August 25, 2014


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Abstracts

New article by Dr. Carole Estabrooks
The Relationship Among Evidence-Based Practice and Client Dyspnea, Pain, Falls, and Pressure Ulcer Outcomes in the Community Setting.
Non UofA Access
Doran D, Lefebre N, O’Brien-Pallas L, Estabrook CA, White P, Carryer J, et al.
Worldviews on evidence-based nursing 2014 Aug 5

There are gaps in knowledge about the extent to which home care nurses’ practice is based on best evidence and whether evidence-based practice impacts patient outcomes. AIM: The purpose of this study was to investigate the relationship between evidence-based practice and client pain, dyspnea, falls, and pressure ulcer outcomes in the home care setting. Evidence-based practice was defined as nursing interventions based on best practice guidelines. METHODS: The Nursing Role Effectiveness model was used to guide the selection of variables for investigation. Data were collected from administrative records on percent of visits made by Registered Nurses (RN), total number of nursing visits, and consistency of visits by principal nurse. Charts audits were used to collect data on nursing interventions and client outcomes. The sample consisted of 338 nurses from 13 home care offices and 939 de-identified client charts. Hierarchical generalized linear regression approaches were constructed to explore which variables explain variation in client outcomes. RESULTS: The study found documentation of nursing interventions based on best practice guidelines was positively associated with improvement in dyspnea, pain, falls, and pressure ulcer outcomes. Percent of visits made by an RN and consistency of visits by a principal nurse were not found to be associated with improved client outcomes, but the total number of nursing visits was. LINKING EVIDENCE TO ACTION: Implementation of best practice is associated with improved client outcomes in the home care setting. Future research needs to explore ways to more effectively foster the documentation of evidence-based practice interventions. © 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.

New article by Dr. Ali Hutchinson
Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review.
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Allen J, Hutchinson AM, Brown R, Livingston PM.
BMC health services research 2014 Aug 15;14(1):346

Provision of high quality transitional care is a challenge for health care providers in many western countries. This systematic review was conducted to (1) identify and synthesise research, using randomised control trial designs, on the quality of transitional care interventions compared with standard hospital discharge for older people with chronic illnesses, and (2) make recommendations for research and practice. METHODS: Eight databases were searched; CINAHL, Psychinfo, Medline, Proquest, Academic Search Complete, Masterfile Premier, SocIndex, Humanities and Social Sciences Collection, in addition to the Cochrane Collaboration, Joanna Briggs Institute and Google Scholar. Results were screened to identify peer reviewed journal articles reporting analysis of quality indicator outcomes in relation to a transitional care intervention involving discharge care in hospital and follow-up support in the home. Studies were limited to those published between January 1990 and May 2013. Study participants included people 60 years of age or older living in their own homes who were undergoing care transitions from hospital to home. Data relating to study characteristics and research findings were extracted from the included articles. Two reviewers independently assessed studies for risk of bias. RESULTS: Twelve articles met the inclusion criteria. Transitional care interventions reported in most studies reduced re-hospitalizations, with the exception of general practitioner and primary care nurse models. All 12 studies included outcome measures of re-hospitalization and length of stay indicating a quality focus on effectiveness, efficiency, and safety/risk. Patient satisfaction was assessed in six of the 12 studies and was mostly found to be high. Other outcomes reflecting person and family centred care were limited including those pertaining to the patient and carer experience, carer burden and support, and emotional support for older people and their carers. Limited outcome measures were reported reflecting timeliness, equity, efficiencies for community providers, and symptom management. CONCLUSIONS: Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care. Further research that involves the person and their family/caregiver in transitional care interventions is needed.

New article by Dr. Shannon Scott
The Development of a Classification Schema for Arts-Based Approaches to Knowledge Translation.
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Archibald MM, Caine V, Scott SD.
Worldviews on evidence-based nursing 2014 Aug 18

Arts-based approaches to knowledge translation are emerging as powerful interprofessional strategies with potential to facilitate evidence uptake, communication, knowledge, attitude, and behavior change across healthcare provider and consumer groups. These strategies are in the early stages of development. To date, no classification system for arts-based knowledge translation exists, which limits development and understandings of effectiveness in evidence syntheses. PURPOSE: We developed a classification schema of arts-based knowledge translation strategies based on two mechanisms by which these approaches function: (a) the degree of precision in key message delivery, and (b) the degree of end-user participation. We demonstrate how this classification is necessary to explore how context, time, and location shape arts-based knowledge translation strategies. DISCUSSION: Classifying arts-based knowledge translation strategies according to their core attributes extends understandings of the appropriateness of these approaches for various healthcare settings and provider groups. The classification schema developed may enhance understanding of how, where, and for whom arts-based knowledge translation approaches are effective, and enable theorizing of essential knowledge translation constructs, such as the influence of context, time, and location on utilization strategies. LINKING EVIDENCE TO ACTION: The classification schema developed may encourage systematic inquiry into the effectiveness of these approaches in diverse interprofessional contexts.

New article by Dr. Kim Fraser
Uncovering the Meaning of Home Care Using an Arts-Based and Qualitative Approach.
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Fraser K, Archibald M, Nissen C.
Canadian journal on aging 2014 Aug 11:1-13

The need for home care is increasing in Canada, yet little is known about the home care experience of clients and their families. Uncovering the meaning of the home care experience is an important step towards developing understanding and public awareness. We explored the experiences of home care using arts-based methods and individual interviews with 11 participants (one client and 10 family caregivers). Participants discussed the numerous ways formal home care and family caregiving affected their lives, how they coped with these effects, their experiences in hospitals or assisted living facilities, and aspects of the home care experience they liked or disliked. Participants agreed that home care facilitated a better quality of life for families and clients, although they acknowledged some challenges with it. The artistic outputs produced by participants facilitated interview dialogue and fostered understanding of key themes within the research team.

CALL FOR ABSTRACTS:
IHI National Forum on Quality Improvement in Health Care Scientific Symposium
8 December Orlando FL
DEADLINE 10 September

The Scientific Symposium is an all-day event that takes place in conjunction with the IHI National Forum on Monday, December 8, 2014, in Orlando, Florida, USA. Every year, the Scientific Symposium attracts the best work in the science of health and health care improvement. We aim to foster dialog and shared learning among participants. The day features keynote speakers, rapid-fire presentations of peer-reviewed papers, interactive methods sessions, and networking.

CALL FOR ABSTRACTS:
Margaret Scott Wright Research Day
7 November 2014 Edmonton AB
DEADLINE 30 September

Participate in Margaret Scott Wright Research and Innovation Day on Friday, November 7, 2014 to consider what Nursing Research 2.0 means, connect with others to spearhead change, and contribute to changing the future of nursing and its research.

Publications

KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice & Methodology
Aging

KT

Shortfalls in residents’ transfer documentation: Challenges for emergency department staff.
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Morphet J, Griffiths DL, Innes K, Crawford K, Crow S, Williams A.
Australasian emergency nursing journal : AENJ 2014 Aug;17(3):98-105

Increasing numbers of residents are transferred from aged care facilities to emergency departments. Frequently, residents arrive with inadequate documentation regarding their presenting complaint or medical history, making it difficult for emergency department staff to make decisions about care. METHODS: A retrospective review of emergency department records was undertaken for residents transferred from residential aged care facilities to two emergency departments in Melbourne, Victoria in 2012. RESULTS: 2880 resident transfers were included in the sample, of which 408 transfers were randomly selected for documentation review. Clinically important documentation was frequently absent including: the reason for transfer to the ED (n=197, 48.2%); baseline cognitive function (n=244, 59.7%); and vital signs at time of complaint (n=285, 69.9%). When the reason for transfer was absent, residents with an altered conscious state had more investigations and spent longer in the emergency department than when the reason for transfer was recorded. CONCLUSION: Inadequate documentation negatively impacted the resident’s journey through the emergency department. There is evidence that inadequate documentation contributes to poor patient outcomes. To minimise the gaps in the transfer documentation regular staff development and quality assurance programs may be required in residential aged care facilities. Copyright © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

An organizational intervention to influence evidence-informed decision making in home health nursing. Canada-flat-icon
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Gifford W, Lefebre N, Davies B.
The Journal of nursing administration 2014 Jul-Aug;44(7/8):395-402

The aims of this study were to field test and evaluate a series of organizational strategies to promote evidence-informed decision making (EIDM) by nurse managers and clinical leaders in home healthcare. BACKGROUND: EIDM is central to delivering high-quality and effective healthcare. Barriers exist and organizational strategies are needed to support EIDM. METHODS: Management and clinical leaders from 4 units participated in a 20-week organization-focused intervention. Preintervention (n = 32) and postintervention (n = 17) surveys and semistructured interviews (n = 15) were completed. RESULTS: Statistically significant increases were found on 4 of 31 survey items reflecting an increased organizational capacity for participants to acquire and apply research evidence in decision making. Support from designated facilitators with advanced skills in finding, appraising, and applying research was the highest rated intervention strategy. CONCLUSIONS: Results are useful to inform the development of organizational infrastructures to increase EIDM capacity in community-based healthcare organizations.

Keys to successfully embedding scientific research in nursing homes: a win-win perspective.
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Verbeek H, Zwakhalen SM, Schols JM, Hamers JP.
Journal of the American Medical Directors Association 2013 Dec;14(12):855-857.

This editorial sets out key issues to successful research in nursing homes, aiming to (1) address the right clinical and policy questions; (2) develop, evaluate, and implement evidence-based innovations; and (3) adequately educate nursing home staff and increase levels of expertise. We highlight the importance of an interdisciplinary and structural collaboration between academia and nursing homes so as to embed scientific research within nursing home practice, policy, and education. Structural interdisciplinary collaboration will help to equip nursing homes in delivering sustainable long term care for the future against the background of an increasing demand for care and scarcity of resources. We propose an Academic Collaborative Centre on Care for Older People as a model to achieve this.

Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial Canada-flat-icon
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Zwarenstein M, Shiller SK, Croxford R, Grimshaw JM, Kelsall D, Paterson JM, et al.
Implementation science 2014 Aug 6;9(1):87

Evidence of the effectiveness of printed educational messages in narrowing the gap between guideline recommendations and practice is contradictory. Failure to screen for retinopathy exposes primary care patients with diabetes to risk of eye complications. Screening is initiated by referral from family practitioners but adherence to guidelines is suboptimal. We aimed to evaluate the ability of printed educational messages aimed at family doctors to increase retinal screening of primary care patients with diabetes. METHODS: Design: Pragmatic 2×3 factorial cluster trial randomized by physician practice, involving 5,048 general practitioners (with 179,833 patients with diabetes).Setting: Ontario family practitioners.Interventions: Reminders (that retinal screening helps prevent diabetes-related vision loss and is covered by provincial health insurance for patients with diabetes) with prompts to encourage screening were mailed to each physician in conjunction with a widely-read professional newsletter. Alternative printed materials formats were an ‘outsert’ (short, directive message stapled to the outside of the newsletter), and/or a two-page, evidence-based article (‘insert’) and a pre-printed sticky note reminder for patients.Main outcome measure: A successful outcome was an eye examination (which includes retinal screening) provided to a patient with diabetes, not screened in the previous 12 months, within 90 days after visiting a family practitioner. Analysis accounted for clustering of doctors within practice groups. RESULTS: No intervention effect was detected (eye exam rates were 31.6% for patients of control physicians, 31.3% for the insert, 32.8% for the outsert, 32.3% for those who received both, and 31.2% for those who received both plus the patient reminder with the largest 95% confidence interval around any effect extending from -1.3% to 1.1%) CONCLUSIONS: This large trial conclusively failed to demonstrate any impact of printed educational messages on screening uptake. Despite their low cost, printed educational messages should not be routinely used in attempting to close evidence-practice gaps relating to diabetic retinopathy screening.Trial registration: ISRCTN72772651

Application of theory to enhance audit and feedback interventions to increase the uptake of evidence-based transfusion practice: an intervention development protocol.
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Gould NJ, Lorencatto F, Stanworth SJ, Michie S, Prior ME, Glidewell L, et al.
Implementation science 2014 Jul 29;9:92-014-0092-1

Audits of blood transfusion demonstrate around 20% transfusions are outside national recommendations and guidelines. Audit and feedback is a widely used quality improvement intervention but effects on clinical practice are variable, suggesting potential for enhancement. Behavioural theory, theoretical frameworks of behaviour change and behaviour change techniques provide systematic processes to enhance intervention. This study is part of a larger programme of work to promote the uptake of evidence-based transfusion practice. OBJECTIVES: The objectives of this study are to design two theoretically enhanced audit and feedback interventions; one focused on content and one on delivery, and investigate the feasibility and acceptability. METHODS: Study A (Content): A coding framework based on current evidence regarding audit and feedback, and behaviour change theory and frameworks will be developed and applied as part of a structured content analysis to specify the key components of existing feedback documents. Prototype feedback documents with enhanced content and also a protocol, describing principles for enhancing feedback content, will be developed. Study B (Delivery): Individual semi-structured interviews with healthcare professionals and observations of team meetings in four hospitals will be used to specify, and identify views about, current audit and feedback practice. Interviews will be based on a topic guide developed using the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Analysis of transcripts based on these frameworks will form the evidence base for developing a protocol describing an enhanced intervention that focuses on feedback delivery. Study C (Feasibility and Acceptability): Enhanced interventions will be piloted in four hospitals. Semi-structured interviews, questionnaires and observations will be used to assess feasibility and acceptability. DISCUSSION: This intervention development work reflects the UK Medical Research Council’s guidance on development of complex interventions, which emphasises the importance of a robust theoretical basis for intervention design and recommends systematic assessment of feasibility and acceptability prior to taking interventions to evaluation in a full-scale randomised study. The work-up includes specification of current practice so that, in the trials to be conducted later in this programme, there will be a clear distinction between the control (usual practice) conditions and the interventions to be evaluated.

A short report on knowledge exchange through research-based theatre: ‘Inside out of mind’
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Schneider J, Lowe S, Myers T, Scales K, Bailey S, Middleton J.
Social science & medicine (1982) 2014 Jul 19;118C:61-65

The short report describes the development from page to stage of a work of theatre based on an ethnographic study. The originating research focused on the work of health care assistants (nurse’s aides) whose direct impact on the quality of life of highly dependent people is often overlooked. The research followed hospital personnel on wards specialising in the ‘challenging behaviour’ associated with dementia in central England. Conventional research outputs failed to engage the health care assistants themselves, so we turned to theatre to remedy this. The development of the field notes into theatre was characterised by the artistic freedom given to the playwright, in contrast to more data-led approaches to theatre making. The account of the process of creating the play, Inside Out of Mind, is followed a description of how the work was received by specialist and general audiences totalling 2000+. The discussion seeks to locate the whole enterprise in relation to the field of research-based theatre and explores how the production and its associated learning events relate to definitions of research-based theatre in the light of recent attempts to encapsulate this broad and diverse methodology. Copyright © 2014. Published by Elsevier Ltd.

Read-back improves information transfer in simulated clinical crises.
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Boyd M, Cumin D, Lombard B, Torrie J, Civil N, Weller J.
BMJ quality & safety 2014 Aug 11

Safe and effective healthcare is frustrated by failures in communication. Repeating back important information (read-back) is thought to enhance the effectiveness of communication across many industries. However, formal communication protocols are uncommon in healthcare teams. AIMS: We aimed to quantify the effect of read-back on the transfer of information between members of a healthcare team during a simulated clinical crisis. We hypothesised that reading back information provided by other team members would result in better knowledge of that information by the receiver than verbal response without read-back or no verbal response. METHOD: Postanaesthesia care unit nurses and anaesthetic assistants were given clinically relevant items of information at the start of 88 simulations. A clinical crisis prompted calling an anaesthetist, with no prior knowledge of the patient. Using video recordings of the simulations, we noted each time a piece of information was mentioned to the anaesthetist. Their response was coded as read-back, verbal response without read-back or no verbal response. RESULTS: If the anaesthetists read back the item of information, or otherwise verbally responded, they were, respectively, 8.27 (p<0.001) or 3.16 (p=0.03) times more likely to know the information compared with no verbal response. CONCLUSIONS: Our results suggest that training healthcare teams to use read-back techniques could increase information transfer between team members with the potential for improved patient safety. More work is needed to confirm these findings.

Strengthening the Dementia Care Triad Identifying Knowledge Gaps and Linking to Resources
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Jensen CJ, Inker J.
American Journal of Alzheimer’s Disease and Other Dementias 2014 Aug 11

This article describes a project to identify the needs of family caregivers and health care providers caring for persons with dementia. Participants included 128 caregivers, who completed a survey, and 27 health care providers, who participated in a focus group and completed a survey. Caregivers reported their primary source of information about the disease was the doctor; however, the majority also reported they were primarily informed of medications and not about needed resources. Health care providers identified limited time with patients and families, and lack of awareness of community services, as their main challenges. Recommendations include strengthening the partnership between physicians, patients, and caregivers (the dementia care triad) through additional support and training for physicians and caregivers, increasing awareness of the Alzheimer’s Association, and utilization of technology for families and professionals to track the needs of persons with dementia. © The Author(s) 2014.

No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention. Canada-flat-icon
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Ivers NM, Sales A, Colquhoun H, Michie S, Foy R, Francis JJ, et al.
Implementation science : IS 2014 Jan 17;9:14-5908-9-14

Audit and feedback interventions in healthcare have been found to be effective, but there has been little progress with respect to understanding their mechanisms of action or identifying their key ‘active ingredients.’ DISCUSSION: Given the increasing use of audit and feedback to improve quality of care, it is imperative to focus further research on understanding how and when it works best. In this paper, we argue that continuing the ‘business as usual’ approach to evaluating two-arm trials of audit and feedback interventions against usual care for common problems and settings is unlikely to contribute new generalizable findings. Future audit and feedback trials should incorporate evidence- and theory-based best practices, and address known gaps in the literature. SUMMARY: We offer an agenda for high-priority research topics for implementation researchers that focuses on reviewing best practices for designing audit and feedback interventions to optimize effectiveness.

Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework.
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Murphy K, O’Connor DA, Browning CJ, French SD, Michie S, Francis JJ, et al.
Implementation science : IS 2014 Mar 3;9:31-5908-9-31

Dementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs’ reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines. METHODS: Semi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale. RESULTS: A total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of ‘Beliefs about consequences’); discomfort in using validated tools (‘Emotion’), possibly due to limited training and confidence (‘Skills’; ‘Beliefs about capabilities’); limited awareness of the need for, and forgetting to conduct, a depression assessment (‘Knowledge’; ‘Memory, attention and decision processes’). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment (‘Knowledge’); possessing the necessary skills and confidence (‘Skills’; ‘Beliefs about capabilities’); and having adequate time and resources (‘Environmental context and resources’). CONCLUSIONS: This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs’ uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.

