December 17, 2019

Multi-sectoral, interdisciplinary health research is increasingly recognizing integrated knowledge translation (iKT) as essential. It is characterized by diverse research partnerships, and iterative knowledge engagement, translation processes and democratized knowledge production. This paper reviews the methodological complexity and decision-making of a large iKT project called Seniors – Adding Life to Years (SALTY), designed to generate evidence to improve late life in long-term care (LTC) settings across Canada. We discuss our approach to iKT by reviewing iterative processes of team development and knowledge engagement within the LTC sector. We conclude with a brief discussion of the important opportunities, challenges, and implications these processes have for LTC research, and the sector more broadly.

The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC. METHODS: 11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers. RESULTS: Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management. CONCLUSIONS: Depressive symptoms are common in LTC residents -particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.

The International Learning Collaborative (ILC) is an organisation dedicated to understanding why fundamental care, the care required by all patients regardless of clinical condition, fails to be provided in healthcare systems globally. At its 11th annual meeting in 2019, nursing leaders from 11 countries, together with patient representatives, confirmed that patients’ fundamental care needs are still being ignored and nurses are still afraid to ‘speak up’ when these care failures occur. While the ILC’s efforts over the past decade have led to increased recognition of the importance of fundamental care, it is not enough. To generate practical, sustainable solutions, we need to substantially rethink fundamental care and its contribution to patient outcomes and experiences, staff well-being, safety and quality, and the economic viability of healthcare systems. KEY ARGUMENTS: We present five propositions for radically transforming fundamental care delivery:Value: fundamental care must be foundational to all caring activities, systems and institutionsTalk: fundamental care must be explicitly articulated in all caring activities, systems and institutions.Do: fundamental care must be explicitly actioned and evaluated in all caring activities, systems and institutions.Own: fundamental care must be owned by each individual who delivers care, works in a system that is responsible for care or works in an institution whose mission is to deliver care. RESEARCH: fundamental care must undergo systematic and high-quality investigations to generate the evidence needed to inform care practices and shape health systems and education curricula. CONCLUSION: For radical transformation within health systems globally, we must move beyond nursing and ensure all members of the healthcare team-educators, students, consumers, clinicians, leaders, researchers, policy-makers and politicians-value, talk, do, own and research fundamental care. It is only through coordinated, collaborative effort that we will, and must, achieve real change.

Older adults living in long-term care (LTC) are nutritionally vulnerable. The purpose of this study was to determine diet quality of Canadian LTC residents and its association with malnutrition and low calf circumference.

Nurses are increasingly expected to provide care for older persons; however, there are too few nurse educators with expertise in older person care to ensure students graduate with the requisite competencies. METHODS: An integrative review, using Whittemore and Knafl’s framework, was undertaken to identify and synthesise evidence about factors affecting nurse educators’ knowledge, skills or attitudes about older persons and their care. RESULTS: Forty-four articles met the inclusion criteria. All but three papers originated in the USA. Content analysis yielded three central themes: external-level factors, employer-level factors and individual-level factors. Findings demonstrated that external funding from philanthropic organisations and government agencies supported many of the national, regional and site-specific initiatives, which were, in many cases, underpinned by professional regulatory frameworks. Negative attitudes of administrators and reduced budgets of educational institutions impeded the availability of such initiatives. Negative attitudes of individual educators towards older person care and the specialty of gerontology constrained their pursuit of such learning, as did their lack of awareness of current gerontology resources. CONCLUSIONS: The lack of educators with gerontology knowledge, skills and requisite attitudes requires a focused effort from external and professional bodies, and from educational institutions to ensure the resources are available to enhance educator expertise in gerontology. Rigorous study addressing the factors influencing educators’ knowledge, skills or attitudes towards older persons and their care is required. IMPLICATIONS FOR PRACTICE: Addressing the lack of nurse educator expertise in gerontology could help to ensure new nurses have the required competencies to provide quality older person care.

In 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation. Research has been conducted on the implementation processes of this system-wide Lean implementation. However, no research has been done on the sustainability of these Lean efforts. We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare. METHODS: We employed a case study research design. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units ‘cases’ at one acute hospital. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching. RESULTS: We conducted thirty-two interviews across the four cases. Five CMOcs emerged from our realist interview data. These configurations illustrated a ‘ripple-effect’ from implementation outcomes to contexts for sustainability. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. Failure to trigger these mechanisms resulted in resistance. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor ‘sense-making’ and a lack of engagement for frontline staff. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Overall, there was variation between leadership and frontline staff’s perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability. CONCLUSIONS: This research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement.

