August 13, 2019

We examined demographic, individual, and organizational context factors associated with nurses’ job satisfaction in residential long-term care (LTC) settings. Job satisfaction has implications for staff turnover, staff health, and quality of care. Design A cross-sectional analysis of survey data collected in the Translating Research in Elder Care program. Setting and participants N = 756 nurses (registered nurses: n = 308; licensed practical nurses: n = 448) from 89 residential LTC settings in 3 Western Canadian provinces. Methods We used a generalized estimating equation model to assess demographic, individual, and organizational context factors associated with job satisfaction. Job satisfaction was measured using the Michigan Organizational Assessment Questionnaire Job Satisfaction Scale. Results Demographic, individual, and organizational context factors were associated with job satisfaction among nurses in residential LTC settings. At the demographic level, hours worked in 2 weeks (B = 0.002, P = .043) was associated with job satisfaction. At the individual level, emotional exhaustion-burnout (B = −0.063, P = .02) was associated with lower job satisfaction, while higher scores on empowerment (meaning) (B = 0.140, P = .015), work engagement (vigor) (B = 0.096, P = .01), and work engagement (dedication) (B = 0.129, P = .001) were associated with higher job satisfaction. With respect to organizational context, culture (B = 0.175, P < .001), organizational slack-space (eg, perceived availability and use of adequate space; B = 0.043, P = .040), and adequate orientation (B = 0.092, P < .001) were associated with higher job satisfaction. Conclusions and implications We identified previously unexamined modifiable organizational features (organizational slack-space and adequate orientation) as factors associated with LTC nurses’ job satisfaction in the Canadian context. Our findings support future efforts to improve job satisfaction through improvements in organizational space and provision of adequate workplace orientation.

We examined the influence of individual characteristics and organizational context features on nurses’ self-reported use of research evidence in long-term care (LTC) homes. DESIGN: A cross-sectional analysis of survey data collected in the Translating Research in Elder Care program. SETTING AND PARTICIPANTS: 756 nurses (registered nurses and licensed practical nurses) from 89 LTC homes in Western Canada. METHODS: Generalized estimating equation modeling was used to identify which individual characteristics and organizational context features significantly predicted (P < .05) 3 kinds of self-reported research use by nurses: instrumental (the direct application of research findings), conceptual (using research findings to change thinking), and persuasive (using research findings to convince others). RESULTS: Nurses reported a moderate to high level of research use. There were no significant differences in mean research use scores by nursing role. Only 2 variables were associated with all 3 kinds of research use: having a positive attitude toward research, and availability of structural and electronic resources. Additional variables associated with instrumental research use were problem-solving ability, engaging in formal interactions (eg, education sessions), and better perceptions of organizational slack-staff (the availability of sufficient staff). Additional variables associated with conceptual research use were self-determination and job efficacy. Finally, additional variables associated with persuasive research use were belief suspension (the ability to suspend previously held beliefs), organizational citizenship behavior (one’s voluntary commitment to the organization), self-determination, job efficacy, evaluation, and better perceptions of organizational slack-time (perceived availability of extra time). CONCLUSIONS AND IMPLICATIONS: Conceptual and persuasive research use were most strongly influenced by individual characteristics, whereas instrumental research use was predicted equally by individual and organizational variables. Nurses working in LTC are positioned in leadership roles; by targeting both the individual- and organizational-level predictors of nurses’ research use, they can improve conditions for individuals living in LTC.

To conduct a concept analysis of clinical practice contexts (work environments) in healthcare. BACKGROUND: Context is increasingly recognized as important to the development, delivery and understanding of implementation strategies; however, conceptual clarity about what comprises context is lacking. DESIGN: Modified Walker and Avant concept analysis comprised of 5 steps: 1) concept selection; 2) determination of aims; 3) identification of uses of context; 4) determination of its defining attributes; and 5) definition of its empirical referents. METHODS: A wide range of databases were systematically searched from inception to August 2014. Empirical articles were included if a definition and/or attributes of context were reported. Theoretical articles were included if they reported a model, theory, or framework of context or where context was a component. Double independent screening and data extraction was conducted. Analysis was iterative, involving organizing and reorganizing until a framework of domains, attributes and features of context emerged. RESULT: We identified 15,972 references, of which 70 satisfied our inclusion criteria. In total, 201 unique features of context were identified, of these 89 were shared (reported in 2 or more studies). The 89 shared features were grouped into 21 attributes of context which were further categorized into 6 domains of context. CONCLUSION: This study resulted in a framework of domains, attributes and features of context. These attributes and features, if assessed and used to tailor implementation activities, hold promise for improved research implementation in clinical practice. This article is protected by copyright. All rights reserved

We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada. METHODS: We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014. RESULTS: For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes. CONCLUSIONS: Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting.

The provision of care work by families plays an integral role in the quality of life of older adults living in a nursing home setting. This critical interpretive synthesis examines family members’ perceptions of their roles and responsibilities in nursing home settings and interrogates the structural and relational barriers and enablers to family involvement as they relate to fostering an inclusive environment. Electronic databases and published literature were searched for empirical studies that were conducted in a nursing home setting and described involvement from the perspective of family members. Thirty-two articles published between 2006 and 2016 were included in the review. Although involvement comprised a variety of roles and responsibilities, it was grounded in family-resident relationships, influenced by family-staff relationships, and deeply affected by broader sociopolitical factors. We conclude that involvement should be understood as a democratic process with supporting policies and programs to encourage family inclusion in facility life.

To understand obstacles to returning to work, as perceived by people with chronic non-malignant pain and as perceived by employers, and to develop a conceptual model. DESIGN: Synthesis of qualitative research using meta-ethnography. DATA SOURCES: Eleven bibliographic databases from inception to April 2017 supplemented by citation tracking. REVIEW METHODS: We used the methods of meta-ethnography. We identified concepts and conceptual categories, and developed a conceptual model and line of argument. RESULTS: We included 41 studies. We identified three core categories in the conceptual model: managing pain, managing work relationships and making workplace adjustments. All were influenced by societal expectations in relation to work, self (self-belief, self-efficacy, legitimacy, autonomy and the meaning of work for the individual), health/illness/pain representations, prereturn to work support and rehabilitation, and system factors (healthcare, workplace and social security). A mismatch of expectations between the individual with pain and the workplace contributed to a feeling of being judged and difficulties asking for help. The ability to navigate obstacles and negotiate change underpinned mastering return to work despite the pain. Where this ability was not apparent, there could be a downward spiral resulting in not working. CONCLUSIONS: For people with chronic pain, and for their employers, navigating obstacles to return to work entails balancing the needs of (1) the person with chronic pain, (2) work colleagues and (3) the employing organisation. Managing pain, managing work relationships and making workplace adjustments appear to be central, but not straightforward, and require substantial effort to culminate in a successful return to work.

Most deaths in critically ill patients with severe traumatic brain injury are associated with a decision to withdraw life-sustaining treatments. We aimed to identify the behavioural determinants that influence recommendations by critical care physicians to consider the withdrawal of life-sustaining treatments in this population. METHODS: We conducted a descriptive qualitative study based on the Theoretical Domains Framework of critical care physicians caring for patients with severe traumatic brain injury across Canada. We stratified critical care physicians by regions and used a purposive sampling strategy. We conducted semistructured phone interviews using a piloted and pretested interview guide. We transcribed the interviews verbatim and verified the content for accuracy. We performed the analysis using a 3-step approach: coding, generation of specific beliefs and generation of specific themes. RESULTS: We recruited 20 critical care physicians across 4 geographic regions. After reaching saturation, we identified 7 core themes across 4 Theoretical Domains Framework domains for factors relevant to the decision to withdraw life-sustaining treatments. Four factors (i.e., clinical triggers, social triggers, interaction with families and intentions with medical decisions) were identified before the decision is made and 3 were identified during the decision-making process (i.e., considerations, priorities and knowledge needs). We identified multiple themes reflecting internal (n = 18, 8 Theoretical Domains Framework domains) and external (n = 15, 6 Theoretical Domains Framework domains) influences on the decision to withdraw life-sustaining treatments. INTERPRETATION: We identified several core themes and domains considered by critical care physicians in Canada in the decision to withdraw life-sustaining treatments in critically ill patients with severe traumatic brain injury. Future research should aim at identifying the factors influencing surrogate decision-makers in the decision to withdraw life-sustaining treatments in these patients.

Measuring pain in infants is important but challenging, as there is no “gold standard.” The measurement of skin conductance (SC) is considered to be a measure of stress and as a surrogate indicator of pain. The objectives of this study were to identify the extent of research conducted and to synthesize the validity evidence of SC for assessing acute pain in infants. METHODS: The Arksey and O’Malley framework for scoping reviews was followed, and 9 electronic databases were searched. Data were analyzed thematically and presented descriptively including the following main categories: study information/details, sampling information, characteristics of participants and settings, SC outcome measures, and validity evidence. RESULTS: Twenty-eight studies with 1061 infants were included, including 23 cross-sectional observation studies and 5 interventional studies. The most studied infants were those with mild severity of illness (n=13) or healthy infants (n=12). The validity evidence of SC was tested in relation to referent pain measures (13 variables), stimuli (13 variables), age (2 variables), and other contextual variables (11 variables). SC was not significantly correlated with vital signs, except for heart rate in 2 of the 8 studies. SC was significantly correlated with the unidimensional behavioral pain assessment scales and crying time rather than with multidimensional measurements. Fourteen of 15 studies (93.3%) showed that SC increased significantly during painful procedures. CONCLUSIONS: Inconsistent findings on validity of SC exist. Future research should aim to identify the diagnostic test accuracy of SC compared with well-accepted referent pain measures in infants, study the validity evidence of SC in critically ill infants, and utilize rigorous research design and transparent reporting.

The aged population is increasing rapidly across the world and this is expected to continue. People living in residential aged care facilities (RACFs) represent amongst the sickest and frailest cohort of the aged population, with a high prevalence of chronic conditions and complex comorbidities. Given the vulnerability of RACF residents and the demands on the system, there is a need to determine the extent that care is delivered in line with best practice (‘appropriate care’) in RACFs. There is also a recognition that systems should provide care that optimises quality of life (QoL), which includes support for physical and psychological well-being, independence, social relationships, personal beliefs and a caring external environment. The aims of CareTrack Aged are to develop sets of indicators for appropriate care and processes of care for commonly managed conditions, and then assess the appropriateness of care delivered and QoL of residents in RACFs in Australia. METHODS AND ANALYSIS: We will extract recommendations from clinical practice guidelines and, using expert review, convert these into sets of indicators for 15 common conditions and processes of care for people living in RACFs. We will recruit RACFs in three Australian states, and residents within these RACFs, using a stratified multistage sampling method. Experienced nurses, trained in the CareTrack Aged methods (‘surveyors’), will review care records of recruited residents within a 1-month period in 2019 and 2020, and assess the care documented against the indicators of appropriate care. Surveyors will concurrently assess residents’ QoL using validated questionnaires. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Human Research Ethics Committee of Macquarie University (5201800386). The research findings will be published in international and national journals and disseminated through conferences and presentations to interested stakeholder groups, including consumers, national agencies, healthcare professionals, policymakers and researchers.

To identify and map tools measuring behavioural aspects of the nurse-patient relationship. BACKGROUND: The behaviours nurses employ to develop relationships with patients form a key part of nursing practice. Systematically measuring these behaviours provides an objective means of assessing and evaluating how nurses establish and maintain relationships with patients in a variety of settings. Whilst tools exist to measure these behaviours, little is known about their aims/scope, structure, method of development and contexts of use. Such knowledge is crucial for understanding the nature of the literature, including in which contexts and for which patient groups existing tools are suited. DESIGN: Scoping review informed by Joanna Briggs Institute methodology. METHODS: A database search was undertaken using CINAHL, PsycINFO, Pubmed and Embase. Primary research articles, theses and methodological papers that developed, refined and/or administered tools measuring behavioural aspects of the nurse-patient relationship, in any setting and for any patient group, were included. Tools had to measure actual not hypothetical behaviour (e.g., perceptions regarding importance). Data from included studies and tools were mapped. Results are reported in accordance with PRISMA-ScR guidelines. RESULTS: One hundred and twenty-seven studies, containing 35 tools, were included. The literature was characterised by substantial variability, stemming from the continued refinement of tools (e.g., reduction to short forms) but also the development of new tools that appeared to duplicate existing work and the inconsistent use of tools across studies. CONCLUSIONS: The volume of tools available demonstrates the importance of measuring the nurse-patient relationship. However, the existing duplication and variability create challenges in choosing amongst the tools available and show that, as a concept, the nurse-patient relationship remains poorly understood. RELEVANCE TO CLINICAL PRACTICE: Research is required to synthesise, and assess the quality of, existing tools, enabling clinicians, leaders/managers, educators and researchers to administer appropriate tools to evaluate the nurse-patient relationship.

