i.e. performance without assistance from another person) in everyday activities; however, more research is needed to better understand the impact of this technology on independence in the transfers in the bathroom. Additionally, little is known about the role of the environmental factors in the process of implementing bathroom adaptations. Therefore, this cross-sectional study aimed to examine the relationship between the use of assistive products and independence in the transfers in the bathroom. The secondary objective was to determine the role of the environmental factors in predicting the implementation of bathroom adaptations. 193 community-dwelling older adults with disabilities in the basic activities of daily life, who requested public long-term care services in Spain, were included. Data was collected in the participant s homes using a standardised assessment procedure. There was no significant association between the number of categories of assistive products used in the toilet transfer and the independent performance of this task. In a multivariate model, the number of categories of assistive products used in the transfer to shower/bath was positively associated with the independent performance of this transfer (OR = 2.59, 95%CI = 1.48-4.53; p = 0.001). A multivariate analysis revealed that social functioning was significantly associated with the implementation of a bathroom adaptation; social risk was lower in participants who made an adaptation (OR = 0.76, 95%CI = 0.63-0.93; p = 0.006). Assistive products may play an important role in promoting independence in the bathroom. Assistive product needs should be addressed when planning community-based interventions aimed at improving daily life. Moreover, social functioning had a strong influence on the installation of bathroom adaptations, suggesting the importance of paying special attention to social factors in the home adaptations planning process.
S. M. Dyer, E. S. Gnanamanickam, E. Liu, C. Whitehead and M. Crotty.
Australas J Ageing 2018 Dec;37(4):E155-E158
To examine the cognitive status of Australians living in residential aged care facilities (RACFs) and whether or not a dementia diagnosis was recorded. METHODS: Cross-sectional study of 541 residents of 17 RACFs spanning four states. Examination of cognitive status by Psychogeriatric Assessment Scale Cognitive Impairment Scale (PAS-Cog) and dementia diagnosis from medical records. RESULTS: The study population included 65% of residents with a diagnosis of dementia recorded, and 83% had a PAS-Cog score of four or more indicating likely cognitive impairment. More than 20% of participants had likely cognitive impairment (PAS-Cog >/=4), but no diagnosis of dementia; 11% had moderate-to-severe cognitive impairment (PAS-Cog >/=10) but no recorded dementia diagnosis. CONCLUSION: There may be a lack of formal diagnosis of dementia in Australian RACFs. Greater efforts from all health professionals to improve diagnosis in this setting are required. This is an opportunity for improved person-centred care and quality of care in this vulnerable population.
M. Tsuboi, R. Momosaki, M. Vakili and M. Abo.
Geriatr Gerontol Int 2018 Feb;18(2):197-210
To review the best available evidence on nutritional supplementation for activities of daily living and functional ability of older people in residential facilities. METHODS: Electronic searches were carried out using CENTRAL, MEDLINE and EMBASE databases for the years 2006-2016. Randomized controlled trials and cluster-randomized controlled trials that examined the effects of nutrition interventions aimed at improving the energy or protein intake alone or both in combination were included. Two authors independently reviewed all potential studies for inclusion against the eligibility criteria. We reviewed studies for outcome relevance and methodological rigor. Any disagreement was resolved by discussion. RESULTS: A total of eight studies were included, containing four randomized controlled trials and four cluster-randomized controlled trials involving 698 participants. There was significant improvement in handgrip strength (mean difference 1.65 kg, 95% confidence interval 0.09-3.22 kg, P = 0.04), but no difference in activities of daily living (mean difference 2.06, 95% confidence interval -18.28-22.40, P = 0.84), balance (mean difference -1.10, 95% confidence interval -3.04-0.84, P = 0.27), gait velocity (mean difference 0.00, 95% confidence interval -0.03-0.03, P = 1.00) and death (RR 1.90, 95% confidence interval 0.61-5.99, P = 0.27). CONCLUSIONS: Nutritional intervention with older people in residential facilities was effective in improving handgrip strength, but did not significantly improve scores for activities of daily living, balance, gait velocity or preventing death. Further studies with larger sample sizes and of high quality are required to investigate appropriate intervention methods and specific target participants.
M. S. Park, S. Y. Lim, E. Y. Kim, S. J. Lee and S. O. Chang.
Jpn J Nurs Sci 2018 Jan;15(1):77-90
The bedridden elderly with moderate-to-severe dementia account for a large proportion of the residents in nursing homes and form a specialized group requiring customized care in order to encourage their remaining functions, which determine the quality of their residual life. The purpose of this study was to search for ways to invigorate and foster the remaining functions of this complex-disability group, based on practical nursing strategies in nursing homes. METHODS: The qualitative thematic analysis was done by conducting in-depth interviews with 29 nurses working at 11 different nursing homes in South Korea. RESULTS: This study proposed four main themes and 19 sub themes as keys for providing specialized nursing care to the elderly with physical and cognitive disabilities. The main themes encourage the residents’ remaining functions: (i) accurate identification of an elderly resident’s physical, cognitive, and behavioral baseline is necessary in order to determine their functional levels; (ii) nurses provide meticulous management to support the remaining functions in order to prevent further deterioration; (iii) optimized know-how, based on accumulated experience and knowledge, is reflected in nursing strategies that maximize the effects of nursing interventions; and (iv) steady compliance with nursing guidelines and standards in nursing homes creates the best therapeutic environment and brings unexpected positive changes in the elderly’s status. CONCLUSION: A practical nursing strategy to target the group with a demented and complex disability in nursing homes was developed through thematic analysis of the empirical knowledge of nurses. The findings provide new insights for developing specialized nursing interventions and practical nursing models in long-term care facilities.