Readiness for and predictors of evidence-based practice of acute-care nurses: a cross-sectional postal survey.
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Thorsteinsson HS, Sveinsdottir H.
Scandinavian journal of caring sciences 2014 Sep;28(3):572-581

Nurses’ adoption of evidence-based practice (EBP) remains limited although most nurses are familiar with EBP and belief in its value for patient care. Efforts to accelerate nurses’ EBP activities have met with limited success. Knowledge of predictors of nurses’ EBP activities is lacking. AIMS: To describe nurses’ readiness for EBP as measured by their information needs, skills in using electronic bibliographical databases (EBDs) and awareness of available EBP-needed resources; EBP beliefs and frequency of EBP activities, and identify predictors of EBP activities and beliefs. METHODS: This was a cross-sectional survey, distributed to a homogeneous, consecutive sample of 546 acute-care nurses. Response rate was 64.3%; responses from direct-care nurses (n = 298) and administrators (n = 45) were analysed. Descriptive statistics were used to describe readiness for EBP, frequency of certain EBP activities and EBP beliefs. Logistic regression analyses were performed to identify predictors of EBP activities and multiple regression analysis to identify predictors of EBP beliefs. RESULTS: The nurses generally seldom participated in the EBP activities studied, in spite of familiarity with and positive beliefs towards EBP. Evidence-based practice beliefs predicted all three activities studied. Skills in using EBDs predicted information-seeking and evaluating research. Awareness of available EBP-needed resources predicted information-seeking, role predicted evaluating research, while familiarity with EBP predicted using research in practice. Six predictors explained nearly 40% of the variance in EBP beliefs. CONCLUSIONS: Nurses’ EBP activities must be facilitated and accelerated. The findings provide empirical support to the primacy of EBP beliefs in nurses’ engagement in EBP and of the complexity of EBP. While the identified predictors of EBP activities and beliefs are susceptible to change, diverse strategies are needed to influence each one. Strategies should focus on influencing EBP beliefs, that is, by increasing skills in using EBDs, discussion about EBP in the clinical environment and familiarity with EBP. © 2013 Nordic College of Caring Science.

Evaluation of a randomized intervention to increase adoption of comparative effectiveness research by community health organizations.
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Williams JR, Williams WO, Dusablon T, Blais MP, Tregear SJ, Banks D, et al.
The journal of behavioral health services & research 2014 Jul;41(3):308-323

This randomized controlled trial examined the influence of two strategies (informational packets alone and in conjunction with Webinars) aimed at increasing the adoption of motivational interviewing (MI), a patient-centered behavioral health practice supported by evidence from comparative effectiveness studies, among community health organizations responsible for delivering mental and behavioral health services. Data were obtained from 311 directors and staff across 92 community organizations. Hierarchical linear modeling was used to examine changes in decision to adopt MI. The mediating effects of multiple contextual variables were also examined. Results showed that both strategies positively influenced the decision to adopt. The positive impact on decision to adopt was significantly greater among individuals that received informational packets in conjunction with Webinars. Baseline attitudes toward evidence-based practices and pressures for change appeared to mediate this effect.

The effectiveness of four translation strategies on nurses’ adoption of an evidence-based bladder protocol.
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The effectiveness of four translation strategies on nurses’ adoption of an evidence-based bladder protocol.
Frasure JS.
The Journal of neuroscience nursing 2014 Aug;46(4):218-226

The primary purpose of this study was to examine the effects of an intervention consisting of the four translation strategies of educational materials, educational meetings, reminders, and audit and feedback on nurses’ adoption of an evidence-based bladder program for patients with stroke in an acute care setting. The secondary purpose was to evaluate the difference in incontinence episodes of patients with stroke before and after nurses received the intervention. Finally, the purpose was to evaluate the influence of nurses’ attitudes and the demographic characteristics on the adoption and use of the evidence-based bladder program after receiving the intervention. This study was the first to provide empirical support for the influence of the combination of these four translation strategies and nurses’ attitudes toward research on the adoption of evidence-based practice in a time-series design study. Thus, the combined use of the four translation strategies did have an impact on nurses’ adoption of evidence-based practice.

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Health Care Administration and Organization

Boundary spanning by nurse managers: effects of managers’ characteristics and scope of responsibility on teamwork Canada-flat-icon
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Meyer RM, O’Brien-Pallas L, Doran D, Streiner D, Ferguson-Pare M, Duffield C.
Nursing leadership (Toronto, Ont.) 2014 Jun;27(2):42-55

Increasing role complexity has intensified the work of managers in supporting healthcare teams. This study examined the influence of front-line managers’ characteristics and scope of responsibility on teamwork. Scope of responsibility considers the breadth of the manager’s role. A descriptive, correlational design was used to collect cross-sectional survey and administrative data in four acute care hospitals. A convenience sample of 754 staff completed the Relational Coordination Scale as a measure of teamwork that focuses on the quality of communication and relationships. Nurses (73.9%), allied health professionals (14.7%) and unregulated staff (11.7%) worked in 54 clinical areas, clustered under 30 front-line managers. Data were analyzed using hierarchical linear modelling. Leadership practices, clinical support roles and compressed operational hours had positive effects on teamwork. Numbers of non-direct report staff and areas assigned had negative effects on teamwork. Teamwork did not vary by span, managerial experience, worked hours, occupational diversity or proportion of full-time employees. Large, acute care teaching hospitals can enable managers to foster teamwork by enhancing managers’ leadership practices, redesigning the flow or reporting structure for non-direct reports, optimizing managerial hours relative to operational hours, allocating clinical support roles, reducing number of areas assigned and, potentially, introducing co-manager models. Copyright © 2014 Longwoods Publishing.

Concurrent and lagged effects of registered nurse turnover and staffing on unit-acquired pressure ulcers.
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Park SH, Boyle DK, Bergquist-Beringer S, Staggs VS, Dunton NE.
Health services research 2014 Aug;49(4):1205-1225

We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects. DATA SOURCES/SETTING: Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed. METHODS: This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes. FINDINGS: The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers. CONCLUSIONS: We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes. © Health Research and Educational Trust.

“Here for the Residents” A Case Study of Cultural Competence of Personal Support Workers in a Long-Term Care Home Canada-flat-icon
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Tayab A, Narushima M.
Journal of transcultural nursing 2014 Jul 31

This study explores the perception of cultural competence of personal support workers (PSWs) in a long-term care (LTC) home in Ontario. As Canada’s demography becomes older and more diverse, LTC homes will increasingly accommodate residents from various cultural backgrounds. However, few studies have examined cultural competence among PSWs in the LTC home setting. Design: The study employed a qualitative case study approach. Data collection and analysis were conducted in three phases: document analysis of organizational policies, a key informant interview with the Director of Care, and two focus groups with PSWs. Results: Our findings illuminated the PSWs’ broad definition of culture, the process of developing cultural competence and its strong connections to person-centered care, and the organizational factors that facilitate or hinder PSWs’ cultural competence. Implications: The ambiguous perception of cultural competence reported by PSWs suggests the need for more education and further research on this topic.

Stress, Social Support, and Burnout Among Long-Term Care Nursing Staff.
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Woodhead EL, Northrop L, Edelstein B.
Journal of applied gerontology 2014 Aug 6

Long-term care nursing staff are subject to considerable occupational stress and report high levels of burnout, yet little is known about how stress and social support are associated with burnout in this population. The present study utilized the job demands-resources model of burnout to examine relations between job demands (occupational and personal stress), job resources (sources and functions of social support), and burnout in a sample of nursing staff at a long-term care facility (N = 250). Hierarchical linear regression analyses revealed that job demands (greater occupational stress) were associated with more emotional exhaustion, more depersonalization, and less personal accomplishment. Job resources (support from supervisors and friends or family members, reassurance of worth, opportunity for nurturing) were associated with less emotional exhaustion and higher levels of personal accomplishment. Interventions to reduce burnout that include a focus on stress and social support outside of work may be particularly beneficial for long-term care staff. © The Author(s) 2014.

Nursing home administrator self-assessed preparedness.
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Siegel EO, Leo MC, Young HM, Castle NG.
Health care management review 2014 Jul-Sep;39(3):210-222

Nursing home administrators (NHAs) are in key positions to improve nursing home quality. NHAs require state-level licensure, which involves passing a national NHA licensure examination and fulfilling state-level licensure requirements that vary widely across states. With multiple pathways to NHA licensure, little is known about NHAs’ preparation and training to meet the complex demands of this position. PURPOSE: The aim of this study was to explore NHAs’ self-assessed person-job fit based on NHAs’ self-rated preparedness and the importance of the activities that supported their preparation. METHODOLOGY/APPROACH: A descriptive cross-sectional design was used to collect data from NHAs (N = 175) randomly recruited from nursing homes in five states, with a mailed self-administered questionnaire. Data analysis included descriptive statistics, correlations, and t tests/ANOVA. FINDINGS: Thirty percent of respondents reported they were well prepared, overall, for their first NHA position. The findings suggest NHA preferences for more formalized ways to develop their entry-level competencies, with lower preference for On-the-job training, Previous job experience, and Self-study and higher preference for Administrator-in-training, Bachelor’s degree programs, and Mentoring. PRACTICE IMPLICATIONS: There is an urgent need for NHAs who are well prepared to effectively address our nation’s mandates for nursing home quality improvement. With multiple pathways to NHA licensure, this exploratory study provides initial insights about NHAs’ self-assessed preparation and training. The findings suggest that NHAs prefer more formalized ways to prepare for the NHA position. Research is needed to identify specific teaching/learning practices and on-the-job training that maximize the NHAs’ preparation to meet their job demands.