The burden of pain in nursing homes is substantial; however, pain assessment for both acute and chronic conditions remains inadequate, resulting in inappropriate or inadequate treatment. Complexities in assessing resident pain have been attributed to factors (barriers and facilitators) arising at the resident, healthcare provider, and healthcare system levels. OBJECTIVES: In this systematic review protocol, we identify our research approach that will be used to critically appraise and synthesize data in order to assess barriers and facilitators to pain assessment in nursing home residents aged >/=65 years. METHODS: This is a Cochrane style systematic review protocol adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocols reporting standards. This review will include primary (original) qualitative literature concerning either barriers or facilitators to pain assessment in older adult nursing home residents. A thematic analysis approach will be employed in collating and summarizing included data and will be categorized into resident, healthcare provider, and system-level factors. Database searches will include Abstracts in Social Gerontology, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and Web of Science. DISCUSSION: The identification of barriers and facilitators to pain assessment in older adult nursing home residents may assist healthcare providers across all platforms and levels of education to improve pain assessment among nursing home residents. Improving the assessment of pain has the potential to improve quality of care and ultimately quality of life for older adult nursing home residents.

Between 9 July and 15 August 2019, WHO and partners are seeking open input, comments, revisions, additions on the zero-draft proposal for the Decade of Healthy Ageing. The document is 20 pages (excluding annexes) and is divided into 4 sections:

Section 1: A new context needs concerted, sustained action

Section 2: Vision, added value and principles

Section 3: Action areas

Section 4: Partnering for change

Our aim is to publish rigorous original research, reviews and methodologies making use of big data in the context of palliative or end-of-life care. We seek high-quality contributions from across health and social sciences that have the potential to appeal to an international audience of clinicians, researchers, managers, educators and policy makers. Please note that a high priority will be given to original research questions of clinical, public health or societal relevance, relying on innovative methods. Strictly descriptive studies will be given low priority, unless they touch upon population, groups or outcomes that are currently understudied and for which the use of routinely collected is suitable.

The CIHR Sex and Gender Science Chairs Initiative is expected to:
Grow the science of sex and gender research through the development and application of novel methods for elucidating the sex- and gender-related mechanisms that underpin the risk, incidence and response of various health and disease conditions in order to shape new therapies, interventions, programs and policies;
Increase visibility and position Canada as a leader in discipline-specific sex and gender science; and
Support capacity building in sex and gender science among the next generation of health researchers.

The environments in which we live, work, and play are critical to our health, development, and well-being. Evidence shows that urban environments influence our behaviours and impact our biology. With 81% of Canada’s population living in cities, understanding the health promoting potential of cities is an important area of research that can have a big impact on health across population groups.

A 23-month Quality Improvement Collaborative
To improve care for older people with frailty and support their caregivers, CFHI and the Canadian Frailty Network invite you to join the Advancing Frailty Care in the Community (AFCC) Collaborative. This initiative will help you enhance your capacity to partner with patients and family/friend caregivers to improve the identification, assessment and implementation of tailored evidence-informed interventions that address frailty in primary care.
Whether your organization already has clearly established approaches for older people with frailty or is looking to develop some for the first time, our goal is to help you deliver more improvement, for more people, that lasts.

Motivated reasoning in response to disconfirming science information presents a challenging barrier to science communication. This article presents a novel approach to emphasis framing, in which functionally equivalent information is framed using ideologically consistent values and tailored to the audiences. In contrast to traditional framing approaches, science information is held constant across frames and only interpretations of the information are varied. Results from an experiment provide initial support for this ideology-based framing approach. Persuasive effects are stronger for an ideologically congruent frame than for an incongruent frame, and no boomerang effects were observed. We discuss implications and directions for future research.

As a group of Health System Impact (HSI) postdoctoral fellows, Sim and colleagues offer their reflections on ‘driving change’ within the health system and present a framework for understanding the HSI fellow as an embedded researcher. Our commentary offers a different perspective of the fellow’s role by highlighting the integrated knowledge translation (IKT) approach we consider to be foundational to the fellowship experience. Further, we provide several recommendations to enhance Sim and colleagues’ framework to ensure we capture the full value of the fellowship program to the HSI fellow, health system organization, and academic institution.

In Ontario, an online audit and feedback tool that provides primary care physicians with detailed information about patients who are overdue for cancer screening is underused. In the present study, we aimed to examine the effect of messages operationalizing 3 behaviour change techniques on access to the audit and feedback tool and on cancer screening rates. Methods: During May-September 2017, a pragmatic 2x2x2 factorial experiment tested 3 behaviour change techniques: anticipated regret, material incentive, and problem-solving. Outcomes were assessed using routinely collected administrative data. A qualitative process evaluation explored how and why the e-mail messages did or did not support Screening Activity Report access. Results: Of 5449 primary care physicians randomly allocated to 1 of 8 e-mail messages, fewer than half opened the messages and fewer than 1 in 10 clicked through the messages. Messages with problem-solving content were associated with a 12.9% relative reduction in access to the tool (risk ratio: 0.871; 95% confidence interval: 0.791 to 0.958; p = 0.005), but a 0.3% increase in cervical cancer screening (rate ratio: 1.003; 95% confidence interval: 1.001 to 1.006; p = 0.003). If true, that association would represent 7568 more patients being screened. No other significant effects were observed. Conclusions: For audit and feedback to work, recipients must engage with the data; for e-mail messages to prompt activity, recipients must open and review the message content. This large factorial experiment demonstrated that small changes in the content of such e-mail messages might influence clinical behaviour. Future research should focus on strategies to make cancer screening more user-centred.

To appraise and synthesize empirical literature on implementation of evidence within community nursing. To explore the use of implementation theory and identify the strategies required for, and the barriers and facilitators to, successful implementation within this context. BACKGROUND: There is an international consensus that evidence-based practice can improve outcomes for people using health and social care services. However, these practices are not always translated into care delivery. Community nursing is a relatively understudied area; little is known about how innovations in practice are implemented within this setting. METHODS: Systematic mixed-studies review, synthesizing quantitative and qualitative research. The electronic databases AMED, PsycINFO, Ovid Medline, CINAHL Plus, ASSIA, British Nursing Index and EMBASE were used. Two grey literature databases were also searched: OpenGrey and EThOS. English language, peer-reviewed papers published between January 2010 and July 2017 were considered. Criteria included implementation of an innovation and change to practice within adult community nursing. An approach called Critical Interpretive Synthesis was used to integrate the evidence from across the studies into a comprehensible theoretical framework. RESULTS: In total, 22 papers were reviewed. Few studies discussed the use of theory when planning, guiding and evaluating the implementation of the innovation (n=6). A number of implementation strategies, facilitators and barriers were identified across the included studies, highlighting the interplay of both service context and individual factors in successful implementation. CONCLUSION: Implementation is an expanding area of research; yet is challenged by a lack of consistency in terminology and limited use of theory. Implementation within community nursing is a complex process, requiring both individual and organizational adoption, and managerial support. Successful adoption of evidence-based practice however, is only possible if community nurses themselves deem it useful and there is evidence that it could have a positive impact on the patient and/or their primary carer.

Implementation science has been recognized as a potential catalyst for health system reform, in part, because of its contribution of well-grounded conceptual theories, often encapsulated in frameworks. Well-designed frameworks provide a semantic structure, a common language by which to guide systematic approaches to studying implementation and testing interventions. An overview of the types and roles of theory in advancing implementation science is offered in this article. Resources for selecting appropriate frameworks are described along with illustrative examples. The case is made that well-developed theory is what enables knowledge to emerge out of seeming chaos and for translation of that knowledge to be widely and reliably implemented into routine practice so that health and well-being of patients is maximized by delivery of interventions that are rooted in that knowledge.

Beginners to the discipline of implementation science often struggle to determine whether their research questions “count” as implementation science. MAIN TEXT: In this paper, three implementation scientists share a heuristic tool to help investigators determine where their research questions fall in the translational research continuum. They use a “subway model” that envisions a journey to implementation research with stops along the way at efficacy and effectiveness research. CONCLUSIONS: A series of structured questions about intervention efficacy, effectiveness, and implementation can help guide researchers to select research questions and appropriate study designs along the spectrum of translational research.

This paper describes the process and results of a refinement of a framework to characterize modifications to interventions. The original version did not fully capture several aspects of modification and adaptation that may be important to document and report. Additionally, the earlier framework did not include a way to differentiate cultural adaptation from adaptations made for other reasons. Reporting additional elements will allow for a more precise understanding of modifications, the process of modifying or adapting, and the relationship between different forms of modification and subsequent health and implementation outcomes. DISCUSSION: We employed a multifaceted approach to develop the updated FRAME involving coding documents identified through a literature review, rapid coding of qualitative interviews, and a refinement process informed by multiple stakeholders. The updated FRAME expands upon Stirman et al.’s original framework by adding components of modification to report: (1) when and how in the implementation process the modification was made, (2) whether the modification was planned/proactive (i.e., an adaptation) or unplanned/reactive, (3) who determined that the modification should be made, (4) what is modified, (5) at what level of delivery the modification is made, (6) type or nature of context or content-level modifications, (7) the extent to which the modification is fidelity-consistent, and (8) the reasons for the modification, including (a) the intent or goal of the modification (e.g., to reduce costs) and (b) contextual factors that influenced the decision. Methods of using the framework to assess modifications are outlined, along with their strengths and weaknesses, and considerations for research to validate these measurement strategies. CONCLUSION: The updated FRAME includes consideration of when and how modifications occurred, whether it was planned or unplanned, relationship to fidelity, and reasons and goals for modification. This tool that can be used to support research on the timing, nature, goals and reasons for, and impact of modifications to evidence-based interventions.

Developmental evaluation is a growing area of evaluation practice, advocated for informing the adaptive development of change initiatives in complex social environments. The utilisation focus, complexity perspective and systems thinking of developmental evaluation suggest suitability for evaluating knowledge translation initiatives in primary healthcare. However, there are few examples in the literature to guide its use in these contexts and in Indigenous settings. In this paper, we reflect on our experience of using developmental evaluation to implement a large-scale knowledge translation research project in Australian Aboriginal and Torres Strait Islander primary healthcare. Drawing on principles of knowledge translation and key features of developmental evaluation, we debate the key benefits and challenges of applying this approach to engage diverse stakeholders in using aggregated quality improvement data to identify and address persistent gaps in care delivery. DISCUSSION: The developmental evaluation enabled the team to respond to stakeholder feedback and apply learning in real-time to successfully refine theory-informed research and engagement processes, tailor the presentation of findings to stakeholders and context, and support the project’s dissemination and knowledge co-production aim. It thereby contributed to the production of robust, useable research findings for informing policy and system change. The use of developmental evaluation appeared to positively influence stakeholders’ use of the project reports and their responses to the findings. Challenges included managing a high volume of evaluation data and multiple evaluation purposes, balancing facilitative sense-making processes and change with task-focused project management, and lack of experience in using this evaluation approach. Use of an embedded evaluator with facilitation skills and background knowledge of the project helped to overcome these challenges, as did similarities observed between features of developmental evaluation and continuous quality improvement. CONCLUSION: Our experience of developmental evaluation confirmed our expectations of the potential value of this approach for strengthening improvement interventions and implementation research, and particularly for adapting healthcare innovations in Indigenous settings. In our project, developmental evaluation successfully encompassed evaluation, project adaptation, capacity development and knowledge translation. Further work is warranted to apply this approach more widely to improve primary healthcare initiatives and outcomes, and to evaluate implementation research.