Today, we announce plans for a stream of BMJ EBM content to revisit efforts to teach the skills of EBM and ask you to join us. A key aim is to discuss, debate and demonstrate effective teaching. Where necessary, we want to challenge current practice and consider the next paradigm shift in teaching and practice. And where possible, we want to challenge with evidence

The CIHR Institute of Aging Voluntary Sector Outreach Award is a knowledge translation award that recognizes and supports up to two exceptional groups working in non-profit and voluntary sector in their knowledge translation efforts in the area of aging.

The CIHR Institute of Aging is dedicated to fostering excellence and innovation in the area of aging research, and to catalyzing the application of research findings to policies, practices and programs that provide real-world benefit. The Institute aims to position Canada as a global leader in ensuring that initiatives designed to improve the health of older adults take advantage of timely research evidence.

Engaging those who influence, administer and/or who are active users (“knowledge users”) of health care systems, as co-producers of health research, can help to ensure that research products will better address real world needs. Our aim was to identify and review frameworks of knowledge user engagement in health research in a systematic manner, and to describe the concepts comprising these frameworks. METHODS: An international team sharing a common interest in knowledge user engagement in health research used a consensus-building process to: 1) agree upon criteria to identify articles, 2) screen articles to identify existing frameworks, 3) extract, analyze data, and 4) synthesize and report the concepts of knowledge user engagement described in health research frameworks. We utilized the Patient Centered Outcomes Research Institute Engagement in Health Research Literature Explorer (PCORI Explorer) as a source of articles related to engagement in health research. The search includes articles from May 1995 to December 2017. RESULTS: We identified 54 articles about frameworks for knowledge user engagement in health research and report on 15 concepts. The average number of concepts reported in the 54 articles is n = 7, and ranges from n = 1 to n = 13 concepts. The most commonly reported concepts are: knowledge user – prepare, support (n = 44), relational process (n = 39), research agenda (n = 38). The least commonly reported concepts are: methodology (n = 8), methods (n = 10) and analysis (n = 18). In a comparison of articles that report how research was done (n = 26) versus how research should be done (n = 28), articles about how research was done report concepts more often and have a higher average number of concepts (n = 8 of 15) in comparison to articles about how research should be done (n = 6 of 15). The exception is the concept “evaluate” and that is more often reported in articles that describe how research should be done. CONCLUSIONS: We propose that research teams 1) consider engagement with the 15 concepts as fluid, and 2) consider a form of partnered negotiation that takes place through all phases of research to identify and use concepts appropriate to their team needs. There is a need for further work to understand concepts for knowledge user engagement.

Adaptation of existing evidence-based interventions (EBIs) to improve their fit in new contexts is common. A critical first step in adaptation is to identify core functions (purposes) and forms (activities) of EBIs. Core functions should not be adapted as they are what account for the efficacy of EBIs. Despite their importance, core functions are rarely identified by EBI developers; methods for identifying them post hoc are lacking. We present a case study of theory-based methods for identifying core functions and forms post hoc. We developed these methods as the first step in a larger effort to adapt an existing EBI to improve the timeliness of referrals to hospice to a new patient population and care setting. Our methods were rooted in the Planned Adaptation Model (PAM). Through our case study, we developed six steps for identifying core functions and forms, as well as accompanying tools and methods. Our case study further operationalized PAM in several ways. Where PAM offered guiding tenets for identifying core functions and forms (review existing EBI materials, conduct primary data collection, and identify the theory of change), we produced specific tools (interview guides and codebooks) and methods (sampling approaches and analytic methods). Our case study extended PAM with the addition of two steps in the process of identifying core functions and forms: (a) identifying the usual care pathway, including barriers to the outcome of interest encountered in usual care, and (b) mapping EBI core functions onto an extant theory. Identifying core functions and forms is a critical first step in the adaptation process to ensure adaptations do not inadvertently compromise the efficacy or effectiveness of the EBI by compromising core functions. Our case study presents step-by-step methods that could be used by researchers or practitioners to identify core functions and forms post hoc.

Theories occupy different positions in the scientific circle of enquiry as they vary in scope, abstraction, and complexity. Mid-range theories play a crucial bridging role between raw empirical observations and all-encompassing grand-theoretical schemes. A shift of perspective from ‘theories’ as products to ‘theorising’ as a process can enable empirical researchers to capitalise on the two-way relationships between empirical data and different levels of theory and contribute to the advancement of knowledge. This can be facilitated by embracing theoretically informative (in addition to merely theoretically informed) research, developing mechanism-based explanations, and broadening the repertoire of grand-theoretical orientations.

Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention’s effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system. METHODS AND RESULTS: We used French et al.’s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions. CONCLUSIONS: Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions.

Professional practice models (PPMs) guide nursing practice, professional behaviors, and clinical leadership. Health care continues to evolve (e.g., through health system mergers), and nurses may need to adopt and understand new PPMs to confidently align their interventions and professional nursing practice accordingly. The purpose of this project was to create an educational module about a new PPM based on the model of relationship-based care (RBC), which was adopted following a health system merger. The module was presented to a sample of nursing staff and leaders, who subsequently evaluated how it changed their confidence in and understanding and application of RBC in their professional nursing practice. Quantitative data showed that the module was an effective method to increase nurses’ understanding of, and confidence in providing care utilizing, the RBC model. Qualitative data analysis generated themes (team building, need for self-care, being present, lack of time and resources, and resistance to or fear of change) about how implementation of RBC as the organization’s PPM would change professional nursing practice, and barriers related to its implementation.

Two of the most salient problems in nursing homes are the responsive behaviours and falls of older people living with Alzheimer’s disease and related disorders. Intelligent videomonitoring and mobile applications are potential technologies that may help prevent and manage these problems. However, evidence for the needs for technologies in nursing homes is scarce. This study aimed to explore the perceptions and needs of care managers, and of formal and family caregivers in nursing homes regarding these potential technologies. With an exploratory qualitative design based on Rogers’ diffusion of innovation theory, individual interviews and a content analysis were conducted. Results show that the potential users of these technologies consider them relevant in nursing homes. The characteristics that would make these technologies useful in nursing homes are described. These results could be used to develop useful technologies to improve the quality of clinical practice in nursing homes.

Few investigations have examined dementia training programs for rehabilitation professionals. To address this, the Leveraging Existing Abilities in Dementia (LEAD) program was developed and examined with a pilot study. LEAD addressed dementia knowledge; the Strength-Based Approach; strategies for communication, recognizing behaviors, and learning techniques; and documentation. Participants completed pre-program, post-program, and three-month follow-up questionnaires assessing confidence, practice patterns, and dementia knowledge. Confidence and use of treatment strategies increased through the three-month follow-up and dementia knowledge significantly increased following training. LEAD positively impacted rehabilitation professionals’ knowledge, confidence, and use of evidence-based treatment strategies. Implications of LEAD and future research are discussed.

In long-term care facilities (LTCFs), nurses are key healthcare providers for older residents who have depressive symptoms or depression; therefore, they need accurate knowledge of late-life depression, positive attitudes towards depression, and confidence in providing depression care. This cluster-randomized trial was designed to examine the effectiveness of multiple, face-to-face, brief training sessions in improving nurses’ knowledge, attitudes, and confidence in providing late-life depression care in LTCFs. Nine LTCFs were included in the study. In total, 30 nurses from the four LTCFs assigned to the intervention group received three 30-min training sessions and 36 nurses in the five comparison group LTCFs did not. A self-report questionnaire was administered before and after the intervention. There were significant differences between groups concerning improvement in nurses’ knowledge of late-life depression, attitudes towards depression, and confidence in providing depression care. The effect size (Cohen’s d) was 1.55 for knowledge, 1.38 for attitudes, and 0.89 for confidence. This training program was effective in improving LTCF nurses’ knowledge, attitudes, and confidence in providing depression care. On the basis of these findings, we recommend that nurse managers and directors implement similar training programs for nurses in LTCFs to enhance the care quality for older residents.

Infection prevention and control (IPC) is a measure to prevent healthcare-associated infections in healthcare settings. There is limited evidence of the effectiveness of IPC programmes in long-term care facilities (LTCFs). AIM: To review and analyse the effectiveness and the components of IPC programmes in LTCFs for older adults. METHODS: Electronic databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched systematically for English-language articles assessing IPC interventions in LTCFs, published over the last decade (2007-2016). The components of IPC programmes were analysed based on the World Health Organization (WHO) manuals for improving IPC activities. Two reviewers independently assessed the quality of studies using the Cochrane risk-of-bias tool and the risk-of-bias assessment tool for non-randomized studies. FINDINGS: Seventeen studies met the eligibility criteria; 10 studies were randomized trials (58.8%) and the others were non-randomized trials to examine the impact of IPC programmes on infection and/or performance outcomes of healthcare workers. None of the included studies implemented all of the WHO core components. Behavioural change strategies using education, monitoring and feedback were reported to be successful interventions for reducing the threat of healthcare-associated infections. Generally, studies using four or more elements of the WHO multi-modal strategy reported significant reductions in infection rates. CONCLUSIONS: There is some evidence for the effectiveness of IPC interventions using education, monitoring, feedback and four or more elements of the WHO multi-modal strategy to control healthcare-associated infections in LTCFs.