NHS: Developing a high-performance support workforce in acute care: innovation, evaluation and engagement (UK)
August 2014

As the main bedside presence in acute health care, the unregistered nurse support worker, positioned at Agenda for Change pay bands 2 to 4 and assisting the registered nurse, has assumed increased importance in delivering high-quality care in the context of resource constraints. Building upon earlier National Institute for Health Research-funded research, the current study centres on three themes related to such workers. An innovation theme, exploring new approaches to the management and use of support workers, is based on scoping discussions and a survey on the incidence of innovative policy and practice, and six cases highlighting how and why certain trusts are able to innovate. An evaluation stream assesses the impact of six support worker-related initiatives on different outcomes and actors. An engagement stream brings together stakeholders with the aim of sharing ‘good practice’ and examining ways to further develop the use and management of support workers. The findings suggest that developing a high-performance support workforce in acute care is fraught with difficulties: trusts’ attempts to develop this part of the workforce are often resisted, lost in dealing with other priorities, or drawn into complex procedures often associated with clinical governance. However, the study draws lessons from the three streams of work, suggesting the need for a balance between top-down and bottom-up approaches; sensitivity to service needs in extending support roles; and partnership working and inclusive approaches to change.

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Health Care Innovation and Quality Assurance

The art of successful implementation of psychosocial interventions in residential dementia care: a systematic review of the literature based on the RE-AIM framework.
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Boersma P, van Weert JC, Lakerveld J, Droes RM.
International psychogeriatrics 2014 Aug 5:1-17

In the past decades many psychosocial interventions for elderly people with dementia have been developed and implemented. Relatively little research has been done on the extent to which these interventions were implemented in the daily care. The aim of this study was to obtain insight into strategies for successful implementation of psychosocial interventions in the daily residential dementia care. Using a modified RE-AIM framework, the indicators that are considered important for effective and sustainable implementation were defined. Methods: A systematic literature search was undertaken in PubMed, PsycINFO, and Cinahl, followed by a hand search for key papers. The included publications were mapped based on the dimensions of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Results: Fifty-four papers met the inclusion criteria and described various psychosocial interventions. A distinction was made between studies that used one and studies that used multiple implementation strategies. This review shows that to improve their knowledge, caregivers needed at least multiple implementation strategies, only education is not enough. For increasing a more person-centered attitude, different types of knowledge transfer can be effective. Little consideration is given to the adoption of the method by caregivers and to the long-term sustainability (maintenance). Conclusions: This review shows that in order to successfully implement a psychosocial method the use of multiple implementation strategies is recommended. To ensure sustainability of a psychosocial care method in daily nursing home care, innovators as well as researchers should specifically pay attention to the dimensions Adoption, Implementation, and Maintenance of the RE-AIM implementation framework.

Fitting clinical workflow: The case for wound care in a residential aged care home.
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Qian S, Yu P.
Studies in health technology and informatics 2014;204:130-136

Residential aged care homes have, or are in the process of implementing, electronic health record (EHR) systems to improve quality of care and reduce cost. For the system to deliver benefits, it must support nursing tasks and be seamlessly integrated into the nursing workflow. To identify whether and how an EHR system can do this most effectively, direct observation was conducted in a residential aged care home on nurses’ use of EHR for wound care. The work processes of wound care and its documentation were investigated. Problems in the use of EHR were identified: 1) functional deficiencies of the EHR system which included a lack of functions to remind nurses of the existence of a wound chart, unavailability of an existent function when needed and a lack of sufficient detail in the information provided; 2) a lack of mobile devices to allow nurses to access the EHR system at the point-of-care, resulting in nurses using paper for point-of-care documentation. The findings suggest that continuous improvement in both the EHR system and its management is required to achieve integration of people, task, process and technology for the optimal benefits of EHR.

The Optimal Study: Describing the Key Components of Optimal Health Care Delivery to UK Care Home Residents: A Research Protocol.
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Gordon AL, Goodman C, Dening T, Davies S, Gladman JR, Bell BG, et al.
Journal of the American Medical Directors Association 2014 Jul 30

Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally. Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Certified Nursing Assistants: A Key to Resident Quality of Life.
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Morley JE.
Journal of the American Medical Directors Association 2014 Jul 30.

It is clear that improving quality of life as opposed to medical care in nursing homes is highly dependent on CNAs. In many parts of the world this is recognized by the fact that nursing homes follow either a nursing or social model, rather than a medical model.

Management attitudes and technology adoption in long-term care facilities.
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Bezboruah KC, Paulson D, Smith J.
Journal of health organization and management 2014;28(3):344-365

The purpose of this paper is to explore the attitudes of nursing home administrators and key managerial staff toward health information technology (health IT). DESIGN/METHODOLOGY/APPROACH: This research is exploratory in nature, and applies qualitative case-study methodology to further understand health IT adoption by nursing homes through multiple in-depth semi-structured interviews of management, and direct observations of employee behavior at each participating facility. A modified Technology Acceptance Model is used to examine the attitudes and perceptions of administrators. FINDINGS: This study finds that there are differences in the level of health IT adoption by nursing homes. While some administrators are aware of health IT and are implementing or updating their IT systems in a gradual but haphazard manner, others exhibited a lack of interest in implementing change. Overall, there is a lack of systematic planning and decision-making toward health IT adoption. Adoption is not evidence-based, instead driven primarily by real and perceived regulatory requirements combined with a lack of information about, or consideration of, the real costs and benefits of implementing health IT. RESEARCH LIMITATIONS/IMPLICATIONS: Including six in-depth case studies, the sample for this study is small for generalizing the findings. Yet, it contributes to the literature on the slow process of health IT adoption by nursing homes. Moreover, the findings provide guidelines for future research. PRACTICAL IMPLICATIONS: This study demonstrates that nursing home administrators must systematically plan the adoption of health IT, and such decision making should be evidenced-based and participatory so that employees can voice their opinions that could prevent future resistance. ORIGINALITY/VALUE: This study is original and advances knowledge on the reasons for the slow adoption of health IT in nursing homes. It finds that lack of adequate information regarding the utility and benefits of health IT in management adoption decisions can result in haphazard implementation or no adoption at all. This finding has significant value for policy makers’ practitioners for improving accessibility of information regarding the use of health IT in nursing homes that could address the health IT adoption challenge in this industry.

Quality improvement collaboratives and the wisdom of crowds: spread explained by perceived success at group level
Duckers M, Groenewegen P, Wagner C.
Implementation Science 2014;9(1):91

Many studies have been conducted to evaluate the impact of quality improvement collaboratives (QICs) on the quality of healthcare. This article addresses an underexplored topic, namely the use of QICs as ‘intentional spread strategy.’ Its objective is to predict the dissemination of projects within hospitals participating in a change programme based on several QICs. We tested whether the average project success at QIC level (based on opinions of individual project team leaders) explains the dissemination of projects one year later. Findings After one year, 148 project team leaders of 16 hospitals participating in the two-year programme were asked to rate the success of their improvement project on a scale from 1 to 10. At the end of the second year, the programme coordinator of each hospital provided information on the second-year dissemination. Average success scores and dissemination statistics were calculated for each QIC (N = 12). The non-parametric correlation between team leader judgment and dissemination rate at QIC level is 0.73 (P < 0.01). Conclusions Previous work, focusing on the team and hospital level, showed which factors contributed to local success stories. It also illustrated how successes play a role in dissemination processes within programme hospitals. The current study suggests that we cannot ignore the extent to which the dissemination potential of individual projects is defined by their QIC. Aggregated team leader judgments at the QIC level might predict the future dissemination in participating organizations. The findings, however, need to be replicated in larger, independent samples.

Identifying strategies to improve diabetes care in Alberta, Canada, using the knowledge-to-action cycle. Canada-flat-icon
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Manns B, Braun T, Edwards A, Grimshaw J, Hemmelgarn B, Husereau D, et al.
CMAJ open 2013 Nov 20;1(4):E142-50

Strategic clinical networks, a recent development in the health system in Alberta, have been charged with bringing together front-line clinicians, researchers and policy-makers to identify variation in clinical care, and to propose standards, pathways and innovative solutions to improve access and quality of care. Here, we describe a collaborative workshop held between researchers and the Obesity, Diabetes and Nutrition Strategic Clinical Network to describe barriers to and facilitators of care for people with diabetes and to identify quality improvement interventions that should be prioritized. METHODS: Through collaboration between health researchers and the strategic clinical network, and using principles of the knowledge-to-action cycle, we identified barriers to and facilitators of diabetes care using data from a patient survey and a provider focus group (5 primary care physicians and 1 diabetes educator). In addition, we identified best evidence from a systematic review of quality improvement initiatives in diabetes. This information was reviewed at a multistakeholder workshop where potential quality improvement initiatives were considered at various service levels. RESULTS: A pilot survey involving 59 patients with diabetes and a focus group of primary care and allied health care providers identified several important barriers to optimal outcomes in diabetes care, including patient-level financial barriers to care and difficulty navigating the health system. Our collaborative discussion using the knowledge-to-action cycle prioritized feasible, evidence-based interventions to improve outcomes for patients with diabetes, including enabling care by allied health care providers and creating clear care maps and processes for system navigation. INTERPRETATION: We identified important barriers to achieving optimal outcomes in diabetes that may be overcome through the use of evidence-based quality improvement interventions. As recommended within the knowledge-to-action cycle, future research is required to determine whether program implementation improves outcomes and is cost-effective.

