July 20, 2021


New TREC article
To whom health care aides report: Effect on nursing home resident outcomes
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Aloisio LD, Varin MD, Hoben M, Baumbusch J, Estabrooks CA, Cummings GG, et al.
Int J Older People Nurs 2021 Jul 11:e12406.
INTRODUCTION: Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes. DESIGN AND METHODS: We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care. RESULTS: Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, β = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices. DISCUSSION AND IMPLICATIONS: Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs’ increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.

New article by Greta Cummings
Are biases related to attrition, missing data, and the use of intention to treat related to the magnitude of treatment effects in physical therapy trials? A meta-epidemiological study
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Armijo-Olivo S, da Costa BR, Ha C, Saltaji H, Cummings GG, Fuentes J.
Am J Phys Med Rehabil 2021 Jul 3.
The objective of this study is to determine the association between biases related to attrition, missing data, and the use of intention to treat (ITT) and changes in effect size estimates in Physical Therapy (PT) randomized trials. A meta-epidemiological study was conducted. A random sample of RCTs included in meta-analyses in the PT discipline were identified. Data extraction including assessments of the use of intention to treat principle, attrition related bias, and missing data was conducted independently by 2 reviewers. To determine the association between these methodological issues and effect sizes, a 2-level analysis was conducted using a meta-meta-analytic approach. 393 trials included in 43 meta-analyses, analyzing 44,622 patients contributed to this study. Trials which did not use the ITT principle (ES = -0.13; 95%CI -0.26; 0.01), or which were assessed as having inappropriate control of incomplete outcome data tended to underestimate the treatment effect when compared with trials with adequate use of ITT and control of incomplete outcome data (ES = -0.18; 95%CI -0.29; -0.08).Researchers and clinicians should pay attention to these methodological issues since they could provide inaccurate effect estimates. Authors and editors should make sure that intention to treat and missing data are properly reported in trial reports.

New Canadian systematic review on quality and staffing in LTC
The Relationship between Quality and Staffing in Long-Term Care: A Systematic Review of the Literature 2008-2020
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Clemens S, Wodchis W, McGilton K, McGrail K, McMahon M.
Int J Nurs Stud 2021 07/10:104036.
Background Higher staffing levels in long-term care have been associated with better outcomes for residents in several landmark studies. However previous systematic reviews found mixed results, calling into question the effectiveness of higher levels of staff. With persistent concerns about quality, rising resident acuity, and a growing demographic of seniors requiring more services, understanding the relationship between quality and long-term care staffing is a growing concern. Objectives This review considered the following question: What is the influence of nursing and personal care staffing levels (registered nurse, licensed practical nurse, and nursing assistant) and / or skill mix on long-term care residents, measured by quality of care indicators? Design Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guided the report of this systematic review. Data sources Published articles focused on quality and nursing and personal care staffing in long-term care in peer-reviewed databases (MEDLINE, CINAHL, and AGELINE) and several Cochrane databases to retrieve studies published between January 2008 and June 2020. Review methods A systematic review was conducted. 11,096 studies were identified, of which 34 were included in this review. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to evaluate study quality and risk of bias, and five quality measures were selected for in-depth analyses: pressure ulcers, hospitalizations, physical restraints, deficiencies and catherization. Results This review confirms previous review findings that evidence on the relationships between quality and long-term care staffing level and skill mix, remain mixed. Higher staffing levels and skill mix generally supported better rather than worse outcomes. Significant and consistent findings were more evident when staffing levels were further analyzed by indicator and staffing category. For example, registered nurses were consistently associated with significantly fewer pressure ulcers, hospitalizations, and urinary tract infections. Few studies examined the impact of total nursing and personal care hours compared to the impact of specific categories or classes of nursing staff on outcomes. Conclusions Evidence on the relationship between quality and long-term care staffing remains mixed, however some categories of nursing staff may be more effective at improving the quality of certain indicators. Study quality has improved minimally over the last decade. Although research continues to standardize units of measurement, and longitudinal and instrumental variable analyses are increasingly being used, very few studies controlled for endogeneity, conducted adequate risk-adjustment, and used resident-level data. Additional strides must still be made to improve the rigour of long-term care staffing research.

New article by Shannon Scott
Recommendations for Navigating the Experiences of Moral Distress: A Scoping Review
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Deschenes S, Tate K, Scott SD, Kunyk D.
Int J Nurs Stud 2021 07/10:104035.
Background : Moral distress is a complex ethical phenomenon that occurs when one is not able to act according to their moral judgement. Consequences of moral distress negatively impact nurses, patient care, and the healthcare system. There is limited evidence on specific approaches to prepare nurses to manage these ethical situations. Aim : The aim of this scoping review is to identify moral distress interventions for nurses who provide direct patient care, identify gaps in the current moral distress research, and determine areas of focus for future research on this topic. Methods : We employed the framework outlined by Levac, Colquhoun, and O’Brien and Arksey and O’Malley to conduct a scoping review. These steps included the: identification of the research question, identification of relevant studies, study selection, charting the data, collating, summarizing, and reporting the results. We appraised the quality of included studies using the Mixed Methods Appraisal Tool. Results : We identified 5206 articles from the selected databases. Once duplicates were removed, two independent reviewers each screened 4043 title and abstracts. We included 554 articles for full-text screening, with 10 studies included based on inclusion and exclusion criteria. Study designs included before-after studies (n=4), randomized control trials (n=3), concurrent mixed-methods studies (n=2), and one controlled before-after study. All studies were conducted in acute care settings. In four studies, interventions focused on informing nurses on moral distress. Two interventions focused on increasing the nurses’ reflexivity on their workplace experiences. One intervention included formal clinical mentoring and clinical ethics support through interprofessional rounds. Two studies utilized a multicomponent intervention. The overall moral distress scores significantly decreased after intervention implementation in three included studies. Three additional studies showed significant differences in specific survey item scores (e.g., “provision of less-than-optimal care” and “caring for patients they did not feel qualified to care for”), as compared to overall scores, after intervention implementation. In 70% of studies the amount of quality criteria met were 60% or higher according to the Mixed Methods Appraisal Tool. Conclusion : Our review is the first to synthesize intervention studies pertaining to moral distress among nurses. The findings of this review demonstrate that there is no clear pattern regarding which strategies consistently minimize the effects of moral distress among nurses. Future interventions should be tested more broadly by increasing the sample size, assessing length of intervention in relation to moral distress scores, expanding the interventions to other units and institutions, and including other healthcare professionals. Tweetable abstract We reviewed interventions to help nurses with moral distress. Findings show no clear pattern of strategies to minimize their moral distress