This study assessed the feasibility of Be EPIC, a dementia-focused, person-centered communication intervention for personal support workers (PSWs). Be EPIC’s foci includes the environment, person-centered communication, client relationships, and clients’ abilities, social history and preferences.Methods: Feasibility was assessed using semi-structured interviews and focus groups with PSWs. We used a phenomenological approach to assess: acceptability, implementation, practicality, demand, and limited efficacy.Results: The theme supporting the criterion of acceptability was helpful/relevant training. Themes supporting implementation included realistic simulations, interactive training, and positive learning experience at the adult-day center. The theme supporting practicality was support to attend training. Demand for Be EPIC revealed two themes: participants’ personal motivation and barriers to applying newly learned knowledge and skills. The theme reflecting limited efficacy was applying newly learned knowledge and skills with home care clients. Four themes emerged that mapped onto Be EPIC’s foci.Conclusions: The findings support Be EPIC’s feasibility and highlight the need to address structural barriers from employers and government to ensure the delivery of person-centered dementia care.Clinical Implications: The findings highlight the need for and positive impact of person-centered communication training on home care workers, especially the value of learning by doing, reflective practice, and peer support.

Despite cumulative and integrative evidence of registered nurse (RN) staffing on nursing home residents’ outcomes worldwide, few studies integrate the effects of residents’ case mix, healthcare markets, and nurse staffing on psychotropic-medication use and weight loss in Korea. This article examined the relationship between nurse staffing and residents’ quality-of-care outcomes, controlling for long-term healthcare market characteristics in Korea. Using a multilevel cross-sectional design, a disproportionate stratified random sampling was used. Of 87 nursing homes contacted, 60 agreed to participate. Weighted linear regression was used to test the hypotheses. RN hours per resident day (HPRD) had a statistically significant positive impact on reducing the number of residents with psychotropic medication (ss=-.331, p=.008). Greater RN HPRD positively marginally related to fewer residents with cognitive impairment (ss=-0.201, p=.139). Higher turnover of RN staff related to decreased proportions of residents with weight loss (ss=-.331 p=.008). Policymakers should cautiously consider requiring mandatory nurse staffing in nursing homes in Korea, where it is still acceptable to have certified nurse aids as substitutes for RNs.

With the aging of the population, dying with dementia will become one of the most common ways in which older adults will end their final years of life, particularly for those living in a nursing home. Though individuals living with dementia have complex care needs and would benefit from a palliative approach to care, they have traditionally not been recipients of such care. An important aspect of determining quality in end-of-life care is the identification of expert practices, processes or behaviors that may help achieve this care. However, for those living with dementia in nursing homes, we have a limited understanding of how to best support expert end of life care. To redress this gap in knowledge, the purpose of this study was to examine and describe expert care of the individual with dementia approaching death from the perspective of nurses and health care aides (HCAs) identified by their peers as having special expertise in caring for this population. Methods: A qualitative research design known as Interpretative Description was used to conduct the study. Expert nurses and HCAs were identified through a two-phase nomination process. Individual semi-structured interviews were conducted with consenting participants. Data were analyzed using constant comparative analysis to determine the key critical behaviors. Results: Analysis of data collected from expert nurses (n = 8) and HCAs (n = 7) revealed six critical behaviors when caring for residents dying with dementia. All nurses and HCAs unanimously endorsed that the overarching goal of care is similar for all residents who are actively dying; to achieve comfort. The six critical behaviors in caring for residents dying with dementia included: 1) recognizing and responding to changes in a resident’s pattern of behavior; 2) attending to the person; 3) working with the family; 4) engaging with others; 5) responding after the death has occurred; and 6) having a positive attitude toward care of the dying. Conclusions: The critical behaviors described by nurses and HCAs in this study provides emerging evidence of best practices in care of those with dementia and their families, particularly near the end of life within the nursing home setting.