A model for implementing guidelines for person-centered care in a nursing home setting.
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Vikstrom S, Sandman PO, Stenwall E, Bostrom AM, Saarnio L, Kindblom K, et al.
International psychogeriatrics 2014 Aug 19:1-11

Background: Systematic evaluations of knowledge translation interventions in nursing homes to improve practice are scarce. There is also a lack of studies focusing on creating sustainable evidence-based practice in the setting of residential dementia care. Methods: The aim of this paper is to describe a model for implementing national evidence-based guidelines for care of persons with dementia in nursing homes. The secondary aim is to outline the nursing home staff experiences during the first year of the implementation process. The intervention had a participatory action research approach. This included educational activities such as: (i) thematic seminars introducing national guidelines for dementia care, (ii) regular unit-based seminars; and (iii) later dissemination of information in reflective seminars and several days of poster-exhibitions. Areas of practice development were selected on each of the 24 units, based on unit-specific needs, and a quality improvement strategy was applied and evaluated. Each unit met ten times during a period of eight months. Data for this study were extracted from the reflective seminars and poster presentations, analyzed using a qualitative content analysis. Results: Findings showed that implementation of guidelines were perceived by staff as beneficial for both staff and the residents. However, barriers to identification of relevant sources of evidence and barriers to sustainable implementation were experienced. Conclusions: One of our assumptions was that dementia nursing homes can benefit from becoming knowledge driven, with care practices founded in evidence-based sources. Our findings show that to be partly true, even though most staff units found their efforts to pursue and utilize knowledge adversely impacted by time-logistics and practical workload challenges.

Effect evaluation of two types of dementia-specific case conferences in German nursing homes (FallDem) using a stepped-wedge design: study protocol for a randomized controlled trial.
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Reuther S, Holle D, Buscher I, Dortmann O, Muller R, Bartholomeyczik S, et al.
Trials 2014 Aug 12;15(1):319-6215-15-319

Case conferences for people with dementia and challenging behaviors (e.g., apathy) are recommended as useful tools that enable staff in nursing homes to understand the behavior of people with this type of disease. Understanding peoples’ behaviors is the basis for the initiation of targeted interventions to improve the quality of care for people with dementia. Furthermore, case conferences demonstrate positive effects on burnout, dementia-specific burden, and vocational action competence of the staff. The two likely approaches for conducting case conferences include the following: A) using a structured assessment instrument, which guides the staff in understanding the residents’ behaviors and B) using a narrative approach in which the staff must identify the reasons for the residents’ behaviors in an unstructured manner. Case conferences are a complex intervention, and evaluating their multiple effects is challenging. The aim of this study protocol was to describe a likely solution for evaluating this type of complex intervention using a special cluster randomized trial. METHODS: In this stepped-wedged cluster randomized trial, the two interventions will be sequentially implemented every three months in a group of 12 nursing homes (clusters) with a minimum of 360 residents over 19 months (7 months of intervention for each cluster and follow-up). The primary outcome is the reduction of challenging behavior (measured with the neuropsychiatric inventory-nursing home version [NPI-NH]). Secondary outcomes are residents’ quality of life, prescription of psychotropic medications, staff burnout, dementia-related stress, and vocational action competence. The effectiveness of the study will be accompanied by a process evaluation. The primary data will be analyzed using a Bayesian mixed effect model; the secondary data will be analyzed using descriptive statistics and mixed effects models. DISCUSSION: The implementation and effect measurement of complex interventions such as case conferences within a cluster randomized trial are challenging (e.g., complex and intensive training, delayed treatment effect). In this study protocol, the methodological advantages and disadvantages of using the stepped wedge design to answer the research questions are discussed. TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN20203855; registered 10 July 2013.

Functionality and feedback: a protocol for a realist synthesis of the collation, interpretation and utilisation of PROMs data to improve patient care.
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Greenhalgh J, Pawson R, Wright J, Black N, Valderas JM, Meads D, et al.
BMJ open 2014 Jul 22;4(7):e005601-2014-005601

The feedback and public reporting of PROMs data aims to improve the quality of care provided to patients. Existing systematic reviews have found it difficult to draw overall conclusions about the effectiveness of PROMs feedback. We aim to execute a realist synthesis of the evidence to understand by what means and in what circumstances the feedback of PROMs data leads to the intended service improvements. METHODS AND ANALYSIS: Realist synthesis involves (stage 1) identifying the ideas, assumptions or ‘programme theories’ which explain how PROMs feedback is supposed to work and in what circumstances and then (stage 2) reviewing the evidence to determine the extent to which these expectations are met in practice. For stage 1, six provisional ‘functions’ of PROMs feedback have been identified to structure our review (screening, monitoring, patient involvement, demand management, quality improvement and patient choice). For each function, we will identify the different programme theories that underlie these different goals and develop a logical map of the respective implementation processes. In stage 2, we will identify studies that will provide empirical tests of each component of the programme theories to evaluate the circumstances in which the potential obstacles can be overcome and whether and how the unintended consequences of PROMs feedback arise. We will synthesise this evidence to (1) identify the implementation processes which support or constrain the successful collation, interpretation and utilisation of PROMs data; (2) identify the implementation processes through which the unintended consequences of PROMs data arise and those where they can be avoided. ETHICS AND DISSEMINATION: The study will not require NHS ethics approval. We have secured ethical approval for the study from the University of Leeds (LTSSP-019). We will disseminate the findings of the review through a briefing paper and dissemination event for National Health Service stakeholders, conferences and peer reviewed publications. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Did Hospital Engagement Networks Actually Improve Care?
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Pronovost P, Jha AK.
The New England journal of medicine 2014 Aug 21;371(8):691-693

Everyone with a role in health care wants to improve the quality and safety of our delivery system. Recently, the Centers for Medicare and Medicaid Services (CMS) released results of its Partnership for Patients Program (PPP) and celebrated large improvements in patient outcomes. But the PPP’s weak study design and methods, combined with a lack of transparency and rigor in evaluation, make it difficult to determine whether the program improved care. Such deficiencies result in a failure to learn from improvement efforts and stifle progress toward a safer, more effective health care system.

An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities.
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Savvas SM, Toye CM, Beattie ER, Gibson SJ.
Journal of the American Geriatrics Society 2014 Aug;62(8):1583-1589

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P < .001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P = .005), Pain Assessment in Advanced Dementia Scale (P = .001), and Non-communicative Patient’s Pain Assessment Instrument scale (P < .001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P = .001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

‘Between the flags’: implementing a rapid response system at scale.
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Hughes C, Pain C, Braithwaite J, Hillman K.
BMJ quality & safety 2014 Sep;23(9):714-717

While many hospitals are implementing rapid response systems (RRSs) to attend to deteriorating patients in a systematic way, there is little documented evidence on system-wide approaches to adopting RRSs. Here, we report on an initiative which enrolled 220 hospitals in New South Wales, Australia. The ‘between the flags’ approach was modelled on Australia’s surf lifesaving experience, where qualified lifesavers perform thousands of rescues each year. Patients in hospitals who are identified as being ‘between the flags’ are given special attention, just like beach goers.

Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework.
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Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, et al.
Implementation science 2014 Mar 19;9:33-5908-9-3

To be able to design effective strategies to improve healthcare professionals’ implementation behaviors, a valid and reliable questionnaire is needed to assess potential implementation determinants. The present study describes the development of the Determinants of Implementation Behavior Questionnaire (DIBQ) and investigates the reliability and validity of this Theoretical Domains Framework (TDF)-based questionnaire. METHODS: The DIBQ was developed to measure the potential behavioral determinants of the 12-domain version of the TDF (Michie et al., 2005). We identified existing questionnaires including items assessing constructs within TDF domains and developed new items where needed. Confirmatory factor analysis was used to examine whether the predefined structure of the TDF-based questionnaire was supported by the data. Cronbach’s alpha was calculated to assess internal consistency reliability of the questionnaire, and domains’ discriminant validity was investigated. RESULTS: We developed an initial questionnaire containing 100 items assessing 12 domains. Results obtained from confirmatory factor analysis and Cronbach’s alpha resulted in the final questionnaire consisting of 93 items assessing 18 domains, explaining 63.3% of the variance, and internal consistency reliability values ranging from .68 to .93. Domains demonstrated good discriminant validity, although the domains ‘Knowledge’ and ‘Skills’ and the domains ‘Skills’ and ‘Social/professional role and identity’ were highly correlated. CONCLUSIONS: We have developed a valid and reliable questionnaire that can be used to assess potential determinants of healthcare professional implementation behavior following the theoretical domains of the TDF. The DIBQ can be used by researchers and practitioners who are interested in identifying determinants of implementation behaviors in order to be able to develop effective strategies to improve healthcare professionals’ implementation behaviors. Furthermore, the findings provide a novel validation of the TDF and indicate that the domain ‘Environmental context and resources’ might be divided into several environment-related domains.