Healthcare research funders may undertake various roles to facilitate implementation of research findings. Their ability to enact such roles depends on several factors, knowledge of implementation being one essential requirement. However, previous studies do not assess the type or level of knowledge about implementation that research funders possess. This paper therefore presents findings from a qualitative, inductive study of the implementation knowledge of research funders. Three aspects of this knowledge are explored, namely how research funders define implementation, their level of self-assessed implementation knowledge and the factors influencing their self-assessment of implementation knowledge. METHODS: Research funders (n = 18) were purposefully selected from a sample of research funding organisations in Sweden (n = 10). In-depth semi-structured interviews were conducted, recorded and transcribed verbatim. An inductive method using a systematic coding procedure was employed to derive the findings. RESULTS: The research funders defined implementation as either an outcome or a process, with the majority believing that implementation of healthcare research results demands a process, although its complexity varied in the research funders’ view. They perceived their own level of implementation knowledge as either limited or substantial, with a majority regarding it as limited. Clinical research experience, clinical experience and task relevance were singled out as the clearest factors affecting the self-assessment of their own implementation knowledge. CONCLUSIONS: This study, the first to focus on implementation knowledge of research funders, demonstrates that they are a category of policy-makers who may possess knowledge, based on their previous professional experience, that is comparable to some important findings from implementation research. Consequently, the findings not only pinpoint the relevance of professional experience, but also reveal a lack of awareness and knowledge of the results of implementation research among research funders in charge of healthcare research.

In relation to the general Canadian population, Inuit face increased cancer risks and barriers to health services use. In shared decision-making (sdm), health care providers and patients make health care decisions together. Enhanced participation in cancer care decisions is a need for Inuit. Integrated knowledge translation (kt) supports the development of research evidence that is likely to be patient-centred and applied in practice. Objective: Using an integrated kt approach, we set out to promote the use of sdm by Inuit in cancer care. Methods: An integrated kt study involving researchers with a Steering Committee of cancer care system partners who support Inuit in cancer care (“the team”) consisted of 2 theory-driven phases: using consensus-building methods to tailor a previously developed sdm strategy and developing training in the sdm strategy; and training community support workers (csws) in the sdm strategy and testing the sdm strategy with community members. Results: The team developed a sdm strategy that included a workshop and a booklet with 6 questions for use by csws with patients. The sdm strategy (training and booklet) was finalized based on feedback from 5 urban-based Inuit csws who were recruited and trained in using the strategy. Trained csws were matched with 8 community members, and use of the sdm strategy was assessed during interviews, reported as 6 themes. Participants found the sdm strategy to be useful and feasible for use. Conclusions: An integrated kt approach of structured research processes with partners developed a sdm strategy for use by Inuit in cancer care. Further work is needed to test the sdm strategy.

To synthesize qualitative evidence on nurses’ end-of-life care practices in long-term care settings for older adults. BACKGROUND: Qualitative evidence on how nurses describe their own end-of-life care practice has not been reviewed systematically. DESIGN: Qualitative systematic review. DATA SOURCES: Databases MEDLINE, CINAHL, PsycINFO, EMBASE, Mednar, Google Scholar, and Ichushi were searched for published and unpublished studies in English or Japanese. METHODS: The review followed the Joanna Briggs Institute approach to qualitative systematic reviews. Each study was assessed by two independent reviewers for methodological quality. The qualitative findings were pooled to produce categories and synthesized through meta-aggregation. RESULTS: Twenty studies met all inclusion criteria. Their 137 findings were grouped into 10 categories and then aggregated into three synthesized findings: playing multidimensional roles to help residents die with dignity, needing resources and support for professional commitment, and feeling mismatch between responsibilities and power, affecting multidisciplinary teamwork. CONCLUSION: Nurses play multidimensional roles as the health care professionals most versed in residents’ complex needs. Managers and policymakers should empower nurses to resolve the mismatch and help nurses obtain needed resources for end-of-life care that ensures residents die with dignity.

Positive and effective staff-resident interactions are imperative to adequately assess and meet the needs of cognitively impaired residents in nursing homes and optimize their quality of life. AIM: The purpose of this study was to quantify, describe, and analyze the interaction between staff and cognitively impaired residents in nursing homes, using the Quality of Interaction Schedule (QuIS). METHOD: This descriptive analysis utilized baseline data from the first 2 cohorts in a randomized clinical trial including 341 residents from 35 nursing homes. RESULTS: Five hundred fifty-six staff-resident interactions were evaluated; majority were positive (n = 466, 83.8%) and the remaining were either neutral (n = 60, 10.8%) or negative (n = 30, 5.4%). The quality of interactions varied by interaction location, interpersonal distance, and resident participation. CONCLUSION: Future research should focus on decreasing the negative/neutral interactions and explore staff characteristics (eg, gender, level of experience) and facility factors (eg, size, ownership) that might influence the quality of interactions.

Unbefriended older adults are those who lack the capacity to make medical decisions and do not have a completed advance directive that can guide treatment decisions or a surrogate decision maker. Adult orphans are those who retain medical decision-making capacity but are at risk of becoming unbefriended due to lack of a completed advance health care directive and lack of a surrogate decision maker. In a follow-up to the 2016 American Geriatrics Society (AGS) position statement on unbefriended older adults, we examined clinicians’ experiences in caring for unbefriended older adults and adult orphans. Methods: Clinicians recruited through the AGS (N = 122) completed an online survey about their experiences with unbefriended older adults regarding the perceived frequency of contact, clinical concerns, practice strategies, and terminology; and also with adult orphans regarding the perceived frequency of contact, methods of identification, and terminology. Results: Almost all inpatient (95.9%) and outpatient (86.4%) clinicians in this sample encounter unbefriended older adults at least quarterly and 92.2% of outpatient clinicians encounter adult orphans at least quarterly. Concerns about safety (95.9%), medication self-management (90.4%), and advance care planning (86.3%) bring unbefriended older adults to outpatient clinicians’ attention “sometimes” to “frequently.” Prolonged hospital stays (87.7%) and delays in transitioning to end-of-life care (85.7%) bring unbefriended older adults to inpatient clinicians’ attention “sometimes” to “frequently.” Clinicians apply a wide range of practice strategies to these populations. Participants suggested alternative terminology to replace “unbefriended” and “adult orphan.” Conclusions: This study suggests that unbefriended older adults are frequently encountered in geriatrics practice, both in the inpatient and outpatient settings, and that there is widespread awareness of adult orphans in the outpatient setting. Clinicians’ awareness of both groups suggests avenues for intervention and prevention. Clinical Implications: Health care professionals in geriatric settings will likely encounter older adults in need of advocates. Clinicians, attorneys, and policymakers should collaborate to improve early detection and to meet the needs of this vulnerable population.

To examine the relationship between registered nurse (RN) burnout, job dissatisfaction, and missed care in nursing homes. DESIGN: Cross-sectional secondary analysis of linked data from the 2015 RN4CAST-US nurse survey and LTCfocus. SETTING: A total of 540 Medicare- and Medicaid-certified nursing homes in California, Florida, New Jersey, and Pennsylvania. PARTICIPANTS: A total of 687 direct care RNs. MEASUREMENTS: Emotional Exhaustion subscale of the Maslach Burnout Inventory, job dissatisfaction, and missed care. RESULTS: Across all RNs, 30% exhibited high levels of burnout, 31% were dissatisfied with their job, and 72% reported missing one or more necessary care tasks on their last shift due to lack of time or resources. One in five RNs reported frequently being unable to complete necessary patient care. Controlling for RN and nursing home characteristics, RNs with burnout were five times more likely to leave necessary care undone (odds ratio [OR] = 4.97; 95% confidence interval [CI] = 2.56-9.66) than RNs without burnout. RNs who were dissatisfied were 2.6 times more likely to leave necessary care undone (OR = 2.56; 95% CI = 1.68-3.91) than RNs who were satisfied. Tasks most often left undone were comforting/talking with patients, providing adequate patient surveillance, patient/family teaching, and care planning. CONCLUSION: Missed nursing care due to inadequate time or resources is common in nursing homes and is associated with RN burnout and job dissatisfaction. Improved work environments with sufficient staff hold promise for improving care and nurse retention.

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

Providing quality palliative care in residential aged care facilities (RACFs) (aged care homes) is a high priority for ageing populations worldwide. Older people admitted to these facilities have palliative care needs. Nursing assistants (however termed) are the least qualified staff and provide most of the direct care. They have an important role at the frontline of care spending more time with residents than any other care provider but have been found to lack the necessary knowledge and skills to provide palliative care. The level of competence of this workforce to provide palliative care requires evaluation using a valid and reliable instrument designed for nursing assistants’ level of education and the responsibilities and practices of their role. METHOD: The overall study purpose was to develop and test an instrument capable of evaluating the knowledge, skills and attitudes of nursing assistants within a palliative approach in RACFs. Development consisted of a four-phase mixed-methods sequential design. In this paper, the results and key findings following psychometric testing of the instrument in Phase 4 is reported using data collected from a random sample of 17 RACFs and 348 nursing assistants in the Greater Sydney region. Study hypotheses were tested to confirm discriminative validity and establish the utility of the instrument in both research and training assessment. RESULTS: Individual item properties were analysed for difficulty, discrimination and item-total correlations. Discriminative and structural validity, and internal consistency and test-retest reliability were demonstrated. Three separate questionnaires comprising 40 items were finalised: The Palliative Approach for Nursing Assistants (PANA)_Knowledge Questionnaire (17 items), the PANA_Skills Questionnaire (13 items) and the PANA_Attitudes Questionnaire (10 items). CONCLUSIONS: This study provides preliminary evidence for the validity and reliability of three new questionnaires that demonstrate sensitivity for nursing assistants’ level of education and required knowledge, skills and attitudes for providing a palliative approach. Implications for practice include the development of palliative care competencies through structured education and training across this workforce, and ongoing professional development opportunities for nursing assistants, especially for those with the longest tenure.

In care homes, staff well-being, job confidence and opinion of the care provided to residents are central to morale and care quality. In this study, care home staff in the East Midlands region of England completed self-reported outcome and experience surveys in two rounds. Mean scores for each home are shown using a scale from 0 (all chose lowest option) to 100 (all chose highest option). High scores are good. Results: In round 1, 332 staff in 15 homes submitted responses; in round 2, 207 staff in 9 homes. Mean scores in round 1 and round 2 were similar, although those of some homes scores differed significantly, cancelling each other out. Overall, Work Wellbeing mean score was 83 (care home range 48-97), with worthwhileness (92) the highest ranked item and anxiety at work (78) the lowest. Job Confidence mean score was 84 (range 59-94), with able to manage the work (86) highest and involvement in decisions that affect staff (79) lowest. Care Provided mean score was 86 (range 59-97), with treat people kindly (91) highest and well organised (80) lowest. Homes rated as outstanding by the Care Quality Commission had higher scores on average than those rated good, which were higher than those rated as needing improvement. Conclusions: This study has demonstrated the practicality of measuring staff views of their Work Wellbeing, Job Confidence and Care Provided in care homes. Rather than wait for adverse quality outcomes to be detected, this approach offers a way to track staff morale and declared capability over time.

The provision of quality care in nursing home (NH) facilities is an ongoing challenge, and the literature indicates that the quality of care (QOC) is often suboptimal. While it is highly recommended that NH facilities adopt a culture of person-centered care (PCC) to ensure quality care, the outcomes of this shift on staff working in NH settings has not been well studied. The purpose of this article was to understand the theoretical relationship between staff and job satisfaction, stress, turnover, and staff outcomes in PCC NH settings, by utilizing Cohen-Mansfield’s (1995) comprehensive occupational stress model. METHODS: An integrative review of the electronic databases of research published in English between 2000 and 2015 was conducted. RESULTS: A review of 11 papers suggested that job satisfaction in the nursing workforce is positively related to consistency in QOC delivery and increased quality of life among residents in NHs. Management support and PCC practices positively correlate with improved QOC, staff satisfaction, and staff retention. CONCLUSIONS: This review showed that PCC intervention and training representing the key concept of workplace resources has a positive impact on NH staff job stress and satisfaction. CLINICAL RELEVANCE: Supporting the NH workforce through PCC training is essential for promoting job satisfaction and reducing job-related stress as well as turnover, which in turn will improve QOC delivered to the residents living in NHs.

