February 9, 2021


Any LTC Stakeholder, Anywhere in the World – WHO survey on COVID-19 and Ethical Issues
ASKLTC: An invitation to complete and share a time-limited, WHO-sponsored Survey of Ethics-Related Issues During the COVID-19 Pandemic

The Ethics Quality Improvement Lab team at William Osler Health System (Ontario, Canada) recently won the World Health Organization Health Ethics and Governance Unit and PHEPREN (the Public Health Emergency Preparedness and Response Ethics Network) bid for projects addressing ethical aspects of public health preparedness and response to COVID-19. This project investigates ethical issues faced in long term care settings in low, middle, and high income countries.

The Ethics Quality Improvement Lab hopes to discover what ethical issues long term care residents, their families, the staff, physicians, and other stakeholders have faced during the COVID-19 pandemic so that they can help better inform the WHO’s future guidance in public health emergencies.

This survey offers the opportunity to ask which ethical issues are identified by stakeholders across the globe so that relevant similarities and differences can be identified. These learnings can also help to inform future ethical guidance in various communities.

Please complete, share, and distribute this survey widely.

The Lancet reports on LTC and COVID in Canada
COVID-19 highlights Canada’s care home crisis

COVID-19 deaths in long-term care have been called a national disgrace, and experts are calling for the army to intervene. Paul Webster reports from Toronto.
When Canada’s national health data agency reported in June, 2020, that Canada had the worst record among wealthy nations for COVID-19-related deaths in long-term care facilities for older people, many observers referred to it as a “national disgrace”. At that time, as the first wave of COVID-19 in Canada began to subside, its 2039 homes for older people accounted for about 80% of all COVID-19-related deaths. 6 months later, as the second wave of COVID-19 sweeps the country, little has changed, and Canada’s long-term facilities remain dangerously prone to the disease.

Globe and Mail commentary on burnout levels among Canadian LTC staff by Carole Estabrooks and Yuting Song
Canada’s nursing home workers are nearing catastrophic levels of burnout

It’s been almost a year since nursing home workers began fighting on the front lines of COVID-19 – a year of extreme trauma.

Canadian resource on supporting LTC staff
Mental Health Supports for LTC Team Members

Ontario CLRI
This has a large number of resources including links to emergency help, Cognitive Behavioral Tools, and online tools to build resilience and coping skills.

New TREC articles
The Action Project Method Applied in Nursing Home Settings
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Charlotte Jensen, Andrea Gruneir, Matthias Hoben, et al.
Innovation in Aging 2020 12/16;4:184-185
The action-project method (APM), developed in counselling psychology and used in various disciplines, has been shown to be useful for understanding major life transitions in different contexts. We argue that the APM is beneficial for studying the impact of nursing home (NH) home admission and daily life of residents and their families/friends. The APM enables researchers to explore how residents and their families/friends experience NH-life at individual and supraindividual levels of analysis. We applied the APM to solicit the views of residents and individuals close to them to understand their priorities for quality care. The APM data collection consisted of three stages. First, a resident and family member or other caregiver met with the interviewer who initiated a conversation about their experience in the NH. The interviewer then left the room but video-recorded the conversation. Second, the interviewer met with each participant to review the video with each participant offering reflection on the original conversation. These sessions were also recorded. Following transcription and analysis of the conversations, 3 lay-language narratives were created: 1 for each individual and 1 for the pair. Third, participants reviewed their own and the pair’s narrative for additional comments. The APM offers a means to give a voice to NH residents and allows for people to talk about their experiences without the presence of a researcher. By using the APM, researchers can break down individual actions of participants and how these actions come together to form the project of navigating care in NHs.

Developing an RAI-MDS Behavior-Based Pain Scale for Long-Term Care Residents With Advanced Dementia
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Jennifer Knopp-Sihota, Matthias Hoben, Jeff Poss and Carole Estabrooks.
Innovation in Aging 2020 12/16;4:203-204
In Canadian and many international long-term care (LTC) facilities, pain assessment frequently relies on data from the Resident Assessment Instrument – Minimum Data Set 2.0 (RAI-MDS). The RAI-MDS produces a two-item scale, measuring both pain frequency and pain intensity. This scale correlates well with self-reported pain in cognitively intact LTC residents, but despite repeated testing, is less valid for use in residents with more advanced cognitive impairment who are unable to self-report their pain. In this study we aimed to develop and validate a behaviour-based pain assessment scale for long-term care residents using data available in the RAI-MDS. To construct our initial scale, we reviewed the literature and compiled a list of observable indicators of pain (e.g., grimacing) and linked these with 28 similar items available in the RAI-MDS. Using Delphi techniques, we further refined this to 20 items. We then evaluated the psychometric properties of our scale using two independent, representative samples, of urban LTC residents in Western Canada. Exploratory factor analyses were conducted in sample one (n=16,282) and confirmatory factor analyses (CFA) were then conducted in sample two (n=15,785) in order to test, and confirm, our model. A two-factor solution was identified grouping RAI-MDS items into subscales 1) change in status (e.g., new onset restlessness) and 2) behaviours (e.g., crying). Commonly recognized model fit indices were acceptable suggesting the adequacy of the two-factor solution. Results provide preliminary support for the use of behavioural-based pain assessment scale using RAI-MDS data. Further evaluation and validation of our scale is warranted.