As dementia increases and the availability of at-home caregivers decreases, the need grows for effective training for direct care workers. Direct care workers have demanding schedules with restrictive availability and lack professional incentives to pursue specialized training. This study explored the impact of the Mason Music & Memory Initiative (M(3)I), a web-based, micro-learning training for direct care workers, combined with the implementation of the Music & Memory intervention. The training provided a foundational understanding of dementia and the person-centered music intervention. Twenty-five direct care workers, across two long-term care communities, completed the training modules over four weeks. All participants completed a pre- and posttest, determining their knowledge and understanding of dementia and the Music & Memory intervention adopted by their facilities. Many workers found the training to be informative and inspiring, noting improved behaviors in residents during the implementation of the M(3)I.

Traumatic injuries are increasingly affecting older patients who are prone to more complications and poorer recovery compared to younger patients. Practices of trauma health care providers therefore need to be adapted to meet the needs of geriatric trauma patients. OBJECTIVE: to assess the implementation of the American College of Surgeons best practice guidelines on geriatric trauma management across level I to III Canadian trauma centres. METHODS: 69 decision-makers working in Canadian trauma centres were approached to complete a web-based practice survey. Percentages and means were calculated to describe the level of best practice guideline implementation. RESULTS: 50 decision-makers completed the survey for a response rate of 72%. Specialised geriatric trauma resources were utilised in 37% of centres. Implementation of mechanisms to evaluate common geriatric issues (e.g. frailty, malnutrition and delirium) varied from 28 to 78% and protocols for the optimisation of geriatric care (e.g. Beers criteria to adjust medication, anticoagulant reversal and early mobilisation) from 8 to 56%. Guideline recommendations were more often implemented in level I and level II trauma centres. The adjustment of trauma team activation criteria to the geriatric population and transition of care protocols were more frequently used by level III centres. CONCLUSION: despite the growing number of older patients admitted in Canadian trauma centres annually, the implementation of best practice guidelines on geriatric trauma management is still limited. Prospective multicentre studies are required to develop and evaluate interdisciplinary knowledge translation initiatives that will promote the uptake of guidelines by trauma centres.

Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement. METHODS: A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed. RESULTS: All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87-197 vs. post 84-245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions. DISCUSSION: Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned. CONCLUSIONS: Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.

The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes. METHODS: PROVEN’s protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility’s adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status. RESULTS: In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation). CONCLUSIONS: Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers’ and organizational leaders’ ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.

The East Lancashire Clinic model is a consultancy-based approach to supporting care home staff to assess and respond to reactive behaviours of people with dementia and reduce the need to refer into secondary mental health services. The clinics are person centred and solution focused, aiming to promote recognition of unmet needs and early interventions implemented by staff. The pilot was able to resolve most cases and reduce referral rates into secondary care services. Through working collaboratively, it empowers staff to improve the care of all their residents, improves relationship with secondary care services and has potential to offer efficiency savings.

The demand for high-quality end-of-life care is rising. Frequently evidenced concerns about the provision of end-of-life in care homes relate to inter-disciplinary communication and engagement in advance care planning. A number of interventions employing different mechanisms have been designed to address these issues. Therefore, the aim of this systematic critical realist review was to describe and explain the effectiveness of interventions designed to improve end-of-life care in care homes. Electronic searches were conducted in ScienceDirect, MEDLINE, PubMed, PsychINFO, and CINAHL from January 2000 to August 2018. Forty one studies were included in the review. While most of the evidence identified in this review was not strong, there was evidence to suggest that education and inter-professional collaboration can be effective intervention mechanisms for improving end-of-life care in care homes. High staff turnover was a significant contextual mechanism impacting on the sustainability of interventions. In terms of human agency, it is important to note a consistent finding related to the dedication and enthusiasm of care home staff who deliver end-of-life care.

Assessing individual and organisational capacity for evidence use is essential for developing evidence-based strategies.Aims and objectives: This study aimed to assess the psychometric and practical properties of existing tools to assess the capacity to use evidence at the individual and organisational levels of health policy and identify the best instruments.Methods: A systematic review of the databases of ISI Web of Science, Embase, Scopus, and PubMed was conducted up to 6 June 2018. Search engines, websites of key organisations, and the reference lists of selected articles were also used to find relevant studies. The search strategy for each database was written individually. Psychometric properties were assessed using the Standards for Educational and Psychological Testing (SEPT) and pragmatic properties were assessed using the protocol proposed by Lewis et al (2018). Simple statistics were used to describe the psychometric and pragmatic properties of the identified instruments.Results: Overall, 16 instruments were identified. SEER had the highest validity score. Reliability was estimated for 38% of the instruments. Responsiveness was assessed in only 19% of the studies. The results showed that internal consistency was reported for 40% of the articles using statistical analysis. Pragmatic properties of the studied instruments were verified; 75% usefulness, 56% actionability, 50% sensitive to change and 56% user-friendly, 19% compatible, 38% feasibility.Discussion and conclusions: There are few instruments with strong psychometric evidence, and without high-quality instruments, it would be difficult to determine the factors that affect implementation. Therefore, special attention is needed for the systematic development of instruments and their reporting standards.