Redesigning acute care for cognitively impaired older adults: Optimizing health care services.
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LaMantia MA, Boustani MA, Jhanji S, Maina M, Nazir A, Messina FC, et al.
Dementia (London, England) 2014 Aug 15

Cognitive impairment (CI) is one of several factors known to influence hospitalization, hospital length of stay, and rehospitalization among older adults. Redesigning care delivery systems sensitive to the influence of CI may reduce acute care utilization while improving care quality. To develop a foundation of fundamental needs for health care redesign, we conducted focus groups with inpatient and outpatient providers to identify barriers, facilitators, and suggestions for improvements in care delivery for patients with CI. DESIGN AND METHODS: Focus group sessions were conducted with providers to identify their approach to caring for cognitively impaired hospitalized adults; obstacles and facilitators to providing this care; and suggestions for improving the care process. Using a thematic analysis, two reviewers analyzed these transcripts to develop codes and themes. RESULTS: Seven themes emerged from the focus group transcripts. These were: (1) reflections on serving the cognitively impaired population; (2) descriptions of perceived barriers to care; (3) strategies that improve or facilitate caring for hospitalized older adults; (4) the importance of fostering a hospital friendly to the needs of older adults; (5) the need for educating staff, patients, and caregivers; (6) the central role of good communication; and (7) steps needed to provide more effective care. IMPLICATIONS: Providing effective acute care services to older adults with CI is an important challenge in health care reform. An understanding derived from the perspective of multiple professional disciplines is an important first step. Future research will build on this preliminary study in developing new acute care models for patients with CI. © The Author(s) 2014

The significance of ‘facilitator as a change agent’ – organisational learning culture in aged care home settings.
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Grealish L, Henderson A, Quero F, Phillips R, Surawski M.
Journal of clinical nursing 2014 Aug 4

To explore the impact of an educational programme focused on social behaviours and relationships on organisational learning culture in the residential aged care context. BACKGROUND: The number of aged care homes will continue to rise as the frail older elderly live longer, requiring more formal care and support. As with other small- to medium-sized health services, aged care homes are faced with the challenge of continuous development of the workforce and depend upon registered nurses to lead staff development. DESIGN: A mixed-method evaluation research design was used to determine the impact of an educational programme focused on social aspects of learning on organisational learning culture. METHODS: One hundred and fifty-nine (pre) and 143 (post) participants from three aged care homes completed the Clinical Learning Organisational Culture survey, and three participant-researcher registered nurse clinical educators provided regular journal entries for review. RESULTS: While each site received the same educational programme over a six-month period, the change in organisational learning culture at each site was notably different. Two aged care homes had significant improvements in affiliation, one in accomplishment and one in recognition. The educators’ journals differed in the types of learning observed and interventions undertaken, with Eucalyptus focused on organisational change, Grevillea focused on group (student) change and the Wattle focused on individual or situational change. CONCLUSION: Clinical educator activities appear to have a significant effect on organisational learning culture, with a focus on the organisational level having the greatest positive effect on learning culture and on individual or situational level having a limited effect. RELEVANCE TO CLINICAL PRACTICE: Clinical educator facilitation that is focused on organisational rather than individual interests may offer a key to improving organisational learning culture. © 2014 John Wiley & Sons Ltd.

Interventions to Reduce Inappropriate Prescribing of Antipsychotic Medications in People With Dementia Resident in Care Homes: A Systematic Review.
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Thompson Coon J, Abbott R, Rogers M, Whear R, Pearson S, Lang I, et al.
Journal of the American Medical Directors Association 2014 Aug 8

Antipsychotic medications are commonly used to manage the behavioral and psychological symptoms of dementia. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia. AIMS: To assess the effectiveness of interventions used to reduce inappropriate prescribing of antipsychotics to the elderly with dementia in residential care. METHOD: Systematic searches were conducted in 12 electronic databases. Reference lists of all included studies and forward citation searching using Web of Science were also conducted. All quantitative studies with a comparative research design and studies in which recognized methods of qualitative data collection were used were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by 1 reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. RESULTS: Twenty-two quantitative studies (reported in 23 articles) were included evaluating the effectiveness of educational programs (n = 11), in-reach services (n = 2), medication review (n = 4), and multicomponent interventions (n = 5). No qualitative studies meeting our inclusion criteria were identified. Eleven studies were randomized or controlled in design; the remainder were uncontrolled before and after studies. Beneficial effects were seen in 9 of the 11 studies with the most robust study design with reductions in antipsychotic prescribing levels of between 12% and 20%. Little empirical information was provided on the sustainability of interventions. CONCLUSION: Interventions to reduce inappropriate prescribing of antipsychotic medications to people with dementia resident in care homes may be effective in the short term, but longer more robust studies are needed. For prescribing levels to be reduced in the long term, the culture and nature of care settings and the availability and feasibility of nondrug alternatives needs to be addressed. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

AHRQ: Findings and Lessons from AHRQ’s Clinical Decision Support Demonstration Projects (US)
June 2014

A new report and accompanying videos from the Agency for Healthcare Research and Quality (AHRQ) “Findings and Lessons from AHRQ’s Clinical Decision Support Demonstration Projects” shows how organizations can successfully develop, implement and evaluate the best methods and approaches for incorporating clinical decision support (CDS) into clinical workflows. The report and accompanying videos show the approaches Brigham and Women’s Hospital and the Yale School of Medicine took toward creating processes and tools for translating clinical knowledge and narrative guidelines into formats that can be used by multiple electronic health record (EHR) systems and for implementing CDS across a range of care settings.

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Research Practice & Methodology

Designing questionnaires: healthcare survey to compare two different response scales
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Dell-Kuster S, Sanjuan E, Todorov A, Weber H, Heberer M, Rosenthal R.
BMC medical research methodology 2014 Aug 3;14(1):96-2288-14-96

A widely discussed design issue in patient satisfaction questionnaires is the optimal length and labelling of the answering scale. The aim of the present study was to compare intra-individually the answers on two response scales to five general questions evaluating patients’ perception of hospital care. METHODS: Between November 2011 and January 2012, all in-hospital patients at a Swiss University Hospital received a patient satisfaction questionnaire on an adjectival scale with three to four labelled categories (LS) and five redundant questions displayed on an 11-point end-anchored numeric scale (NS). The scales were compared concerning ceiling effect, internal consistency (Cronbach’s alpha), individual item answers (Spearman’s rank correlation), and concerning overall satisfaction by calculating an overall percentage score (sum of all answers related to the maximum possible sum). RESULTS: The response rate was 41% (2957/7158), of which 2400 (81%) completely filled out all questions. Baseline characteristics of the responders and non-responders were similar. Floor and ceiling effect were high on both response scales, but more pronounced on the LS than on the NS. Cronbach’s alpha was higher on the NS than on the LS. There was a strong individual item correlation between both answering scales in questions regarding the intent to return, quality of treatment and the judgement whether the patient was treated with respect and dignity, but a lower correlation concerning satisfactory information transfer by physicians or nurses, where only three categories were available in the LS. The overall percentage score showed a comparable distribution, but with a wider spread of lower satisfaction in the NS. CONCLUSIONS: Since the longer scale did not substantially reduce the ceiling effect, the type of questions rather than the type of answering scale could be addressed with a focus on specific questions about concrete situations instead of general questions. Moreover, the low correlation in questions about information provision suggests that only three possible response choices are insufficient. Further investigations are needed to find a more sensitive scale discriminating high-end ratings. Otherwise, a longitudinal within-hospital or a cross-sectional between-hospital comparison of patient care is questionable.

Methodological development of the interactive INTERLINKS Framework for Long-term Care.
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Billings J, Leichsenring K.
International journal of integrated care 2014 Jun 23;14:e021

There is increasing international research into health and social care services for older people in need of long-term care (LTC), but problems remain with respect to acquiring robust comparative information to enable judgements to be made regarding the most beneficial and cost-effective approaches. The project ‘INTERLINKS’ (‘Health systems and LTC for older people in Europe’) funded by the EU 7th Framework programme was developed to address the challenges associated with the accumulation and comparison of evidence in LTC across Europe. It developed a concept and method to describe and analyse LTC and its links with the health and social care system through the accumulation of policy and practice examples on an interactive web-based framework for LTC. This paper provides a critical overview of the theoretical and methodological approaches used to develop and implement the INTERLINKS Framework for LTC, with the aim of providing some guidance to researchers in this area. INTERLINKS has made a significant contribution to knowledge but robust evidence and comparability across European countries remain problematic due to the current and growing complexity and diversity of integrated LTC implementation.

Intervention Synthesis: A Missing Link between a Systematic Review and Practical Treatment(s)
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Glasziou PP, Chalmers I, Green S, Michie S.
PLoS medicine 2014 Aug 12;11(8):e1001690

Effective delivery of treatments requires clear procedural details of the essential elements of treatment. Hence, if a systematic review finds that a class of interventions is effective, then the users of the review will want to know: “Which version of the intervention should I use?” Current methods to guide selection or synthesis from the variations of a treatment used across trials in a systematic review are poorly developed, and absent from most instructions on systematic review methods. We identify three basic approaches: (i) single-trial-based choice, where criteria such as feasibility, cost, effectiveness, or familiarity guide which trial’s treatment to adopt; (ii) common components hybrid, which extracts then combines—based on frequency and importance—components of several trials; and (iii) model-guided synthesis, where a model of the mechanisms of effect is used to code and assess the importance of components for the version(s) recommended. Whichever method is used, we suggest review authors provide an “intervention options table”, which describes the pros and cons of some intervention alternatives used in an individual trial or set of trials. If clinicians and policymakers are to be expected to base their practices on the results of systematic reviews in practice, these three approaches will need to be more widely adopted.

Seeing the forests and the trees–innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol.
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Ivers N, Tricco AC, Trikalinos TA, Dahabreh IJ, Danko KJ, Moher D, et al.
Systematic reviews 2014 Aug 12;3(1):88

To improve quality of care and patient outcomes, health system decision-makers need to identify and implement effective interventions. An increasing number of systematic reviews document the effects of quality improvement programs to assist decision-makers in developing new initiatives. However, limitations in the reporting of primary studies and current meta-analysis methods (including approaches for exploring heterogeneity) reduce the utility of existing syntheses for health system decision-makers. This study will explore the role of innovative meta-analysis approaches and added value of enriched and updated data for increasing the utility of systematic reviews of complex interventions for health system decision-makers. METHODS: We will use the dataset from our recent systematic review of 142 randomized trials of diabetes quality improvement programs to evaluate novel approaches for exploring heterogeneity. These will include exploratory methods, such as multivariate meta-regression analyses and all-subsets combinatorial meta-analysis. We will then update our systematic review to include new trials and enrich the dataset by surveying authors of all included trials. In doing so, we will explore the impact of previously unpublished variables, such as details of study context, on the effectiveness of the intervention. We will use innovative analytical methods on the enriched and updated dataset to identify key success factors in the implementation of quality improvement interventions for diabetes. Decision-makers will be involved throughout to help identify and prioritize variables to be explored and to aid in the interpretation and dissemination of results. DISCUSSION: This study will inform future systematic reviews of complex interventions and describe the value of enriching and updating data for exploring heterogeneity in meta-analysis. It will also result in an updated comprehensive systematic review of diabetes quality improvement interventions that will be directly relevant to health system decision-makers in developing interventions to improve outcomes for people with diabetes.Systematic review registration: PROSPERO registration no. CRD42013005165.