New article by Whitney Berta
The Impact of the Long-term Care Homes Act and Public Reporting on Physical Restraint and Potentially Inappropriate Antipsychotic Use in Ontario’s Long-term Care Homes
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K. Walker, S. Shearkhani, Y. Q. Bai, K. S. McGilton, W. B. Berta and W. P. Wodchis.
J Gerontol A Biol Sci Med Sci 2020 Mar 9;75(4):813-819
BACKGROUND: 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.

New article by Janice Keefe
Long-Term Residential Care Policy Guidance for Staff to Support Resident Quality of Life
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M. J. Hande, J. Keefe and D. Taylor.
Gerontologist 2021 Jan 8
BACKGROUND AND OBJECTIVES: Amidst a complex policy landscape, long-term residential care (LTRC) staff must navigate directives to provide safe care while also considering resident-preferred quality of life (QoL) supports, which are sometimes at odds with policy expectations. These tensions are often examined using a deficit-based approach to policy analysis, which highlights policy gaps or demonstrates how what is written creates problems in practice. RESEARCH DESIGN AND METHODS: This study used an asset-based approach by scanning existing LTRC regulations in 4 Canadian jurisdictions for promising staff-related policy guidance for enhancing resident QoL. A modified objective hermeneutics method was used to determine how 63 existing policy documents might be interpreted to support Kane’s 11 QoL domains. RESULTS: Analysis revealed regulations that covered all 11 resident QoL domains, albeit with an overemphasis on safety, security, and order. Texts that mentioned other QoL domains often outlined passive or vague roles for staff. However, policy texts were found in all 4 jurisdictions that provided clear language to support staff discretion and flexibility to navigate regulatory tensions and enhance resident QoL. DISCUSSION AND IMPLICATIONS: The existing policy landscape includes promising staff-related LTRC regulation in every jurisdiction under investigation. Newer policies tend to reflect more interpretive approaches to staff flexibility and broader QoL concepts. If interpreted through a resident QoL lens and with the right structural supports, these promising texts offer important counters to the rigidity of LTRC policy landscape and can be leveraged to broaden and enhance QoL effectively for residents in LTRC.

New article by Gillian Harvey and Alison Kitson
Academic Health Science Centres as Vehicles for Knowledge Mobilisation in Australia? A Qualitative Study.

Alexandra Edelman, Robyn Clay-Williams, Michael Fischer, et al.
International Journal of Health Policy and Management 2020:-
Background Despite increasing investments in academic health science centres (AHSCs) in Australia and an expectation that they will serve as vehicles for knowledge translation and exchange, there is limited empirical evidence on whether and how they deliver impact. The aim of this study was to examine and compare the early development of four Australian AHSCs to explore how they are enacting their impact-focused role. Methods A descriptive qualitative methodology was employed across four AHSCs located in diverse health system settings in urban and regional locations across Australia. Data were collected via semi-structured interviews with 15 academic, industry and executive board members of participating AHSCs. The analysis combined inductive and deductive elements, with inductive categories mapped to deductive themes corresponding to the study aims. Results AHSCs in Australia are in an emergent state of development and are following different pathways. Whilst varied approaches to support research translation are apparent, there is a dominant focus on structure and governance, as opposed to action-oriented roles and processes to deliver strategic goals. Balancing collaboration and competition between partners presents a challenge, as does identifying appropriate ways to evaluate impact. Conclusion The early stage of development of AHSCs in Australia presents an important opportunity for formative learning and evaluation to optimise their enactment of knowledge mobilisation processes for impact.