The objective of the study was to assess the impact of an intervention in which people with dementia attended meetings to discuss their individual care plans on their quality of life. Fifty-two older people (M = 86.7 years, SD = 7.3) diagnosed with moderate-to-severe dementia living in four nursing homes in Spain participated in the study. The intervention was implemented with 27 residents at two of the nursing homes; the other 25 cases at the other two homes acted as controls. A proxy measure of quality of life was used. Improvements were found in quality of life as assessed by staff members, in both within and between-group comparisons, which suggests that including older people with dementia in care-planning meetings may improve their quality of life. However, further controlled studies are needed to confirm these preliminary results.

The charge nurse in long-term care facilities (LTCFs) performs a multiplicity of tasks that range from oversight of the entire facility to directly assisting residents in activities of daily living. In order to refine resident-centred care strategies and to increase the quality of care provided in LTCFs, this study aims at gaining a more nuanced understanding of the different dimensions of the charge nurse role as a central figure in these institutions. METHODS: Data were generated through semi-structured interviews. A purposive sample of ten Registered Nurses in a charge nurse role, diverse in experience, age, gender and background, was recruited from five LTCFs in Ontario, Canada. The study used a combination of conventional and direct qualitative content analyses. FINDINGS: All tasks performed by the charge nurses were categorised in four dimensions: clinical, supervisory, team support and managerial. Administration was a cross-cutting sub-dimension which has gained presence over the years. Depending on the shift worked and the organisational structure of the facility, each dimension gained or lost weight as part of the overall role. CONCLUSION: These findings suggest that the charge nurse role is in a state of flux and lacking standardisation within and across facilities. LTCFs would benefit from increasing recognition of the role according to the wide range of tasks performed and responsibilities assumed, and by recruiting their charge nurses accordingly. IMPLICATIONS FOR PRACTICE: The proposed conceptual framework could be used to map and assess charge nurses’ workloads and responsibilities, in order to enhance staff satisfaction and resident-centred care in LTCFs.

Effective hand hygiene is one of the most important measures for protecting nursing home residents from nosocomial infections. Infections with multi-resistant bacteria’s, associated with healthcare, is a known problem. The nursing home setting differs from other healthcare environments in individual and organisational factors such as knowledge, behaviour, and attitude to improve hand hygiene and it is therefore difficult to research the influential factors to improve hand hygiene. Studies have shown that increasing knowledge, behaviour and attitudes could enhance hand hygiene compliance in nursing homes. Therefore, it may be important to examine individual and organisational factors that foster improvement of these factors in hand hygiene. We aim to explore these influences of individual and organisational factors of hand hygiene in nursing home staff, with a particular focus on the function of role modelling by nursing managers. METHODS: We conducted a mixed-methods study surveying 165 nurses and interviewing 27 nursing managers from nursing homes in Germany. RESULTS: Most nurses and nursing managers held the knowledge of effective hand hygiene procedures. Hygiene standards and equipment were all generally available but compliance to standards also depended upon availability in the immediate work area and role modelling. Despite a general awareness of the impact of leadership on staff behaviour, not all nursing managers fully appreciated the impact of their own consistent role modelling regarding hand hygiene behaviours. CONCLUSION: These results suggest that improving hand hygiene should focus on strategies that facilitate the provision of hand disinfectant materials in the immediate work area of nurses. In addition, nursing managers should be made aware of the impact of their role model function and they should implement this in daily practice.

As citizens, patients and family members are participating in numerous and expanding roles in health system organizations, attention has turned to evaluating these efforts. The context-specific nature of engagement requires evaluation tools to be carefully designed for optimal use. We sought to address this need by assessing the appropriateness and feasibility of a generic tool across a range of health system organizations, engagement activities and patient groups. METHODS: We used a mixed-methods implementation research design to study the implementation of an engagement evaluation tool in seven health system organizations in Ontario, Canada focusing on two key implementation outcome variables: appropriateness and feasibility. Data were collected through respondent feedback questions (binary and open-ended) at the end of the tool’s three questionnaires as well as interviews and debriefing discussions with engagement professionals and patient partners from collaborating organizations. RESULTS: The three questionnaires comprising the evaluation tool were collectively administered 29 times to 405 respondents yielding a 52% response rate (90% and 53% of respondents respectively assessed the survey’s appropriateness and feasibility [quantitatively or qualitatively]). The questionnaires’ basic properties were rated highly by all respondents. Concrete suggestions were provided for improving the appropriateness and feasibility of the questionnaires (or components within) for different engagement activity and organization types, and for enhancing the timing of implementation. DISCUSSION AND CONCLUSIONS: Our study findings offer guidance for health system organizations and evaluators to support the optimal use of engagement evaluation tools across a variety of health system settings, engagement activities and respondent groups.

The stress associated with care of patients with dementia has led to high nursing staff turnover. This study aims to explore patient factors that are related to nursing burden. METHODS: The present study examined nursing care burden related to 55 institutionalized dementia patients using the Modified Nursing Care Assessment Scale (M-NCAS). Cognition was assessed with the Severe Impairment Battery (SIB), activities of daily living (ADLs) were measured with the Alzheimer’s Disease Functional Assessment of Change Scale (ADFACS), aggression was measured with the Aggressive Behavior Scale (ABS), and the Charlson Comorbidity Index (CCI) was used to assess medical comorbidity. Finally, the Dementia Cognitive Fluctuation Scale (DCFS) was used to assess the presence and severity of cognitive fluctuations (CFs). Linear regression models were used to assess their relationships with nursing care burden. RESULTS: The mean age of the patients was 90.41 years (SD=2.84) and 89.10% were males. ADFACS total score (B = 0.36, beta = 0.42, p = 0.002) and ABS score (B = 2.933, beta = 0.37, p = 0.002) significantly predicted the M-NCAS Attitude score. ABS score was the only significant predictor of M-NCAS Strain score (B = 2.57, beta = 0.35, p = 0.009). CONCLUSIONS: In the long-term care setting, aggressive behavior plays an important role in both subjective and objective nursing burden, while impaired ADLs increase the objective burden for nursing staff.

The purpose of this study was to examine whether a perceived person-centered nursing home environment has a direct relationship with nursing home adjustment and life satisfaction, and whether a perceived person-centered nursing home environment has an indirect relationship with life satisfaction through improved nursing home adjustment. METHODS: 203 nursing home residents who were able to read and speak English and were physically and cognitively able to respond to questionnaires were included in this study. Data were collected from six nursing homes in the Midwestern US. RESULTS: Higher levels of a perceived person-centered nursing home environment had a significantly direct relationship with increased life satisfaction of residents (beta = 0.35), and this relationship was mediated by residents’ improved nursing home adjustment (beta = 0.10). In-depth exploration using sub-domains of the main variables demonstrated that “safety” and “everydayness” of a person-centered nursing home environment were directly related to higher levels of life satisfaction (beta = 0.15 and beta = 0.16, respectively); and “everydayness” was related to three sub-domains of nursing home adjustment: better “relationship development,” “acceptance of the new residence” (beta = 0.32 and beta = 0.24, respectively), and lower “depressed mood” (beta = 0.05). The positive relationship between “everydayness” and life satisfaction was partially mediated by the “relationship development” sub-domain of nursing home adjustment (beta = 0.07). CONCLUSIONS: The findings provide new evidence for the positive association between person-centered care and nursing home adjustment. The findings also provide insights into the mechanism through which the specific sub-domains of person-centered care and nursing home adjustment operate in the path model.

We examined the quality of care provided to older persons with frailty in five Canadian provinces, using administrative health data. In each province, we identified two cohorts of older persons with frailty: decedents and living persons. Using decision rules, we considered individuals to be frail if they were long-term care residents, terminally ill, or met at least two of seven domains, which were based on frailty scales, geriatrician discussions, and health service utilization indicators. We assessed quality of care using selected quality indicators: decrease in length of hospital stay, decrease in the number of in-patient readmissions, decrease in the number of emergency department visits, increase in the level of family physician continuity of care, decrease in the use of mechanical ventilation, and decrease in the number of admissions to intensive care. Using regression analyses, we also found male sex and older age were associated with poorer quality of care in both cohorts. This study provides baseline data for evaluating future efforts to improve the quality of care provided to older persons with frailty.

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme. AIM: To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation. OBJECTIVES: (1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes? DATA SOURCES: Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google (Mountain View, CA, USA) and websites relevant to each individual search. DESIGN: Mapping review and rapid, systematic evidence syntheses. SETTING: Care homes with and without nursing in high-income countries. REVIEW METHODS: Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses. RESULTS: Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising. LIMITATIONS: This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded. CONCLUSIONS: This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation. FUTURE WORK: Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context. STUDY REGISTRATION: This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938. FUNDING: The National Institute for Health Research Health Services and Delivery Research programme.

Quality improvement (QI) may help to avert or mitigate the risks of suboptimal care, but it is often poorly reported in the healthcare literature. We aimed to identify the influences on reporting QI in the area of perioperative care, with a view to informing improvements in reporting QI across healthcare. DESIGN: Qualitative interview study. SETTING: Healthcare and academic organisations in Australia, Europe and North America. PARTICIPANTS: Stakeholders involved in or influencing the publication, writing or consumption of reports of QI studies in perioperative care. RESULTS: Forty-two participants from six countries took part in the study. Participants included 15 authors (those who write QI reports), 12 consumers of QI reports (practitioners who apply QI research in practice), 11 journal editors and 4 authors of reporting guidelines. Participants identified three principal challenges in achieving high-quality QI reporting. First, the broad scope of QI reporting-ranging from small local projects to multisite research across different disciplines-causes uncertainty about where QI work should be published. Second, context is fundamental to the success of a QI intervention but is difficult to report in ways that support replication and development. Third, reporting is adversely affected by both proximal influences (such as lack of time to write up QI) and more distal, structural influences (such as norms about the format and content of biomedical research reporting), leading to incomplete reporting of QI findings. CONCLUSIONS: Divergent terminology and understandings of QI, along with existing reporting norms and the challenges of capturing context adequately yet succinctly, make for challenges in reporting QI. We offer suggestions for improvement.

The objective of this study is to describe antibacterial use in long-term care facilities and to investigate the determinants of use. DESIGN: This study is a quality improvement study conducted from January 2011 to December 2016. SETTING: Long-term care facilities in the canton of Vaud, Western Switzerland, were investigated. PARTICIPANTS: Twenty-three long-term care facilities were included in this study. INTERVENTION: The intervention included the publication of local guidelines on empirical antibacterial therapy and the implementation of physician-pharmacist-nurse quality circles. MEASURES: The main outcome was antibacterial use, expressed as defined daily doses (DDD) per 1000 beds per day. Statistical analyses were performed through a 1-level mixed model for repeated measurements. RESULTS: Antibacterial use decreased from 45.6 to 35.5 DDD per 1000 beds per day (-22%, P < .01) over the 6-year study period, which was mostly explained by reduced fluoroquinolone use (-59%, P < .001). A decrease in range of use among LTCFs was observed during the study period, and 27% of antibacterial use was related to the WATCH group (antibiotics with higher toxicity concerns and/or resistance potential) according to the AWaRe categorization of the WHO, decreasing from 17.3 DDD per 1000 beds per day to 9.5 (-45%) over the study period. The use of antibacterials from the RESERVE group (“last-resort” treatment options) was very low. CONCLUSION AND IMPLICATIONS: A reduction in facility-level antibacterial use and in variability across LTCFs was observed over the study period. The dissemination of empirical antibacterial prescription guidelines and the implementation of physician-pharmacist-nurse quality circles in all LTCFs of the canton of Vaud likely contributed to this reduction. Antibacterials from the WATCH group still represented 27% of the total use, providing targets for future antibiotic stewardship activities.

The safety and quality of care provided to nursing home residents is a significant concern. Little is known whether fostering patient safety culture helps improve the safety and quality of nursing home care. METHODS: This study determined the associations of nursing home patient safety culture performance, as reported by administrators, directors of nursing, and unit leaders in a large national sample of free-standing nursing homes, with several “Nursing Home Compare” performance indicators. We conducted the survey in 2017 using the Agency for Healthcare Research and Quality Survey on Patient Safety Culture for nursing homes to collect data on 12 core domains of safety culture scores. Survey data were linked to other nursing home files for multivariable regression analyses. RESULTS: Overall, 818 of the 2254 sampled nursing homes had at least 1 completed survey returned for a response rate of 36%. After adjustment for nursing home, market, and state covariates, every 10 percentage points increase in overall positive response rate for safety culture was associated with 0.56 fewer health care deficiencies (P=0.001), 0.74 fewer substantiated complaints (P=0.004), reduced fines by $2285.20 (P=0.059), and 20% increased odds of being designated as 4-star or 5-star (vs. 1 to 3 star) facilities (odds ratio roughly=1.20, P<0.05). CONCLUSIONS: Efforts to improve nursing home performance in patient safety culture have the potential to improve broad safety and quality of care measures encapsulated in the Nursing Home Compare publication.