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Aging

From nursing home to acute care: Signs, symptoms, and strategies used to prevent transfer.
Non UofA Access
Ashcraft AS, Owen DC.
Geriatric nursing (New York, N.Y.) 2014 Jul-Aug;35(4):316-320

Older adults are vulnerable to experiencing physiologic changes that may permanently decrease functional abilities when transferring from the nursing home (NH) to the acute care setting. Making the right decision about who and when to transfer from the nursing home (NH) to acute care is critical for optimizing quality care. The specific aims of this study were to identify the common signs and symptoms exhibited by NH residents at the time of transfer to acute care and to identify strategies used to prevent transfer of NH residents. Using survey methodology, this descriptive study found change in level of consciousness, chest pressure/tightness, shortness of breath, decreased oxygenation, and muscle or bone pain were the highest ranked signs/symptoms requiring action. Actions to prevent transfer focused on stabilizing resident conditions and included hydration, oxygen, antibiotics, medications, symptom management, and providing additional physical assistance. When transfer was warranted, actions concentrated on the practical tasks of getting the residents transferred. Copyright © 2014 Mosby, Inc. All rights reserved.

Valuing narrative in the care of older people: a framework of narrative practice for older adult residential care settings.
Non UofA Access
Buckley C, McCormack B, Ryan A.
Journal of clinical nursing 2014 Sep;23(17-18):2565-2577

To report on the development of a framework of narrative practice, in residential care settings for older people. BACKGROUND: Residential care settings for older people provide care for people who are no longer able to live in their own home. To date, the impact and structure of nursing practice on care provision in these settings has proved difficult to conceptualise within a specific nursing theory framework. DESIGN: A hermeneutic approach incorporating narrative methods was used. METHODS: Forty-six narrative interviews with older people in residential care were secondary-analysed for key themes through a three-stage process: by the first author, four focus groups of 12 clinical nurse managers and two independent experts. Themes were also derived from a focus group of eight residents who explored person-centredness and narrative. Finally, the combined findings were used to derive a single set of themes. RESULTS: The secondary data analysis process led to the development of a framework of narrative practice for the care of older people in residential settings. The framework is influenced by narrative enquiry, person-centred practice and practice development. It has four pillars, prerequisites, care processes, care environment and narrative aspects of care. To operationalise the framework of narrative practice, three narrative elements, narrative knowing, narrative being and narrative doing, need to be considered. Working with the foundational pillars and the narrative elements would enable staff to ‘work in a storied way’ and provide person-centred outcomes and a narrative informed philosophy of care for older adults in residential care. CONCLUSION: This framework provides nurses with a template that confirms the identity of the older person taking account of their biography. RELEVANCE TO CLINICAL PRACTICE: The framework outlines an approach that provides staff with a template on how to provide person-centred care in a narrative way. © 2013 John Wiley & Sons Ltd.

Quality-of-life measures for use within care homes: a systematic review of their measurement properties.
Non UofA Access
Aspden T, Bradshaw SA, Playford ED, Riazi A.
Age and Ageing 2014 Aug 3

OBJECTIVE: the aims of this review were (i) to identify quality-of-life (QoL) measures which have had their measurement properties validated in people residing in care homes or nursing homes, and to critically compare and summarise these instruments and (ii) to make recommendations for measurement instruments. METHODS: bibliographic databases PsycINFO, PubMed, Cochrane, CINAHL and Embase were searched for articles evaluating measurement properties of QoL instruments in people residing in care homes. Methodological quality of studies was assessed using the consensus-based standards for the selection of health measurement instruments checklist. Measurement properties of instruments were appraised using a systematic checklist. RESULTS: the search strategy resulted in 3252 unique citations, of which 15 articles were included in this review. These articles assessed 13 instruments, 8 of which were dementia or Alzheimer specific instruments. The QUALIDEM, a dementia-specific observational instrument, had the widest array of information available on its measurement properties, which were mostly satisfactory. Most measurement instruments lacked information on hypotheses testing and content validity. Information on responsiveness and measurement error was not available for any instrument. CONCLUSIONS: for people with dementia living in care homes, the QUALIDEM is recommended for measuring QoL. For residents without dementia, we recommend Kane et al.’s Psychosocial Quality of Life Domains questionnaire. Studies of higher methodological quality, assessing a wider range of measurement properties are needed to allow a more fully informed choice of QoL instrument. © The Author 2014.

Mapping support policies for informal carers across the European Union.
Non UofA Access
Courtin E, Jemiai N, Mossialos E.
Health policy (Amsterdam, Netherlands) 2014 Aug 1

At a time when health and social care services in European countries are under pressure to contain or cut costs, informal carers are relied upon as the main providers of long-term care. However, still little is known about the availability of direct and indirect support for informal carers across the European Union. METHODS: Primary data collection in all EU member states was supplemented with an extensive review of the available literature. RESULTS: Various forms and levels of support have been implemented across Europe to facilitate the role of informal caregivers. Financial support is the most common type of support provided, followed by respite care and training. Most countries do not have a process in place to systematically identify informal carers and to assess their needs. Policies are often at an early stage of development and the breadth of support varies significantly across the EU. CONCLUSIONS: Policy developments are uneven across the member states, with some countries having mechanisms in place to assess the needs and support informal carers while others are only starting to take an interest in developing support services. Given the unprecedented challenges posed by population ageing, further research and better data are needed to capture and monitor information on informal carers, to help design adequate support policies and eventually to evaluate their impact across the EU. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Psycho-social impact of visual impairment on health-related quality of life among nursing home residents.
Non UofA Access
Dev MK, Paudel N, Joshi ND, Shah DN, Subba S.
BMC health services research 2014 Aug 15;14:345-6963-14-345

Visual impairment (VI) affects physical, psychological, and emotional well-being, and social life as well. The purpose of this exploratory study was to assess the psycho-social impact of VI on health-related quality of life (HRQoL) among nursing home residents. METHODS: This cross-sectional study involved 272 residents of 60 years or older residing in seven nursing homes of the Kathmandu Valley, Nepal. Comprehensive ocular examinations, including near and distance vision assessment and refractions were carried out. VI was defined as visual acuity (VA) less than 6/18 in the better eye. Residents were divided into two groups: one group did not have VI (in whom VA was greater than or equal to 6/18 in the better eye), and the other had VI (in whom VA was worse than 6/18 in the better eye).Face-to-face interviews were conducted filling out a 36-item The Medical Outcomes Study Short-Form (SF-36) questionnaire. The SF-36 questionnaire was scored according to the scoring algorithm SF-36 subscales. RESULTS: The mean age of residents was 74.68 ± 8.19 years (range, 60-99 years) and the majority were female (78.68%). The mean composite score of SF-36 was 46.98 ± 13.08. VI detrimentally affected scores of both the physical and the mental components, but the impact of VI was slightly greater for the physical component than that for the mental component. There was a trend towards a lower composite score as well as each subscale score of the SF-36 in participants with VI than in those without VI. CONCLUSION: VI has a negative effect on HRQoL. HRQoL is reduced among nursing home residents and the reduction in the HRQoL bears a positive association with VI.

Staff-resident interactions in long-term care for people with dementia: the role of meeting psychological needs in achieving residents’ well-being.
Non UofA Access
Willemse BM, Downs M, Arnold L, Smit D, de Lange J, Pot AM.
Aging & mental health 2014 Aug 13:1-9

Objectives: The aim of this study is to explore the extent to which staff-resident interactions address or undermine residents’ psychological needs and how such interactions are associated with residents’ well-being. Method: Data on staff-resident interactions and residents’ well-being were collected for 51 residents from nine long-term care settings using dementia care mapping (DCM). DCM yields a count and detailed description of staff-resident interactions that either address (personal enhancers – PEs) or undermine (personal detractions – PDs) residents’ psychological needs, and every 5-minute scores for each resident’s mood and engagement (ME-value). The relationship between PEs and PDs and well-being was analysed by studying residents’ ME-values before and three time frames after a PE or PD occurred. Results: A total of 76 PEs and 33 PDs were observed. The most common PEs were those addressing psychological needs for comfort and occupation. However residents’ well-being increased most often after PEs that addressed residents’ need for identity, attachment and inclusion. The most common PDs were those which undermined the need for comfort, inclusion and occupation. Residents’ well-being decreased most often after PDs that undermined the need for comfort. Conclusion: Increasing interactions which address residents’ need for attachment, identity and inclusion and eliminating interactions which undermine residents’ need for comfort may be particularly important in achieving residents’ well-being. In the long run, residents’ well-being could be achieved by staff availing of the opportunities to empower and facilitate residents, thus meeting their needs for occupation. These findings provide directions for training in person-centred care.

Primary Care-Based Memory Clinics: Expanding Capacity for Dementia Care. Canada-flat-icon
Non UofA Access
Lee L, Hillier LM, Heckman G, Gagnon M, Borrie MJ, Stolee P, et al.
Canadian journal on aging 2014 Aug 11:1-13

The implementation in Ontario of 15 primary-care-based interprofessional memory clinics represented a unique model of team-based case management aimed at increasing capacity for dementia care at the primary-care level. Each clinic tracked referrals; in a subset of clinics, charts were audited by geriatricians, clinic members were interviewed, and patients, caregivers, and referring physicians completed satisfaction surveys. Across all clinics, 582 patients were assessed, and 8.9 per cent were referred to a specialist. Patients and caregivers were very satisfied with the care received, as were referring family physicians, who reported increased capacity to manage dementia. Geriatricians’ chart audits revealed a high level of agreement with diagnosis and management. This study demonstrated acceptability, feasibility, and preliminary effectiveness of the primary-care memory clinic model. Led by specially trained family physicians, it provided timely access to high-quality collaborative dementia care, impacting health service utilization by more-efficient use of scarce geriatric specialist resources.