New articles by Shannon Scott
Understanding Determinants of Sustainability Through a Realist Investigation of a Large-Scale Quality Improvement Initiative (Lean): A Refined Program Theory.
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R. Flynn and S. D. Scott.
J Nurs Scholarsh 2020 Jan;52(1):65-74
Implementation science research seeks to understand ways to best ensure uptake of research-based initiatives to health care; however, there is little research done on how to sustain such efforts. Sustainability is the degree to which an initiative continues to be used in practice after efforts of implementation have ended. Sustainability research is a growing field of implementation science that needs further research to understand how to predict and measure the long-term use of effective initiatives to improve health care. The question of what influences the sustainability of research-based initiatives to improve health care remains unknown. PURPOSE: The purpose of this article was to present a refined program theory on the contextual factors and mechanisms that influence the sustainability of one large-scale quality management initiative (Lean) in pediatric health care. DESIGN: We conducted a multiphase realist investigation to explain under what contexts, for whom, how, and why Lean efforts are sustained or not sustained in pediatric health care through the generation of an explanatory program theory. METHODS: This article presents the theoretical triangulation of our multiphase realist investigation, resulting in a refined program theory. We integrated the initial program theories (IPTs) from each research phase to form a refined program theory. It involved going back and forth from the initial IPT to the findings from each phase and our middle-range theories and examining the most substantiated IPTs on the contextual factors and mechanisms that influenced the sustainability of Lean efforts. FINDINGS: The refined program theory depicts the complex nature to sustaining Lean efforts and that sustainability as a small, often unrepresentative portion of something much larger or more complex that cannot yet be seen or understood. The approach and nature of implementation is critical to shaping contexts for sustainability. Outcomes from implementation become facilitating or hindering contexts for sustainability. Customization to context is an important contextual factor for sustainability. Sense making, value congruency, and staff engagement are critical aspects from early implementation that enable or hinder processes of sustainment. Such mechanisms can trigger staff empowerment that can lead to a greater likelihood of sustainability. CONCLUSIONS: These findings have important implications for sustainability research, in understanding the determinants of sustainability of research-based initiatives in health care. CLINICAL RELEVANCE: It is important to understand and explain determinants of sustainability through theory-driven evaluative research in order to assist key stakeholders in sustaining the effective research-based initiatives made to improve healthcare services, patient care, and outcomes.

Cultural Adaptation of Digital Knowledge Translation Tools for Acute Otitis Media in Low- to Middle-Income Countries: Mixed Methods Usability Study
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S. Meherali, L. Hartling and S. D. Scott.
JMIR Form Res 2021 Jan 20;5(1):e13908
BACKGROUND: Acute otitis media (AOM) is the most common pediatric bacterial ear infection. AOM presents challenges to parents who lack accurate information. Digital knowledge translation tools offer a promising approach to communicating complex health information. We developed AOM knowledge translation tools for Canadian parents and augmented them for Pakistani parent end users. OBJECTIVE: This pilot study aimed to (1) develop AOM knowledge translation tools for Canadian parents, (2) adapt the knowledge translation tools across cultural contexts, and (3) evaluate the usability of the adapted knowledge translation tools. METHODS: Parents’ perceptions of the translated knowledge translation tools’ usability were explored using a mixed-methods design. We recruited parent participants from a hospital in Pakistan to complete usability surveys (n=47) and focus group interviews (n=21). Descriptive statistics and content analysis were used to analyze data. RESULTS: Usability results showed the usefulness and effectiveness of both adapted knowledge translation tools. Parents reported preferring a digital media narrative format in their own language. Findings revealed that culturally adapted knowledge translation tools are effective in transferring health information to parents. CONCLUSIONS: Digital knowledge translation tools offer a promising approach to improving health literacy and communicating complex health information to parents of children with AOM. Culturally adapting the tools generated important knowledge that will contribute to knowledge translation advancements. Evaluation of the tool effectiveness is a critical next step to exploring the impact of knowledge translation tools on child health outcomes.

New article by Susan Slaughter
Making the Most of Mealtimes (M3): Association Between Relationship-Centered Care Practices, and Number of Staff and Residents at Mealtimes in Canadian Long-Term Care Homes
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V. Trinca, H. Chaudhury, S. E. Slaughter, C. Lengyel, N. Carrier and H. Keller.
J Am Med Dir Assoc 2020 Dec 16
OBJECTIVES: To determine if (1) number of staff or residents, when considering home-level factors and presence of family/volunteers, are associated with relationship-centered care practices at mealtimes in general and dementia care units in long-term care (LTC); and (2) the association between number of staff and relationship-centered care is moderated by number of residents and family/volunteers, profit status or chain affiliation. DESIGN: Secondary analysis of the Making the Most of Mealtimes (M3) cross-sectional multisite study. SETTING AND PARTICIPANTS: Thirty-two Canadian LTC homes (Alberta, Manitoba, Ontario, and New Brunswick) and 639 residents were recruited. Eighty-two units were included, with 58 being general and 24 being dementia care units. METHODS: Trained research coordinators completed the Mealtime Scan (MTS) for LTC at 4 to 6 mealtimes in each unit to determine number of staff, residents, and family or volunteers present. Relationship-centered care was assessed using the Mealtime Relational Care Checklist. The director of care or food services manager completed a home survey describing home sector and chain affiliation. Multivariable analyses were stratified by type of unit. RESULTS: In general care units, the number of residents was negatively (P = .009), and number of staff positively (P < .001) associated with relationship-centered care (F(9,48) = 5.48, P < .001). For dementia care units, the associations were nonsignificant (F(5,18) = 2.74, P = .05). The association between staffing and relationship-centered care was not moderated by any variables in either general or dementia care units. CONCLUSION AND IMPLICATIONS: Number of staff in general care units may increase relationship-centered care at mealtimes in LTC. Number of residents or staff did not significantly affect relationship-centered care in dementia care units, suggesting that other factors such as additional training may better explain relationship-centered care in these units. Mandating minimum staffing and additional training at the federal level should be considered to ensure that staff have the capacity to deliver relationship-centered care at mealtimes, which is considered a best practice.

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