The Cognitive Daisy is an innovative assessment system created to provide healthcare staff with an instant snapshot of the cognitive status of older adults in residential care. The Cognitive Daisy comprises a flower head consisting of 15 colour coded petals depicting information about: visual-spatial perception, comprehension, communication, memory and attention. This study confirmed the practicality of the Cognitive Daisy protocol for assessing cognition in a sample of 33 older adults living in residential care and endorsed the use of the Cognitive Daisy as a tool for recognising the cognitive status of care home residents.

Nursing home information technology (NH IT) adoption trends are not measured regularly. Evidence indicates digital footprints are growing, but gaps about NH IT adoption and quality impacts remain. We hypothesize as NH IT adoption grows, quality improves. This research assessed ternary (2014-2017) trends in IT and quality measures using a primary survey of U.S. NHs. Survey measures included nine dimensions/domains and total IT sophistication. Administrators completed 815 Year 1 surveys. Each year mean total IT sophistication scores in nine dimensions/domains consistently increased. Eighteen significant correlations (r > .13, absolute value) between IT sophistication and quality measures existed. Regression shows that for every 10 units increase in administrative activity extent of IT use, a decrease of 1.3% occurs in the percentage of low-risk long-stay residents with bowel or bladder incontinence. Increases in NH IT sophistication positively impact quality. Estimating ongoing trends in NH IT sophistication provides new information that should be consistently available.

The goals of palliative care are to relieve suffering and promote quality of life. Palliative care for older persons has been less prioritised than palliative care for younger people with cancer, which may lead to unnecessary suffering and decreased quality of life at the final stage of life. AIM: To evaluate whether a palliative care intervention had any influence on the perceived quality of life of older persons (>/=65 years). METHODS: This study was conducted as a complex intervention performed with an experimental crossover design. The intervention was implemented in 20 nursing homes, with a six-month intervention period in each nursing home. Twenty-three older persons (>/=65 years) in the intervention group and 29 in the control group were interviewed using the WHOQOL-BREF and WHOQOL-OLD questionnaires at both baseline and follow-up. The collected data were analysed using the Wilcoxon signed-rank test to compare paired data between baseline and follow-up. RESULTS: In the intervention group, no statistically significant increases in quality of life were found. This result contrasted with the control group, which revealed statistically significant declines in quality of life at both the dimension and item levels. Accordingly, this study showed a trend of decreased health after nine months in both the intervention and control groups. CONCLUSION: It is reasonable to believe that quality of life decreases with age as part of the natural course of the ageing process. However, it seems that the palliative care approach of the intervention prevented unnecessary quality of life decline by supporting sensory abilities, autonomy and social participation among older persons in nursing homes. From the ageing perspective, it may not be realistic to strive for an increased quality of life in older people living in nursing homes; maybe the goal should be to delay or prevent reduced quality of life. Based on this perspective, the intervention prevented decline in quality of life in nursing home residents. IMPLICATIONS FOR PRACTICE: The high number of deaths shows the importance to identify palliative care needs in older persons at an early stage to prevent or delay deterioration of quality of life.

To explore the experiences of occupational therapists and physiotherapists and to reveal any factors that can facilitate delivering a complex care home intervention promoting meaningful activity. DESIGN:: Qualitative interview study using data from three focus groups conducted longitudinally post intervention implementation. Data were analysed thematically. SETTING:: Three residential care homes in South London, UK. SUBJECTS:: All therapists involved in the implementation of the intervention: three occupational therapists and three physiotherapists. RESULTS:: Three interconnected themes emerged from the analysis: (1) developing trusting relationships, (2) empowering staff and (3) remaining flexible. Therapists described how successfully implementing a complex care home intervention was dependant on developing trusting relationships with care staff. This enabled the therapists to empower care staff to take ownership of the intervention and help embed it in care home culture, facilitating long-term change. The therapists described how remaining flexible in their approach helped keep care staff engaged for the duration of implementation. CONCLUSION:: This study has revealed several important factors that can help facilitate therapists delivering complex interventions in care homes.

The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency. OBJECTIVE: To explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale QI intervention. DESIGN: Multiple methods within six hospitals including 88 interviews (with Productive Ward leads, ward staff, Patient and Public Involvement representatives and senior managers), 10 ward manager questionnaires and structured observations on 12 randomly selected wards. RESULTS: Resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Nonetheless, material legacies (eg, displaying metrics data; storage systems) have remained in place for up to a decade after initial implementation as have some specific practices (eg, protected mealtimes). Variations in timing of adoption, local implementation strategies and contextual changes influenced assimilation into routine practice and subsequent legacies. Productive Ward has informed wider organisational QI strategies that remain in place today and developed lasting QI capabilities among those meaningfully involved in its implementation. CONCLUSIONS: As an ongoing QI approach Productive Ward has not been sustained but has informed contemporary organisational QI practices and strategies. Judgements about the long-term sustainability of QI interventions should consider the evolutionary and adaptive nature of change processes.

To provide high-quality palliative care to nursing home residents, staff need to understand the basic principles of palliative care. OBJECTIVES: To evaluate the extent of agreement with the basic principles of palliative care of nurses and care assistants working in nursing homes in five European countries, and to identify correlates. METHODS: Cross-sectional study in 214 homes in Belgium, England, Italy, the Netherlands and Poland. Agreement with basic principles of palliative care was measured with the Rotterdam MOVE2PC. We calculated percentages and odds ratios of agreement and an overall score between 0 (no agreement) and 5 (total agreement). RESULTS: Most staff in all countries agreed that palliative care involves more than pain treatment (58% Poland to 82% Belgium) and includes spiritual care (62% Italy to 76% Belgium) and care for family or relatives (56% Italy to 92% Belgium). Between 51% (Netherlands) and 64% (Belgium) correctly disagreed that palliative care should start in the last week of life and 24% (Belgium) to 53% (Poland) agreed that palliative care and intensive life-prolonging treatment can be combined. The overall agreement score ranged between 1.82 (Italy) and 3.36 (England). Older staff (0.26; 95% CI 0.09;0.43, p=0.003), nurses (0.59; 95% CI 0.43;0.75, p < 0.001), and staff who had undertaken palliative care training scored higher (0.21; 95% CI 0.08;0.34, p= 0.002). CONCLUSIONS: The level of agreement of nursing home staff with basic principles of palliative care was only moderate and differed between countries. Efforts to improve the understanding of basic palliative care are needed.

Angela Coulter has written a report for BertelsmannStiftung, a German organization whose mission is to ensure social participation by all citizens. She describes national policies for establishing shared decision making in the healthcare systems of nine leading countries.

Person-centered care (PCC) is regarded as good quality care for persons with dementia. This study aimed to explore and understand the association between PCC and organizational, staff and unit characteristics in nursing homes (NHs). METHODS: Staff from 175 NH units in Norway (n = 1,161) completed a survey, including measures of PCC and questions about staff characteristics and work-related psychosocial factors. In addition, data about organizational and structural factors and assessment of the physical environment in the units were obtained. The distribution of these factors in regular units (RUs) and special care units (SCUs) is described, and the differences between the two types of units are analyzed. Furthermore, multilevel linear regression analyses explored the extent to which variables were associated with PCC. RESULTS: Higher levels of PCC were associated with a greater job satisfaction, three years or more of health-related education, a lower level of quantitative demands and role conflict, a higher level of perception of mastery, empowering leadership, innovative climate and perception of group work, in addition to the type of unit and the physical environment in the NH unit designed for people with dementia. SCU and staff job satisfaction explained most of the variation in PCC. CONCLUSION: This study shows an association between PCC and organizational, staff and unit characteristics in NH. These findings indicate that providing PCC in NH care is closely linked to how the staff experiences their job situation in addition to both organizational and structural factors and the physical environment. Attention needs to be given to such factors when planning NH care.

There is consensus in dissemination and implementation (D&I) science that addressing contextual factors is critically important for understanding translation of health care delivery interventions but little agreement on which contextual factors are key determinants of implementation outcomes. We describe the application of the Practical Robust Implementation and Sustainability Model (PRISM), which expands the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to identify contextual factors across four diverse programs. Multiple qualitative methods were used to collect multilevel, multistakeholder perspectives from the adopting organizations and staff. We identified measures for evaluating context through the various domains of PRISM to guide health services research across the phases of program implementation. The PRISM domains of Recipients, Implementation and Sustainability Infrastructure, and External Environment identified important multilevel contextual factors, including variability in operational processes and available resources. These domains helped to facilitate planning and implementation phases of the four interventions and guide purposeful adaptations. We found assessments of PRISM domains useful to systematically assess multilevel contextual factors across various content areas as well as phases of program implementation. Additionally, these contextual factors were found to be relevant to RE-AIM outcomes. Lessons learned can be applied to future research as there is a need to investigate the measurement properties of PRISM and continue to test which contextual factors are most important to successful implementation and for which outcomes.

Although many contextual factors can facilitate or impede primary care managers’ work with quality and safety, research on how these factors influences the managers’ continuous improvement efforts is scarce. This study explored how primary care managers experience the impact of a variety of contextual factors on their daily quality and safety work. DESIGN: The study has a qualitative design. Nine semistructured qualitative interviews were conducted at the participants’ workplaces. Systematic text condensation was used for analysis. SETTING: Five nursing homes and three home care services in Norway. PARTICIPANTS: Female primary care managers at different levels, working in different units and municipalities varying in size and location. RESULTS: The participants cited the lack of time and money as a significant impediment to quality and safety, and these resources had to be carefully allocated. They emphasised the importance of networks and competence for their quality and safety work. Delegation of responsibility among employees helped create engagement, improved competence and ensured that new knowledge reached all employees. External guidelines and demands helped them to systematise their work and explain the necessity of quality and safety work to their employees, if they were compliant with daily clinical practice in the organisation. CONCLUSIONS: Numerous contextual factors influence the managers by determining the leeway that they have in quality and safety work, by setting the budgetary constraints and defining available competence, networks and regulation. At first glance, these factors appear fixed, but our findings underscore the importance of primary care managers acting on and negotiating the environment in which they conduct their daily quality and safety work. More research is needed to understand how these managers strategise to overcome the impediments to quality and safety.

Summarising quality improvement (QI) research through systematic literature review has great potential to improve patient care. However, heterogeneous terminology, poor definition of QI concepts and overlap with other scientific fields can make it hard to identify and extract data from relevant literature. This report examines the compromises and pragmatic decisions that undertaking literature review in the field of QI requires and the authors propose recommendations for literature review authors in similar fields.Methods Two authors (EJ and JF) provide a reflective account of their experiences of conducting a systematic literature review in the field of QI. They draw on wider literature to justify the decisions they made and propose recommendations to improve the literature review process. A third collaborator, (WC) co-created the paper challenging author{\textquoteright}s EJ and JF views and perceptions of the problems and solutions of conducting a review of literature in QI.Results Two main challenges were identified when conducting a review in QI. These were defining QI and selecting QI studies. Strategies to overcome these problems include: select a multi-disciplinary authorship team; review the literature to identify published QI search strategies, QI definitions and QI taxonomies; Contact experts in related fields to clarify whether a paper meets inclusion criteria; keep a reflective account of decision making; submit the protocol to a peer reviewed journal for publication.Conclusions The QI community should work together as a whole to create a scientific field with a shared vision of QI to enable accurate identification of QI literature. Our recommendations could be helpful for systematic reviewers wishing to evaluate complex interventions in both QI and related fields.

The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families. METHODS: In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research’s domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P). RESULTS: Implementation facilitators identified by Champions included: the intervention’s adaptable mode of presentation and minimal time burden (IC) as well as the program’s customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI). CONCLUSIONS: Despite the promise of PROVEN’s intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN’s implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.

Technologies and methods to speed up the production of systematic reviews by reducing the manual labour involved have recently emerged. Automation has been proposed or used to expedite most steps of the systematic review process, including search, screening, and data extraction. However, how these technologies work in practice and when (and when not) to use them is often not clear to practitioners. In this practical guide, we provide an overview of current machine learning methods that have been proposed to expedite evidence synthesis. We also offer guidance on which of these are ready for use, their strengths and weaknesses, and how a systematic review team might go about using them in practice.