The risks and limited benefits of using antipsychotics for managing agitation, aggression, distress and psychosis in people living with dementia are well recognised and NICE recommends conducting a structured assessment to identify and address any underlying causes.
A person living with dementia should only try an antipsychotic if they are at risk of harming themselves or others, or if they are severely distressed. The antipsychotic should be tried alongside other activities to try to help their distress.
Medicines optimisation teams should continue to explore effective ways to implement the national policy to reduce the harms from inappropriate prescribing of antipsychotics, in line with recommendations from the NICE guidance on medicines optimisation, managing medicines for adults receiving social care in the community and managing medicines in care homes.
Options for local implementation:
Review and, if appropriate, optimise prescribing of antipsychotics in people living with dementia, in accordance with the NICE guideline on dementia and the NICE quality standard on dementia (currently being updated, publication due June 2019).
Ensure that staff who deliver care and support to people living with dementia and their carers, are offered appropriate training, as recommended by NICE.
Tuesday 23 April 10:00-11:00 MT
Presenter: Marjorie Silverman
This webinar will share findings from an Ottawa-based research study funded by the Alzheimer Society of Canada. The study, which is currently in its last year of funding, looked at the experiences of place, space and neighbourhood of care partners of people with dementia. How do care partners interact with the built, natural, and social environment? How are they supported locally? The findings have implications for both research and practice, and the development of dementia friendly communities in Canada.
Thursday 18 April 10:00-11:00 MT
Presenters: Caren Ginsberg, Ingrid Nembhard, Yuna Lee, Susan Edgman-Levitan
This AHRQ Webcast will provide an overview of one study using nurse care coordination as a strategy to improve patients’ experience with primary care. Speakers will discuss how staff’s creative ideas improved patient care experiences, the organizational challenges these ideas entail and ways to address these challenges.
The IFA in partnership with DaneAge is proud to host the IFA Copenhagen Summit on Cognitive Reserve, a global forum to share successful policies and best practices that encourage a life course approach to brain health. On 24-25 October 2019 in Copenhagen, Denmark, experts in the fields of public health, policy, healthy ageing and cognitive health will meet to deliberate how to ensure that cognitive reserve is embedded within a life course approach to policy and practice.
A well-developed knowledge translation (KT) plan is often a proposal requirement for health research funding agencies in Canada and abroad. In addition, various sectors are demonstrating greater attention to the utilization and impact of research. The Specialist Knowledge Translation Training (SKTT™) workshop was developed on the premise that scientists, and increasingly, other practitioners and educators, are agents of change in creating research impact, promoting research utilization, and ensuring that research findings reach the appropriate audiences. This course was designed to teach the unique skill set that surrounds KT practice.
This is a one day introduction to knowledge translation planning and practice for graduate students.In this course, participants will:
Develop improved knowledge and understanding of KT as it relates to healthcare and other sectors
Learn about evidence-based and innovative KT strategies and develop awareness of how to evaluate impact
Learn to develop KT plans using the KT Planning Template
Improve their ability to communicate research findings to multiple (non-academic) audiences
The Lead, Implementation Science, under the direction of the Director, Research Impact, plays a key role in supporting OHTN, front-line organizations and service providers in the application of implementation science principles to programs and services, building capacity and sharing knowledge. This position will play a key role in establishing relationships and networks with, among, and between OHTN and its partners. This position provides leadership to ensure robust implementation science, evaluation and quality improvement frameworks are developed, implemented, analyzed, reported and communicated to advance rapid uptake of knowledge to achieve measurable impact. As well, the Lead, Implementation Science will engage with internal and external stakeholders to develop tools, reports and training as it relates to building capacity building capacity and sharing knowledge about implementation science and practice.
Earlier this year, the Institute announced the creation of the IRPP Centre of Excellence on the Canadian Federation. A permanent research body to be housed at the Institute, made possible by a contribution of $10 million from the Government of Canada, its mission will be to reinforce research capacity on issues related to federalism.
The Executive Director will establish and lead this important new research centre. Reporting to the President and CEO of the IRPP, the Executive Director will
Set the strategic direction for the new Centre and develop its policy research initiatives and activities, based on extensive consultations with key academic leaders, federalism experts and other practitioners in the public and private sector.
Identify research priorities and develop the research program accordingly;
Recruit authors and contributors to undertake research projects, oversee their execution and completion, and ensure their results are widely disseminated;
Deliver timely, high-quality, policy-relevant analysis that informs Canada’s policy agenda and complements the IRPP’s other research and activities;
Stay abreast of activities and policy directions in similar organizations to identify potential collaborations and the implications for the centre’s strategic direction;
Monitor leading-edge thinking and practice on federalism worldwide and participate in key knowledge networks to inform the Centre’s research agenda;
Build and maintain relationships with key stakeholders, partners, and potential sponsors and donors to develop new projects, partnerships, funding agreements and opportunities for influence;
Act as a spokesperson for the Centre and promote its research; and,
Ensure the Centre’s presence in each region of the country at least once a year.
As a member of the IRPP’s management team, the Executive Director will work in close collaboration with the CEO; the Vice President, Research; the Vice President, Operations; and the Editor-in-Chief of Policy Options magazine.
Office of Lifelong Learning and Physician Learning Program, University of Alberta
DEADLINE: Open until filled
As a research associate, you will study the implementation of a quality improvement initiative in surgical departments across Alberta, with the goal of informing ongoing implementation in future sites. You will draw on your expertise in qualitative data methodologies, experience in health care research, and knowledge of implementation science to plan and carry out a project to examine implementation strategies, their impacts and outcomes in five different pilot sites. Results of this project will be key in informing roll-out of the initiative in additional future sits. As such, you’ll contribute significantly to furthering implementation science and quality improvement in Albertan hospitals.