Integrated knowledge translation describes the process of partnered research between different stakeholders with the goal of producing research that ultimately achieves a greater impact when put into practice. A better understanding of research partnerships and integrated knowledge translation has implications for future partnerships and collaborative initiatives in practice. Our research describes and expands upon previous work done to identify barriers and attitudes toward collaboration in the context of research funding opportunities that required researcher-knowledge-user partnerships. METHODS: A survey was sent out to researchers funded by the Canadian Institutes of Health Research and knowledge-users who worked collaboratively on their research projects. There were two mirror versions of the survey, one for researchers and one for knowledge-users. Descriptive statistics, chi(2) analysis and Mann-Whitney U analysis were used to understand the processes, barriers, perceived impact and sustainability of the partnerships. RESULTS: The results revealed that, although there were differences in the roles of researchers and knowledge-users, both groups felt very positive towards their partnerships. Some of the barriers identified as inhibiting effective partnerships were resource constraints (funding/time) and differences in contribution and involvement amongst team members. Despite these barriers, both researchers and knowledge-users felt that the partnership was not only sustainable, but also helped create an impact. CONCLUSIONS: Our results provide useful information for funding agencies launching opportunities requiring or encouraging collaborative research projects between researchers and knowledge-users.

The published literature provides few insights regarding how to develop or consider the effects of knowledge co-production partnerships in the context of delivery system science. OBJECTIVE: To describe how a healthcare organisation-university-based research partnership was developed and used to design, develop and implement a practice-integrated decision support tool for patients with a physician recommendation for colorectal cancer screening. DESIGN: Instrumental case study. PARTICIPANTS: Data were ascertained from project documentation records and semistructured questionnaires sent to 16 healthcare organisation leaders and staff, research investigators and research staff members. RESULTS: Using a logic model framework, we organised the key inputs, processes and outcomes of a healthcare organisation-university-based research partnership. In addition to pragmatic researchers, partnership inputs included a healthcare organisation with a supportive practice environment and an executive-level project sponsor, a mid-level manager to serve as the organisational champion and continual access to organisational employees with relevant technical, policy and system/process knowledge. During programme design and implementation, partnership processes included using project team meetings, standing organisational meetings and one-on-one consultancies to provide platforms for shared learning and problem solving. Decision-making responsibility was shared between the healthcare organisation and research team. We discuss the short-term outcomes of the partnership, including how the partnership affected the current research team’s knowledge and health system initiatives. CONCLUSION: Using a logic model framework, we have described how a healthcare organisation-university-based research team partnership was developed. Others interested in developing, implementing and evaluating knowledge co-production partnerships in the context of delivery system science projects can use the experiences to consider ways to develop, implement and evaluate similar co-production partnerships.

Assess the effectiveness of psychoeducational interventions with respect to burden, anxiety and depression in family caregivers of people with dementia living at home. BACKGROUND: In Dementia, the family assumes the role of main caregiver, maintaining the patient in a good state of health. Nevertheless, burden, anxiety and depression may have negative repercussions in caregivers. Therefore, professional supports through psychoeducational programs are recommended as interventions for improving caregivers’ health. DESIGN: A quantitative Systematic review. DATA SOURCES: Electronic searches were performed in CINAHL/AMED/CENTRAL/Web of Science/LILACS/PUBMED from January 2005-August 2018. REVIEW METHODS: The review was conducted using the JADAD-Scale to assess bias risk and the quality of the Randomized-Controlled-Trials and the CONSORT-instrument to assess study quality report. The extracted data were reviewed by independent reviewer pairs. The review was reported using PRISMA. RESULTS: A total of eighteen Randomized-Controlled-Trials met inclusion criteria. Seven were classified as Technology-based-Interventions and eleven as Group-based-Interventions. CONCLUSION: Psychoeducational interventions for caregivers allow them to increase their knowledge of the illness, develop problem-solving-skills and facilitate social support. Technology-based-Interventions significantly affect burden while Group-based-Interventions affect anxiety, depression, insomnia and burden and quality of life and self-efficacy. IMPACT: Research findings can be use to classify caregivers in future interventions according to illness stage to obtained more precise results.