Although geriatric depression is a prevalent, serious, and under-recognized mental health condition in residential care facilities, there is a dearth of related research in Canada. This exploratory mixed methods study examines the perspectives and practices of regulated nurse professionals on assessment of geriatric depression in residential care facilities in Alberta. Findings from the quantitative surveys (n = 635) and qualitative interviews (n = 14) suggest that geriatric depression is not systematically assessed in these care settings due to multiple challenges, including confusing assessment protocol, inconsistent use and contested clinical utility of current assessment methods in facilities, limited availability of mental health professionals in facilities, and the varied views of regulated nurse professionals on who is responsible for depression assessment in facilities. Implications and future research directions are discussed.

This review considers how research into the impact of music on people with dementia has been conducted, with a focus on the means used to measure outcomes. Although there is a rapidly growing amount of research in this relatively new area, it has evolved largely independently within different fields, such as psychology, music therapy and nursing. Using principles from the meta-narrative review method, this paper systematically surveys the qualitative and quantitative measures which have been used in studies relating to music and dementia from 1980 to the present day. Data extracted include the outcome measures used, the type of musical interventions, the setting of the studies, and methodology and study design. The quantitative studies greatly outnumber the qualitative studies, and most research has been done in long-term care settings. Instruments which measure neuropsychiatric symptoms of dementia, especially agitation, were the most frequently used. Other domains that were targeted in the studies included quality of life, physiological change, music-related outcomes and cognitive skills; the inter-relations between these domains are represented as a diagram. Researchers’ rationales for choosing to target these outcomes are discussed. Although reduction of neuropsychiatric symptoms is a valuable outcome, it is important that researchers are open to the possibility of other outcomes. We suggest that measuring an increase in positive responses might be an alternative to measuring a reduction of negative symptoms, and we highlight the importance of listening to people with dementia and carers when designing studies.

To identify the attitudes and needs of nursing home residents regarding physical activity. BACKGROUND: Nursing home residents often have mobility problems and are at high risk for further mobility impairment. From their point of view, being physically active is an important part of their perceived quality of life. However, no study has synthesised existing qualitative literature on residents’ attitudes and needs regarding physical activity. DESIGN: Synthesis of qualitative studies. METHODS: A systematic review and synthesis of qualitative studies was performed, using ENTREQ statement for reporting. Three databases (PubMed, CINAHL and PsycINFO) were searched, supplemented by a hand search. Qualitative studies published in English or German were included if they addressed the attitudes and needs of residents concerning the promotion of physical activities. Finally, 12 studies were critically reviewed, and a thematic synthesis was conducted. RESULTS: Four analytical themes relating to residents’ attitudes were identified: “promoting physical activity increases the quality of life,” “accepting the conditions,” “personal initiative is significant” and “promoting physical activity is not helpful.” Relating to residents’ needs, the analyses yielded five themes: “living autonomously,” “continuing life as before,” “competent care,” “individually adapted programme and support,” and “barrier-free accessibility.” CONCLUSION: Nursing home residents have different attitudes and needs regarding being physically active. It is important to perceive these attitudes and needs of each resident and to offer an individually adapted programme and support. Further research should consider motivational strategies for residents who are not very much familiar with being physically active and offer exercise programmes with individual parts to address residents’ preferences. RELEVANCE TO CLINICAL PRACTICE: To motivate and activate residents, institutions should be aware of residents’ individual attitudes and needs regarding physical activity. Further development of interventions concerning mobility promotion activities and their implementation in long-term care settings should consider the outlined factors.

The pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate. The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation. Methods: This was a retrospective, cross-sectional multi-center study that occurred in five NHs in southern Wisconsin between January 2013 and September 2014. All NH residents with an antibiotic prescribing events for suspected lower respiratory tract infections (LRTI), skin and soft tissue infections (SSTI), and urinary tract infections (UTI), initiated in-facility, from an emergency department (ED), or an outpatient clinic were included in this sample. We assessed appropriateness of antibiotic prescribing using the Loeb criteria based on documentation available in the NH medical record or transfer documents. We compared appropriateness by setting and infection type using the Chi-square test and estimated associations of demographic and clinical variables with inappropriate antibiotic prescribing using logistic regression. Results: Among 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the ED. Inappropriate antibiotic prescribing for urinary tract infections differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 (95% CI: 1.64-5.44, P < .001) times increased odds of inappropriate use. Conclusions: Antibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings. Further research is needed to characterize antibiotic prescribing patterns for patients managed in these settings as this likely represents an important, yet under recognized, area of consideration in attempts to improve antibiotic stewardship in NHs.

The unprecedented increase in the number of older adults moving into aged care facilities has created a challenge for quality person-centered care service provision. This study examined the impact of written life-stories on knowledge and attitudes of care staff about the residents when compared to usual file notes. METHODS: A randomized controlled study was carried out with 40 staff working in an aged care residential facility. Staff were randomly assigned to a control condition, in which they read file notes (n = 21) or to an experimental condition, in which they read life stories (n = 19) about residents who they knew, and completed the Knowledge of Resident Scale (KRS) before and after their assigned reading. RESULTS: A main effect for time was found for eight of the ten questions on the KRS, suggesting that irrespective of whether a participant read life stories or file notes, there was a significantly positive impact on knowledge and attitudes toward residents. However, significantly greater improvement was shown for one item on the KRS in the experimental condition when compared to the control condition, indicating that historical knowledge of residents was greater when staff read life stories than when they read file notes, F (1,38) = 6.50, p = 0.02. CONCLUSION: These results provide preliminary evidence that knowledge and attitudes of care staff can increase about the residents for whom they care following reading file notes and life stories. The increase is similar, except in the area of historical information, where it is greater for the group who read life stories.

The number of older people with unmet care and support needs is increasing substantially due to the challenges facing the formal and informal care system in the United Kingdom. Addressing these unmet needs is becoming one of the urgent public health priorities. In order to develop effective solutions to address some of these needs, it is important first to understand the care and support needs of older people. METHODS: A scoping review was conducted, using the Arksey and O’Malley original and enhanced framework, to understand the care and support needs of older people, focusing on those living at home with chronic conditions in the UK. The search was conducted using five electronic data bases, grey literature and reference list checks. The WHO International Classification of Functioning, Disability and Health (ICF) framework was used to analyse and categorise the literature findings. RESULTS: Forty studies were included in the final analysis- 32 from academic literature and 8 from grey literature. The review highlighted that older adults faced a range of physical, social and psychological challenges due to living with chronic conditions and required care and support in three main areas: 1) social activities and relationships; 2) psychological health; and 3) activities related to mobility, self-care and domestic life. The review also highlighted that many older people demonstrated a desire to cope with their illness and maintain independence, however, environmental factors interfered with these efforts including: 1) lack of professional advice on self-care strategies; 2) poor communication and coordination of services; and 3) lack of information on services such as care pathways. A gap in the knowledge was also identified about the care and support needs of two groups within the older population: 1) older workers; and 2) older carers. CONCLUSIONS: The review highlighted that older people living with chronic conditions have unmet care needs related to their physical and psychological health, social life, as well as the environment in which they live and interact. Findings of this review also emphasized the importance of developing care models and support services based around the needs of older people.

The transition of older patients (over 65 years of age) from hospital to their own home is a time when patients are at high risk. No measure currently exists to assess the experience, quality and safety of care transitions relevant to UK population. We aim to describe the development and initial testing of the Partners at Care Transitions Measure (PACT-M) as a patient-reported questionnaire for evaluation of the quality and safety of care transitions from hospital to home in older patients. METHODS: We used an established measure development procedure which includes conceptualising the components of care transitions, item development, conducting a modified Delphi process and pilot-testing of the PACT-M with patients over 65 years old using telephone administration. RESULTS: Pilot testing of the PACT-M suggests that the components identified cover the issues of most importance to patients. Face validity testing showed that the measure in its current form is acceptable to older patients. CONCLUSIONS: The measure developed in this study shows promise for use by those involved in planning, implementing and evaluating discharge care, and could be used to inform interventions to improve the transition from hospital to home for older patients.

To assess the diagnostic accuracy of commonly used signs and symptoms of low-intake dehydration in older care home residents. DESIGN: Prospective diagnostic accuracy study. SETTING: 56 care homes offering residential, nursing, and/or dementia care to older adults in Norfolk and Suffolk, United Kingdom. PARTICIPANTS: 188 consecutively recruited care home residents aged >/=65 years, without cardiac or renal failure and not receiving palliative care. Overall, 66% were female, the mean age was 85.7 years (standard deviation 7.8), and the median Mini-Mental State Examination MMSE score was 23 (interquartile range 18-26). INDEX TESTS: Over 2 hours, participants underwent double-blind assessment of 49 signs and symptoms of dehydration and measurement of serum osmolality from a venous blood sample. Signs and symptoms included skin turgor; mouth, skin, and axillary dryness; capillary refill; sunken eyes; blood pressure on resting and after standing; body temperature; pulse rate; and self-reported feelings of thirst and well-being. REFERENCE STANDARD: Serum osmolality, with current dehydration defined as >300 mOsm/kg, and impending dehydration >/=295 mOsm/kg. OUTCOME MEASURES: For dichotomous tests, we aimed for sensitivity and specificity >70%, and for continuous tests, an area under the curve in receiver operating characteristic plots of >0.7. RESULTS: Although 20% of residents had current low-intake dehydration and a further 28% impending dehydration, none of the commonly used clinical signs and symptoms usefully discriminated between participants with or without low-intake dehydration at either cut-off. CONCLUSIONS/IMPLICATIONS: This study consolidates evidence that commonly used signs and symptoms of dehydration lack even basic levels of diagnostic accuracy in older adults, implying that many who are dehydrated are not being identified, thus compromising their health and well-being. We suggest that these tests be withdrawn from practice and replaced with a 2-stage screening process that includes serum osmolarity, calculated from sodium, potassium, urea, and glucose levels (assessed routinely using the Khajuria and Krahn equation), followed by serum osmolality measurement for those identified as high risk (calculated serum osmolarity >295 mmol/L).

To explore the effectiveness of a new mental health promotion activities program by including the criterion variables of happiness and depressive mood. DESIGN: A double-blinded, clustered, randomized and controlled trial. METHOD: A list of older residents was provided by the senior social worker at a geriatric institution. The participant inclusion criteria were living on one of four different floors that had separate and noninterfering spaces and having comparable disabilities. The researchers randomly selected residents on two floors as members of the intervention group; the other residents were considered the control group. The intervention groups attended 6 weeks of the 3L-Mind-Training program, whereas the control group only engaged in regular health promotion activities. The mini version of the Chinese Happiness Inventory was adapted to measure happiness. The Geriatric Depression Scale short-form was used to measure depression in older people. The generalized estimating equation was used to analyze the short-term and durative effects. FINDINGS: The 126 residents ranged in age from 65-97 years old and 90% of the residents relied on wheelchairs. The intervention activities provided significant immediate and durative effects both on subjective well-being enhancement and depressive mood relief. When evaluating the overall intervention activity, 93.8% of the aged residents indicated that this program was helpful and allowed them to view life events positively. CONCLUSION AND IMPACT: A well-planned mind-training program could help older people reform their viewpoint and create a more fun and happy experience of ageing. TRIAL REGISTRATION: Data came from the project, initiated in 2014, which was funded by the Ministry of Science and Technology in Taiwan and was approved by the Institutional Review Board in Chung Shan Medical University (No. CS15009). The trial registration number of the study was No. ChiCTR1900021811.