New articles by Janet Squires
The validity of skin conductance for assessing acute pain in mechanically ventilated infants: A cross-sectional observational study
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Hu J, Harrold J, Squires JE, Modanloo S, Harrison D.
Eur J Pain 2021 Jun 8.
BACKGROUND: Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants. METHODS: A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12 months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures. RESULTS: From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman’s rho = 0.4-0.62) and the four-item NFCS (Spearman’s rho = 0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve = 0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain. CONCLUSIONS: SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation. SIGNIFICANCE OF THE STUDY: Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.

Family-centred care in the Neonatal Intensive Care Unit: A concept analysis and literature review
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Larocque C, Peterson WE, Squires JE, Mason-Ward M, Mayhew K, Harrison D.
Journal of Neonatal Nursing 2021 07/01.
Purpose Family-centred care (FCC) in the Neonatal Intensive Care Unit (NICU) is an aspect of high-quality neonatal nursing. The aim of this manuscript is to clarify the meaning of FCC in the NICU to inform future research. Methods Rodger’s evolutionary concept analysis. Three databases were searched, each representing a different discipline: CINAHL, Medline, and PsycINFo. Results A total of 188 full-text papers were included. The concept of FCC in the NICU was defined according to its surrogate and related terms, antecedents, attributes, and consequences. Discussion Although interdisciplinary in nature, academic literature about FCC in the NICU is dominated by a biomedical perspective. Important conceptual departures, namely developmental care and family-integrated care are discussed. Conclusion Considering FCC as a model of care may be too reductionist; it should be regarded as a philosophy. Further work should explore the delivery of FCC for increasingly specialized NICU populations, such as perioperative infants.

New Canadian qualitative review on implementing evidence in LTC
Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis
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McArthur C, Bai Y, Hewston P, Giangregorio L, Straus S, Papaioannou A.
Implement Sci 2021 Jul 9;16(1):70-021-01140-0.
BACKGROUND: The long-term care setting poses unique challenges and opportunities for effective knowledge translation. The objectives of this review are to (1) synthesize barriers and facilitators to implementing evidence-based guidelines in long-term care, as defined as a home where residents require 24-h nursing care, and 50% of the population is over the age of 65 years; and (2) map barriers and facilitators to the Behaviour Change Wheel framework to inform theory-guided knowledge translation strategies. METHODS: Following the guidance of the Cochrane Qualitative and Implementation Methods Group Guidance Series and the ENTREQ reporting guidelines, we systematically reviewed the reported experiences of long-term care staff on implementing evidence-based guidelines into practice. MEDLINE Pubmed, EMBASE Ovid, and CINAHL were searched from the earliest date available until May 2021. Two independent reviewers selected primary studies for inclusion if they were conducted in long-term care and reported the perspective or experiences of long-term care staff with implementing an evidence-based practice guideline about health conditions. Appraisal of the included studies was conducted using the Critical Appraisal Skills Programme Checklist and confidence in the findings with the GRADE-CERQual approach. FINDINGS: After screening 2680 abstracts, we retrieved 115 full-text articles; 33 of these articles met the inclusion criteria. Barriers included time constraints and inadequate staffing, cost and lack of resources, and lack of teamwork and organizational support. Facilitators included leadership and champions, well-designed strategies, protocols, and resources, and adequate services, resources, and time. The most frequent Behaviour Change Wheel components were physical and social opportunity and psychological capability. We concluded moderate or high confidence in all but one of our review findings. CONCLUSIONS: Future knowledge translation strategies to implement guidelines in long-term care should target physical and social opportunity and psychological capability, and include interventions such as environmental restructuring, training, and education.

New article by Alison Kitson
Advancing Nursing Practice Through Fundamental Care Delivery
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Ryder M, Kitson AL, O’Brien TS, Timmins F.
J Nurs Manag 2021 Jul 1.
There is growing awareness that there needs to be a reorientation of the nursing profession towards the fundamentals of care (Feo et al., 2019). These fundamentals often receive a low priority in clinical practice settings (Feo et al., 2019), and gaps in fundamental care provision are being exposed in nursing care internationally (McSherry et al., 2018). The concern is significant worldwide, and for this reason, many initiatives are developing to tackle the issue. The International Learning Collaborative (ILC) (2021), a global social learning and lobbying network, is leading the way on this. This network is committed to improving the delivery of person-centred and safe fundamental care, promoting excellence of fundamental care through the integration of clinical practice, research and education, and share the best evidence of Fundamentals of Care (FoC) (International Learning Collaborate 2021, Kitson 2018).

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