Reduced food intake is prevalent in people in residential and hospital care settings. Little is known about the use of finger foods (i.e. foods eaten without cutlery) with respect to increasing feeding independence and food intake. The Social Care Institute for Excellence (Malnutrition Task Force: State of the Nation, 2017) recommends the use of finger foods to enable mealtime independence and to prevent loss of dignity and embarrassment when eating in front of others. The aim of this review is to identify and evaluate the existing literature regarding the use and effectiveness of finger foods among adults in health and social care settings. METHODS: An integrative review methodology was used. A systematic search of electronic databases for published empirical research was undertaken in October 2018. Following screening of titles and abstracts, the full texts of publications, which investigated outcomes associated with the provision of finger foods in adult care settings, were retrieved and assessed for inclusion. Two independent investigators conducted data extraction and quality assessment using Critical Appraisal Skills Programme checklists. Thematic analysis was used to summarise the findings. RESULTS: Six studies met the inclusion criteria. Four themes were identified: Finger food menu implementation; Importance of a team approach; Effect on nutrition; and Influence on wellbeing. Study designs were poorly reported, with small sample sizes. CONCLUSIONS: There is some evidence that the provision of finger foods may positively affect patient outcomes in long-term care settings. There is a paucity of research evaluating the use of a finger food menu in acute care settings, including economic evaluation. Future high quality trials are required.

A simple and predictable method of evaluating eating and swallowing has not been yet established; thus, it is difficult to implement advance care planning according to deterioration in this function. This study aimed to clarify the association between a simple evaluation of eating and swallowing function and 1-year mortality in advanced dementia patients in nursing homes in Japan. METHODS: The study included 325 residents with advanced dementia. In a baseline survey, we examined medical history, physical function, and eating and swallowing function. We recorded mortality for 1year from baseline. Kaplan-Meier survival analysis and Cox proportional regression were performed to investigate the association between the simple evaluation of eating and swallowing function and mortality. RESULTS: Statistical analysis included data from 312 of the 325 residents who had completed the baseline survey (7 individuals with non-oral ingestion and 6 who were alive but did not reside in the nursing home 1year later were excluded). The participants’ mean age was 85.2 years, and 79.5 % of participants were female. At the 1-year follow-up, 70 patients had died. According to Cox proportional regression analysis, age, male gender, history of cerebrovascular disorder, poor results of palpation of masseter muscle tension, and modified water swallowing test were significantly associated with 1-year mortality. CONCLUSION: The results of palpation of masseter muscle tension and modified water swallowing test were associated with 1-year mortality. These routine observations can predict mortality, and may thus provide evidence of the opportunity to implement advance care planning.

Dementia-specific and proxy-completed preference-based measures have been proposed for use in intervention studies involving people living in residential care, in instances where generic, self-reported preference-based measures have been deemed inappropriate. OBJECTIVE: This study was conducted to investigate the construct validity, criterion validity, and responsiveness of DEMQOL-Proxy-U and of self- and proxy-completed EQ-5D-5L. METHODS: The analysis used a 3-wave, individual-level data set of 1004 people living with dementia in residential care that included self-completed EQ-5D-5L and formal-carer and informal-carer proxy-completed EQ-5D-5L and DEMQOL-Proxy-U utility values, in addition to other nonutility cognitive measures (Functional Assessment Staging [FAST], Clinical Dementia Rating [CDR], Cohen-Mansfield Agitation Inventory [CMAI]) and health-related quality of life (HRQOL) measures (nursing home version of the Quality of Life with Alzheimer’s disease scale [QOL-AD-NH], Quality of Life in Late-Stage Dementia [QUALID] scale). Construct validity, criterion validity, and responsiveness were assessed using correlation, Bland-Altman plots, and panel data regression models. RESULTS: Self-completed EQ-5D-5L failed to reflect clinically important differences and changes in FAST, CDR, and CMAI but did capture the resident’s own view of HRQOL (QOL-AD-NH). As dementia severity increased, collection of EQ-5D-5L-proxy and DEMQOL-Proxy-U data was more feasible than collection of self-completed EQ-5D-5L. These formal-carer and informal-carer proxy measures also better reflected changes in FAST, CDR, and CMAI but did not capture the resident’s own view of HRQOL (QOL-AD-NH), despite adequately capturing the proxy’s own view of the resident’s HRQOL (QUALID). This indicates discrepancies between a proxy’s view and resident’s view of the impact that tangible declines in health, cognition, or functional abilities have on HRQOL. The EQ-5D-5L-proxy and DEMQOL-Proxy-U were generally poor substitutes. Regardless of which proxy completed it, the EQ-5D-5L-proxy was typically more responsive than the DEMQOL-Proxy-U to changes in CDR, FAST, and CMAI, indicating that use of the DEMQOL-Proxy-U is not always justified. CONCLUSION: Disparities in the measurement properties of different utility measures mean that choices about how to measure utility in trials could affect economic evaluation outcomes and hence how resources are allocated for dementia care.