While the need for palliative care in long-term care facilities is growing, it is unknown whether palliative care in this setting is sufficiently developed. AIM: To describe and compare in six European countries palliative care provision in long-term care facilities and to assess associations between patient, facility and advance care planning factors and receipt and timing of palliative care. DESIGN: Cross-sectional after-death survey regarding care provided to long-term care residents in Belgium, England, Finland, Italy, the Netherlands and Poland. Generalized estimating equations were used for analyses. SETTING/PARTICIPANTS: Nurses or care assistants who are most involved in care for the resident. RESULTS: We included 1298 residents in 300 facilities, of whom a majority received palliative care in most countries (England: 72.6%-Belgium: 77.9%), except in Poland (14.0%) and Italy (32.1%). Palliative care typically started within 2 weeks before death and was often provided by the treating physician (England: 75%-the Netherlands: 98.8%). A palliative care specialist was frequently involved in Belgium and Poland (57.1% and 86.7%). Residents with cancer, dementia or a contact person in their record more often received palliative care, and it started earlier for residents with whom the nurse had spoken about treatments or the preferred course of care at the end of life. CONCLUSION: The late initiation of palliative care (especially when advance care planning is lacking) and palliative care for residents without cancer, dementia or closely involved relatives deserve attention in all countries. Diversity in palliative care organization might be related to different levels of its development.

Attention to culture and its impact on health care can improve the quality of care given, add to our understanding of health care among culturally diverse populations, and encourage a more holistic approach to health care within general care. Connection to culture is important to Aboriginal peoples, and integrating Aboriginal culture into general care in residential aged care facilities may contribute to improving care delivery and outcomes for residents. The literature to date revealed a lack of understanding of the capacity of residential aged care and the health practices of carers in relation to providing cultural care for Aboriginal people. This study aimed to explore how cultural care needs are maintained for Aboriginal residents from their own and their carers’ perspectives. METHODS: Applying an Aboriginal centered research method, an Interpretive Descriptive Approach was used as a theoretical framework to explore data in this study. Semi structured audio-recorded interviews were conducted. An additional file provides a complete description of the interview questions used as a guide for the study [see Additional file 1]. Three Residential Aged Care Centres, in South Australia were used i.e., two rural from centres and one urban metropolitan centre. Seven Aboriginal residents and 19 carers participated in interviews. Data was transcribed and an interpretive analysis was employed to code the transcribed data for themes and sub-themes. The study was guided by an Aboriginal community advisory group with an aim to work under the principle of reciprocity; giving back to the communities, participants and those where the research results may have been relevant. RESULTS: Three themes emerged from the views of the residents and carers: (i) lack of resources and funding; (ii) care practice; and (iii) marginalisation of Aboriginal culture within aged care facilities. CONCLUSION: The findings suggest that carers and residents believe cultural inclusion in general care practices may enrich Aboriginal residents’ daily life, health and well-being in residential aged care facilities. This study may provide carers, aged care centre managers and policy makers with information on the need of resources, funding, organised care plan and management, and cultural competency of carers to be considered to improve Aboriginal aged care protocols for integrating cultural care into practice.

Person-centred care is often described as an ideal way of preserving vulnerable persons’ wellbeing and dignity and an essential component of quality-care delivery. However, the staff find that making the care dignified is the most challenging issue, often because of effectivity, everyday stress and overload. In the interests of making the care more person-centred, systematic intervention involving ‘one-to-one contact’ (resident – carer) was trialled for 30 min twice a week over 12 months in two units in a nursing home in Eastern Norway. OBJECTIVES: The aim of the study was to elicit healthcare staff’s experiences of implementing ‘one-to-one contact’ between residents and carers in nursing homes. METHODS: The study has a grounded-theory inspired design. Two groups of health care staff were each interviewed three times. Data were collected over an 18-month period. ETHICAL CONSIDERATIONS: The study was approved by the Data Protection Official for Research under the auspices of the Norwegian Social Science Data Services. FINDINGS: The core category is ‘One-to-one contact’ at a nursing home is possible, but requires open-mindedness. The core category indicates that open-mindedness is required, since it does not take much for scepticism to take over and cause reversion to habitual practices. The category Expectant but Sceptical describes staff thoughts and experiences before the implementation phase got underway. The category Positive but Undecided describes staff experiences 6 months into the intervention and after 12 months. CONCLUSIONS: This study has revealed that systematic ‘one-to-one contact’ between resident and carer in nursing home is achievable, and that such a simple action might be an important step towards achieving more person-centred care as the resident is seen more as a person. However, in order to make a more person-centred and dignified approach to care constant attentiveness and awareness is required, as there were ongoing factors counteracting it.

Most people with Alzheimer disease and related dementias will experience agitated and/or aggressive behaviors during the later stages of the disease. These behaviors cause significant stress for people living with dementia and their caregivers, including nursing home (NH) staff. Addressing these behaviors without the use of chemical restraints is a growing focus of policy makers and professional organizations. Unfortunately, evidence for nonpharmacological strategies for addressing dementia-related behaviors is lacking. DESIGN: Six-month, preintervention-postintervention pilot study. SETTING: US NHs (n = 4). PARTICIPANTS: Residents with advanced dementia (n = 45). INTERVENTION: Music & Memory, an individualized music program in which the music a resident preferred when she/he was young is delivered at early signs of agitation, using a personal music player. MEASUREMENTS: Dementia-related behaviors for the same residents were measured three ways: (1) observationally using the Agitation Behavior Mapping Instrument (ABMI); (2) staff report using the Cohen-Mansfield Agitation Inventory (CMAI); and (3) administratively using the Minimum Data Set-Aggressive Behavior Scale (MDS-ABS). RESULTS: ABMI score was 4.1 (SD = 3.0) preintervention while not listening to the music, 4.4 (SD = 2.3) postintervention while not listening to the music, and 1.6 (SD = 1.5) postintervention while listening to music (P < .01). CMAI score was 61.2 (SD = 16.3) preintervention and 51.2 (SD = 16.1) postintervention (P < .01). MDS-ABS score was 0.8 (SD = 1.6) preintervention and 0.7 (SD = 1.4) postintervention (P = .59). CONCLUSION: Direct observations were most likely to capture behavioral responses, followed by staff interviews. Nursing-home based, pragmatic trials that rely solely on available administrative data may fail to detect effects of nonpharmaceutical interventions on behaviors. Findings are relevant to evaluations of nonpharmaceutical strategies for addressing behaviors in NHs, and will inform a large, National Institute on Aging-funded pragmatic trial beginning spring 2019.

The prevalence of pain in nursing home (NH) residents is high. Insufficiently treated pain reduces quality of life and often leads to negative health consequences. Pain experience in older people can be influenced by physical, psychosocial, emotional, and spiritual factors. AIMS: To inform development of NH pain management interventions, we studied residents’ pain related perceptions and needs. DESIGN: This was a qualitative descriptive substudy (embedded in ProQuaS, a larger pain project). SETTINGS: Three Swiss NHs. PARTICIPANTS/SUBJECTS: A purposeful sample of eight NH residents with severe pain and no severe cognitive impairment, based on information from the Minimum Data Set. METHODS: Eight semistructured interviews were conducted between October and December 2016. The audio-recorded interviews were transcribed verbatim and analyzed inductively using thematic analysis. RESULTS: Three central themes were identified from the interview data: dealing with major life changes, managing pain, and using formal care. The interviews highlighted the multidimensionality of pain experience in NH residents. In complex pain situations, participants perceived that care workers did not respond adequately to their needs. They had learned to cope with their pain using self-developed strategies and direct consultations with their physicians. CONCLUSIONS: The perceived lack of responsiveness may prompt NH residents to bypass care workers with their pain management concerns. This study’s findings will inform the development of an educational intervention for NH care workers.

Poor identification of sensory impairments in care homes can be due to multiple factors. This scoping review identifies and synthesizes the literature into the detection of hearing and vision loss in the care home environment, and the management of these sensory losses once identified. RESEARCH DESIGN AND METHODS: A scoping review methodology was used to identify primary research of any design published from 1985 to September 2018. Six electronic databases were searched, and articles were also sourced from reference lists, relevant charity organizations and published experts. RESULTS: Six electronic databases and multiple gray literature sources identified 51 articles for inclusion. The evidence confirmed that lack of knowledge in care home staff, poor management of assistive aids, unsuitable environment, lack of connections with optometrists and audiologists, underuse of effective screening tools, and the added complexity of assisting those with dementia are all barriers to effective practice. Conversely, flexible training programs, availability of a variety of assistive aids, simple screening tools, and adaptions to the environment are effective facilitators. DISCUSSION AND IMPLICATION: This review acknowledges that the barriers to identification and management of hearing and vision loss in care homes are multifaceted and that collaboration of multiple stakeholders is required to implement change and improve the residents’ ear and eye care. Recommendations are offered to support more effective service provision tailored to meet the needs of people with sensory impairments living in care homes, and this could subsequently improve best practice.

The global prevalence of dementia is growing rapidly, driving an increased use of residential long-term care (LTC) services. Performance indicators for residential LTC should support targeting of limited resources to promote person-centered care, health, and well-being for both patients and caregivers (formal and informal), yet many performance indicators remain focused on structure, process, or outcome measures that are only assumed to support personally relevant outcomes for those with dementia, without direct evidence of meaningfulness for these individuals. In this article, two complementary approaches to assessing quality in residential LTC serve as a lens for examining a series of tensions related to assessment in this setting. These include measurement-focused approaches using generic psychometrically valid instruments, often used to monitor quality of services, and meaning-focused approaches using individual subjective assessment of personally relevant outcomes, often used to monitor care planning. Examples from the European and U.S. literature suggest an opportunity to strengthen an emphasis on personally meaning-focused outcomes in quality assessment.

End-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents’ likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs. METHODS: Using the framework proposed by Arksey and O’Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study. RESULTS: Three mechanisms were identified: a) promotion of family carers’ understanding about their family member’s health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents’ preferences. CONCLUSION: Family carers’ understanding, shared decision-making, and knowledge of residents’ preferences contribute to palliative-oriented care in NHs. PRACTICE IMPLICATIONS: Discussions about end-of-life should take place early in a resident’s disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.

Concerns have been raised over the practice of transferring nursing home residents to hospital at their end of life. OBJECTIVE: To examine the family and facility factors that may influence the decision to transfer nursing home residents to hospital in the last month of life. RESEARCH DESIGN: Secondary data analysis includes a sample of 119 bereaved family members from 21 nursing homes located in Central Canada. METHOD: A binary logistic regression analysis was conducted to explore the predictors for hospital transfers. RESULTS: Terminal hospital transfers were common: 70% of nursing home residents were sent to hospitals in the last month of their life, and the likelihood of terminal hospital transfers increased by having an adult child as decision-maker (odds ratio (OR) = 5.03; 95% confidence interval (CI) = 1.6, 16; significance level/probability value (p) = 0.007) or having a lower family income (OR = 2.9; 95% CI =1.1, 2.9; p = 0.027). Discussion and implications: The identified predictors for terminal hospital transfers are helpful in targeting and developing interventions to improve end-of-life care. Particular emphasis should therefore be placed on targeting families with low income and children of the nursing home residents for educational initiatives such as advance care planning awareness, in order to prevent terminal hospital transfers. It is hoped that policy-makers and practitioners can start addressing the findings of this study to reduce terminal hospital transfers at end of life and promote quality end-of-life care in nursing homes.

To establish the perception of the older person as care recipients through the Cordial Older Family Nursing Model. METHOD: This study used a qualitative phenomenological approach and in-depth interviews. A total of 18 participants between 65 and 85 years old from the work area of the Community Health Center in Harjamukti, Depok. RESULTS: The finding of this study highlighted five focal themes: (1) the various types of complaints made by the older person, (2) their ability to conduct daily activities, (3) the family support provided to them, (4) the grandchildren and in-laws who are being treated like the older person’s own children, and (5) the expectations of old age among the older person. CONCLUSIONS: Family support for the older person is proven to be a dominant theme among the participants. The evidence indicates older people acknowledge the positive impacts of the Cordial Older Family Nursing Model.

The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams. METHODS: The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here. RESULTS: The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020. CONCLUSION: Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.

Depression is the second most common psychiatric illness in old people. Up to 30% of nursing home residents have minor or major depression. Although depressive disorders in old age can be improved and even cured with adequate therapy, they often go unnoticed in nursing home residents and remain untreated. This highlights a striking deficit in health care and might result not only in lower quality of life among those concerned but also in poor physical functioning, premature mortality, and increased hospitalization rates. METHODS: The aims of the interdisciplinary research project DAVOS are to implement an innovative and stepped structural case management program to improve depression treatment for nursing home residents by a modularized intervention and to assess it in terms of its effectiveness. Intervention modules are in line with recommendations given by the German national treatment guidelines for depression (S3 guidelines). Ten nursing homes in Frankfurt, Germany, will participate in the project, which aims to recruit a study population of 380. The recruitment will continue throughout the trial (open cohort). Persons (>60 years) who live in a nursing home, have no medical diagnosis of dementia, and can provide their informed consent to participate are eligible for inclusion in the study. Residents with a clinical diagnosis of dementia, alcohol or substance-related disorders, or other serious psychiatric illnesses will be excluded. DAVOS is a controlled cluster-randomized study that employs a stepped-wedge design. DISCUSSION: Our main hypothesis is that the implementation of the intervention will lead to a decline in the prevalence of depression and a reduction in depression symptoms among the home residents. In addition, we expect the intervention to have a positive impact on secondary outcomes such as level of functioning, quality of life, and social participation. The project’s results can make an important contribution toward improving the health care of nursing home residents who have late-life depression. TRIAL REGISTRATION: DRKS, DRKS00015686 , Oct. 10, 2018.

Physiotherapy can improve functional ability, prevent falls and reduce pain for older adults in nursing homes. However, there are no legislations or guidelines that specify the parameters of physiotherapy required in nursing homes. With the increasing healthcare demands of ageing populations worldwide, it is important to understand the current use of physiotherapy services to ensure they are both evidence-based and promote equity. OBJECTIVES: (1) When and how are physiotherapy services used by older adults living in nursing homes? (2) What are the factors associated with use of physiotherapy services in nursing homes? (3) How are physiotherapy services in nursing homes documented and monitored? METHODS: Several databases and grey literature (including MEDLINE, PubMed, Pedro and EMBASE) were searched following PRISMA guidelines in March 2018. Searches were limited to English language publications from 1997. Assessment for inclusion, data extraction and quality assessment were completed by two investigators independently using standardised forms. Studies were included if they considered any type of physiotherapy service that involved a qualified physiotherapist (such as exercise, massage and staff education) with older adults (aged 60 years and older) that were primarily permanent residents of a nursing home. Data extracted included proportion of clients that used physiotherapy services, type, frequency and duration of physiotherapy services, and factors associated with physiotherapy service use. RESULTS: Eleven studies were included. Between 10% and 67% of nursing home clients used physiotherapy services. Factors associated with greater use of physiotherapy services included larger size facilities, and if clients had a physical impairment and mild or no cognitive impairment. Types of physiotherapy services reported were pain management and pressure ulcer management. CONCLUSIONS: Physiotherapy service use in nursing homes varied widely. The development of physiotherapy benchmarks and quality standards are needed to support older adults in nursing homes. PROSPERO registration number: CRD42018082460.

There is limited evidence regarding how the decision evolves about whether and when it is best for a person with dementia to move to a care home. The factors leading to the timing of the decision remain particularly unclear. This systematic review of existing literature aims to gain an understanding of the decision-making timing and process to distinguish the drivers of these decisions, and to identify if there is an “optimal” or best time (if any) for a person with dementia to move to a care home. METHODS: Six English language electronic databases were searched up to the end of 2016, along with included papers’ reference lists. Papers were screened against the inclusion criteria and rated for quality. Extracted data were thematically analyzed. RESULTS: The review identified 16 relevant papers. Seven themes were identified: (1) what happened before the move; (2) planning for the move, (3) weighing up the decision, (4) lack of support, (5) drivers of the decision, (6) emotional significance of the move, and (7) continued reflection on the decision. “Time” of the move was largely absent from much of the literature, although inferences were made. Overall, the decision-making process appeared to be cyclic, with family carers constantly re-evaluating when might be the time to make the move with some continuing to reflect on this even subsequently. CONCLUSIONS: Further research is required to understand the “optimal” or best time (if any) for when a person with dementia moves to a care home, and how to determine when someone is ready to move.

Emotions may be pivotal to understanding how fragmented care systems for older adults can generate structural carer burden. Analysing 78 interviews with 32 carers who navigated formal services in a Western Canadian city, we explore and distinguish between emotional responses to navigation challenges and the emotion work that navigation entails. Emotional responses had a temporal dimension, and, at times, both positive and negative emotions coexisted simultaneously. Symbolic and normative understandings of interactions with providers, and of ‘caring well’, shaped emotion work throughout navigation. Discussion focuses on how broader contexts, through emotional processes, indirectly contribute to carer stress and strain.

Little population-level evidence exists to guide the development of interventions for people with dementia in non-nursing home settings. We hypothesized people living at home with moderately severe dementia would differ in social, functional, and medical characteristics from those in either residential care or nursing home settings. DESIGN: Retrospective cohort study using pooled data from the National Health and Aging Trends Study, an annual survey of a nationally representative sample of Medicare beneficiaries. SETTING: US national sample. PARTICIPANTS: Respondents newly meeting criteria for incident moderately severe dementia, defined as probable dementia with functional impairment: 728 older adults met our definition between 2012 and 2016. MEASUREMENTS: Social characteristics examined included age, sex, race/ethnicity, country of origin, income, educational attainment, partnership status, and household size. Functional characteristics included help with daily activities, falls, mobility device use, and limitation to home or bed. Medical characteristics included comorbid conditions, self-rated health, hospital stay, symptoms, and dementia behaviors. RESULTS: Extrapolated to the population, an estimated 3.3 million older adults developed incident moderately severe dementia between 2012 and 2016. Within this cohort, 64% received care at home, 19% in residential care, and 17% in a nursing facility. social, functional, and medical characteristics differed across care settings. Older adults living at home were 2 to 5 times more likely to be members of disadvantaged populations and had more medical needs: 71% reported bothersome pain compared with 60% in residential care or 59% in nursing homes. CONCLUSION: Over a 5-year period, 2.1 million people lived at home with incident moderately severe dementia. People living at home had a higher prevalence of demographic characteristics associated with systematic patterns of disadvantage, more social support, less functional impairment, worse health, and more symptoms compared with people living in residential care or nursing facilities. This novel study provides insight into setting-specific differences among people with dementia.

End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable. AIM: We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents. DESIGN: Systematic review (PROSPERO registration number CRD42017072276). DATA SOURCES: A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions. RESULTS: A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings. CONCLUSION: There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.

To examine the association of resident characteristics, staff mealtime assistance and environmental stimulation with the pace of food intake. Design: A secondary analysis of 36 baseline eating videos involving 19 nursing assistants and 15 residents with dementia in eight nursing homes from a communication intervention study. Methods: The outcome variable was the pace of food intake (the number of bites and drinks per minute). The exploratory variables were resident characteristics (age, gender, dementia stage and eating performance), staff mealtime assistance (frequency of verbal, visual, partial and full physical assistance) and environmental stimulation. Multi-level models were used to examine the association. Results: A faster pace of food intake is associated with being male, better eating performance, staff provision of visual and physical assistance and better quality of environmental stimulation that involved interaction. The pace of food intake was not associated with resident age, staff verbal assistance or partial physical assistance.

The objectives of the study are (1) to test our primary hypothesis that carers using more dysfunctional coping strategies predict lower quality of life in care home residents living with dementia, and this is moderated by levels of resident agitation, and (2) to explore relationships between carer dysfunctional coping strategy use, agitation, quality of life, and resident survival. METHODS: In the largest prospective cohort to date, we interviewed carers from 97 care home units (baseline, 4, 8, 12, 16 months) about quality of life (DEMQOL-Proxy) and agitation (Cohen-Mansfield Agitation Inventory) of 1483 residents living with dementia. At baseline, we interviewed 1566 carers about coping strategies (Brief COPE), averaging scores across care home units. RESULTS: Carer dysfunctional coping strategies did not predict resident quality of life over 16 months (0.03, 95% CI -0.40 to 0.46). Lower resident quality of life was longitudinally associated with worse Cohen-Mansfield Agitation Inventory score (-0.25, 95% CI -0.26 to -0.23). Survival was not associated with carer dysfunctional coping, resident quality of life, or agitation scores. CONCLUSIONS: Carer dysfunctional coping did not predict resident quality of life. Levels of resident agitation were consistently high and related to lower quality of life, over 16 months. Lack of association between carer dysfunctional coping and resident quality of life may reflect the influence of the care home or an insensitivity of aggregated coping strategy scores. The lack of relationship with survival indicates that agitation is not explained mainly by illness. Scalable interventions to reduce agitation in care home residents living with dementia are urgently needed.

This study tested the psychometric properties of the Quality of Life in Late-Stage Dementia (QUALID) Scale using Rasch analysis. The QUALID includes 11 items with a 5-point response scale. Scores range from 11 to 55, and lower scores indicate higher quality of life (QoL). METHODS: Baseline data from a randomized clinical trial including 137 residents from 14 nursing homes were used. Psychometric testing included item mapping, evaluation of response categories, item reliability, construct validity based on INFIT and OUTFIT statistics, and convergent validity based on correlations between QoL and pain, agitation, depression, and function. RESULTS: The Cronbach alpha was .89. All the items except “appears physically uncomfortable” fit the model. There was a significant relationship between QoL and depressive symptoms ( r = .71, P = .001), pain ( r = .26, P = .01), physical function ( r = -.19, P = .03), and agitation ( r = .56, P = .001). The categories were appropriately used. Item mapping suggested a need for easier items.

There are 850,000 people living with dementia in the UK. This is expected to rise to one million by 2025 and continue to increase to two million by 2051. Dementia costs the UK economy £26.3 billion a year and is a significant challenge for the NHS with an estimated 25% of acute beds occupied by people with dementia.
This report presents the Round 4 results of the National Audit of Dementia. The care and support of people with dementia remains a key priority in England and Wales. It is one of the 10 priorities identified by NHS England in the ‘Five Year Forward View’ and the Welsh Government’s Dementia Action Plan 2018-222 emphasises the importance of providing high quality dignified care for people with dementia.
Scores from each hospital are derived from key themes and are shown in comparison to the scores from Round 3. There are several areas where improvement has been made: 96% of hospitals in England and Wales now have a system in place for more flexible family visiting; a large number (88%) of carers (and/or patients) receive a copy of the discharge plan; and more staff report being able to access finger food or snacks for patients with dementia.
Key areas for improvement include striving to ensure that more hospitals assess for delirium and that any member of staff involved in the care of people with dementia must have training relevant to their grade and include identification and management of delirium. This training should be recorded to provide assurance to the public and regulators.

Join us as we learn from real case scenarios and challenges to learn how to support the LGBTQI2S+ community in LTC. You will also learn how to communicate that you are an LGBTQI2S+ friendly and inclusive home.

This is the second webinar in a series of two, focusing on the LGBTQI2S+ community living in long-term care homes. Watch the first webinar!

Our learning objectives are to help you:
• Learn strategies to build culturally-competent staff and volunteer teams.
• Gain a deeper understanding of how to create a culture in your LTC home that feels welcoming and safe to LGBTQ residents.
• Explore opportunities to communicate effectively to residents, families, and the public that you are an LGBTQI2S-friendly and inclusive home

The Practicing Knowledge Translation (PKT) course, is a professional development course on how to apply KT science to real-world implementation projects to enhance and sustain project outcomes. The course focuses on empowering individuals and organizations in the health system with the knowledge, skills, and support to effectively do KT by learning how to:
Develop an Evidence-informed, Theory-driven Program (ETP)
Map barriers & facilitators to change using theories and frameworks
Systematically select and operationalize implementation strategies
Plan for implementation, evaluation and sustainability

This professional development certificate builds capacity to effectively share and implement knowledge and support the development of evidence-based policy and practice. The course “Inform”, held from September 16 to November 10, is the first of three online courses for this certificate.

This tool is designed to provide guidance and supporting material to reviewers on methods for the conduct and reporting of knowledge synthesis.

Understanding Your Care Team has been co-developed with caregivers to help caregivers and patients understand the various types of providers that may be on their care team and their respective roles. Using plain language, each role is defined. This list was developed by the Improving CARE Together project team.

The mentoring scheme will connect people who are planning or running a KT project or activity within Cochrane (mentees) with people who have experience and knowledge of delivering KT activities or projects (mentors). Mentors will support their mentee in building their KT skills and expertise, and guide them in their activity or delivering their project.

The Canadian Journal on Aging/La Revue canadienne du vieillissement is seeking nominations or applications to fill several positions on the Editorial Board. These include: Editor-in-Chief, Associate Editor-in-Chief, Social Policy and Practice Section Editor, Health Sciences and Biological Sciences Section Editor, Social Sciences Section Editor, and Book Review Editor.