Poor oral health may complicate eating and deteriorate nutritional status. However, little is known about how the burden of oral symptoms (OS) is associated with the health-related quality of life (HRQoL) of vulnerable older people in institutional settings. This study explores how the burden of certain OS (chewing problems, swallowing difficulties, dry mouth) is associated with functioning, morbidity, nutritional status and eating habits. It also examines the association between the OS burden and HRQoL. DESIGN: A cross-sectional study in 2017. SETTING: All long-term care wards in Helsinki, Finland. PARTICIPANTS: 2401 older residents (74% females, mean age 83.9). MEASUREMENTS: Nurses assessed the residents and completed questionnaires on the participants’ demographics, functional status, diagnoses, OS and eating habits. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) and HRQoL with a 15-dimensional instrument (15D). RESULTS: Of the residents, 25.4% had one OS and 16.6% two or three OS. OS burden was associated linearly with poorer cognitive and physical functioning and a higher number of comorbidities, edentulousness without dentures, and less frequent teeth brushing/denture cleaning. OS burden was also associated with malnutrition, lower BMI and eating less during main meals. In the multivariate analyses adjusted for various confounding factors, a higher number of OS was associated with lower HRQoL. OS burden correlated with nearly all dimensions of HRQoL. CONCLUSION: Oral symptoms are associated with generic HRQoL. Therefore, OS should be regularly assessed and managed in daily care.

OBJECTIVES: (1) To develop an understanding of how social capital may be conceptualised within the context of end-of-life care and how it can influence outcomes for people with dementia and their families with specific reference to the context and mechanisms that explain observed outcomes. (2) To produce guidance for healthcare systems and researchers to better structure and design a public health approach to end-of-life care for people with dementia. DESIGN: A realist review. DATA SOURCES: MEDLINE, EMBASE, CINAHL and grey literature. ANALYSIS: We conceptualised social capital as a complex intervention and, in order to understand how change is generated, used realist evaluation methods to create different configurations of context, mechanism and outcomes. We conducted an iterative search focusing on social capital, social networks and end-of-life care in dementia. All study designs and outcomes were screened and analysed to elicit explanations for a range of outcomes identified. Explanations were consolidated into an overarching programme theory that drew on substantive theory from the social sciences and a public health approach to palliative care. RESULTS: We identified 118 articles from 16 countries ranging from 1992 to 2018. A total of 40 context-mechanism-outcome configurations help explain how social capital may influence end-of-life care for people with dementia. Such influence was identified within five key areas. These included: (1) socially orientating a person with dementia following diagnosis; (2) transitions in the physical environment of care; (3) how the caregiving experience is viewed by those directly involved with it; (4) transition of a person with dementia into the fourth age; (5) the decision making processes underpinning such processes. CONCLUSION: This review contributes to the dispassionate understanding of how complex systems such as community and social capital might be viewed as a tool to improve end-of-life care for people with dementia. PROSPERO REGISTRATION NUMBER: CRD42018084524.

The All-Party Parliamentary Group on Dementia (APPG) released a report in early Summer 2019 about adopting a “rights-based” approach to tackling dementia as a disability, with a view to understanding – and reducing – societal barriers which adversely affect people living with the condition, on six fronts: employment, social protection, social care, transport, housing, community life.

The number of people with dementia in the UK is expected to roughly double to 1.6 million by 2040 yet, according to a report by the Care Policy and Evaluation Centre (CPEC), the cost of social care is projected to triple from £15.7 billion to £45.4 billion over the same period.

The overall cost of dementia care in the UK (including that provided by the NHS, paid social care and unpaid care) is around £34.7 billion, and this might rise to £94.1 billion by 2040. It is unpaid carers in families that provide £13.9 billion per year of care for people living with dementia by current estimates, and this burden is projected to increase to £35.7 billion by 2040.

Reporting to the Manager, the Senior Lead is responsible for creating effective, physician-focused knowledge translation and implementation plans and tactics to support the strategic goals of the OMA.