Characterizing Social and Recreational Programming in Assisted Living. Canada-flat-icon
Non UofA Access
Hanson HM, Hoppmann CA, Condon K, Davis J, Feldman F, Friesen M, et al.
Canadian journal on aging 2014 Aug 11:1-11

The objectives of this three-phased investigation were to (1) characterize existing recreational programming opportunities for tenants residing in assisted living (AL) and (2) gather perceptions on factors influencing activity program planning and delivery. Using an integrated knowledge translation framework during a one-year collaboration, we targeted 51 publicly funded AL sites from two health authorities in British Columbia. We conducted an activity calendar review, staff survey, and interactive symposia to identify factors that enabled or restricted recreational programming. From the information obtained, we determined that all AL sites delivered recreational programming. Although exercise and physical activity opportunities were perceived as having high importance, most activities were social. Staff reported confidence in delivering this type of programming and believed it met the holistic needs of tenants, including their mental well-being, and fostered a sense of community. Future avenues for increasing physical activity of AL tenants should address individual, site, and organizational characteristics.

A taxonomy of the economic costs of family care to adults Canada-flat-icon
Non UofA Access
Keating NC, Fast JE, Lero DS, Lucas SJ, Eales J.
The Journal of the Economics of Ageing 2014;3(0):11

A systematic scoping review was conducted to evaluate the current state of knowledge of the economic costs incurred by family caregivers to adults with long-term health problems or disabilities. A narrative synthesis of 126 articles published since 1999 was undertaken to develop a taxonomy of the economic costs experienced by these caregivers. Three broad domains of sources of economic costs for caregivers were identified: employment consequences, out-of-pocket expenses and caregiving labor, with sub-categories within each domain. Economic outcomes were identified for each cost domain. Generation of new knowledge across the three cost domains has been uneven, with disproportionate interest in employment consequences. There are knowledge and methods gaps around all of the domains of care arising from failure to measure, or measure consistently, the costs; failure to account for contexts within which care is delivered; and lack of consistency in specifying care thresholds influencing labor force exit and employment consequences. An expanded research agenda on costs of family care should address cumulative and cross-domain care costs. Links between economic and social and health costs are fertile ground for a comprehensive understanding of the full costs of family care.

Cost-consequence analysis of “Washing Without Water” for nursing home residents: a cluster randomized trial
Non UofA Access
Schoonhoven L, van Gaal BGI, Teerenstra S, Adang E, van der Vleuten C, van Achterberg T.
International journal of nursing studies

To compare bed baths for effects on skin integrity and resistance against bathing and costs. Design Cluster randomized trial Setting 56 nursing home wards in the Netherlands. Participants: 500 adult care-dependent residents and 275 nurses from nursing home wards. Methods The experimental condition ‘washing without water’ consists of a bed bath with disposable wash gloves made of non-woven waffled fibers, saturated with a no-rinse, quickly vaporizing skin cleaning and caring lotion. The control condition is a traditional bed bath using soap, water, washcloths and towels. Both conditions were continued for six weeks. Outcome measures were prevalence of skin damage distinguished in two levels of severity: any skin abnormality/lesion and significant skin lesions. Additional outcomes: resistance during bed baths, costs. Results Any skin abnormalities/lesions over time decreased slightly in the experimental group, and increased slightly in the control group, resulting in 72.7% versus 77.6% of residents having any skin abnormalities/lesions after six weeks, respectively (p = 0.04). There were no differences in significant skin lesions or resistance after six weeks. Mean costs for bed baths during six weeks per resident were estimated at € 218.30 (95%CI 150.52–286.08) in the experimental group and € 232.20 (95%CI 203.80–260.60) in the control group (difference € 13.90 (95%CI: -25.61–53.42). Conclusion Washing without water mildly protects from skin abnormalities/lesions, costs for preparing and performing bed baths do not differ from costs for traditional bed bathing. Thus, washing without water can be considered the more efficient alternative.

‘It’s a huge maze, the system, it’s a terrible maze’: Dementia carers’ constructions of navigating health and social care services.
Non UofA Access
Peel E, Harding R.
Dementia (London, England) 2014 Sep;13(5):642-661

Dementia is a challenging, progressive set of conditions which present a large care burden to informal, familial carers. A complex array of health and social care services are needed to support people living with dementia. Drawing on the interlinked ‘Duties to Care’ and ‘Dementia Talking’ projects, in this article we focus on British carers’ talk about health and social care services. We explore data from a mixed-method questionnaire (n = 185), four focus groups and eleven interviews with informal carers of people living with dementia using thematic discourse analysis. Three themes are discussed: (1) services as a ‘maze’; (2) services as overly limited – ‘beyond our remit’; and (3) the battle and fighting discourse deployed by these carers. Our analysis highlights that carers find navigating systemic issues in dementia care time-consuming, unpredictable and often more difficult than the caring work they undertake.
© The Author(s) 2013

Australian Government: Patterns in use of aged care: 2002-03 to 2010-11
August 2014

While permanent care in a residential care facility remains a key service for many older Australians, in recent years greater emphasis has been placed on the provision of home-based support. This report examines how this shift has affected the way that people use aged care programs, and investigates the initial take-up of care. The analysis shows that use of aged care programs before entering permanent residential care is increasing, as is the use of any aged care services in a person’s last year of life.

Health Quality of Ontario: Supportive Interventions for Informal Caregivers of People at the End of Life: A Rapid Review Canada-flat-icon
July 2014

This rapid review aimed to determine the effectiveness of supportive interventions in improving coping/ burden and distress for informal caregivers of patients who are at the end of life.

OECD: The future of health and long-term care spending
2014

This paper proposes a new set of public health and long-term care expenditure projections until 2060, following up on the previous set of projections published in 2006. It disentangles health from long-term care expenditure as well as the demographic from the non-demographic drivers, and refines the previous methodology, in particular by better identifying the underlying determinants of health and long-term care spending and by extending the country coverage to include BRIICS countries. A cost-containment and a cost-pressure scenario are provided together with sensitivity analysis. On average across OECD countries, total health and long-term care expenditure is projected to increase by 3.3 and 7.7 percentage points of GDP between 2010 and 2060 in the cost-containment and the cost-pressure scenarios, respectively. For the BRIICS over the same period, it is projected to increase by 2.8 and 7.3 percentage points of GDP in the costcontainment and the cost-pressure scenarios, respectively.

StatsCan: Ninety years of change in life expectancy, 1921 to 2011 Canada-flat-icon

In 2011, Canadians lived an average of 81.7 years, an increase of almost 25 years since 1921. Dividing the study timeframe into 30-year periods shows that the gains in life expectancy are slowing down. Life expectancy at birth rose more rapidly between 1921 and 1951 (+11.3 years) than between 1951 and 1981 (+7.1 years), or between 1981 and 2011 (+6.2 years). Most of the increases in life expectancy in the past 90 years came from declines in what is frequently called premature death—death among individuals who are younger than age 75. These increases changed over time and amounted to 11.2 years in the first period (1921 to 1951), 6.0 years in the second period (1951 to 1981) and 4.7 years in the third (1981 to 2011). One of the main drivers of the gain were improvements in child and infant (ages 0 to 4) mortality between 1921 and 1951, which added 6.7 out of the total 11.3 year increase in the period. Since 1951, in turn, reduced deaths from circulatory diseases account for most gains in life expectancy (2.8 out of 7.1 years gained between 1951 and 1981 and 4.0 out of 6.2 years gained between 1981 and 2011). Canadians are living longer but, for many adults, the ability to perform key health functions declines as they age. After age 65, the decline in functional health tends to accelerate, with more severe disability (many activity limitations) occurring, on average, around age 77.

Elder Justice Roadmap Project Report (US)
2014

Given the widespread health, legal, social and economic implications of elder abuse, the Elder Justice Roadmap Project sought the input of experts and stakeholders from across the country in order to develop a strategic resource — by the field and for the field — to combat elder abuse, neglect and financial exploitation. The report identifies and prioritizes actions that direct service providers, educators, and researchers can take to benefit older adults facing abuse, neglect or financial exploitation. Likewise, it provides a roadmap for strategic investment and engagement by policymakers in both the public and private sectors to advance our collective efforts to prevent and combat elder abuse at the local, state and national levels.

NIH & Census Bureau: 65+ in the United States: 2010

This report examines a range of topics concerning the population aged 65 and older: age structure and distribution by race and Hispanic origin, longevity and health, economic characteristics, geographic distribution, and sociodemographic characteristics.

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Events

Non UofA

ACRC Clinical Research Conference
Wednesday 15 October 08:00-16:00 $50
Lister Centre, Edmonton AB

Join other study coordinators, administrators and investigators as we focus on hot topics and current challenges in clinical health research.
Be inspired – Hear firsthand why clinical research is invaluable from keynote speaker Dr. Ian MacDonald; an accomplished clinician and investigator with a patient oriented approach to research.
Stay informed – Find out the latest legislative changes from Rachel Hayward (Office of the Information and Privacy Commissioner of Alberta (OIPC)) and how these changes will affect research.
Choose from many topics in clinical health research and learn about best practices to implement at your site.
Network with others and gain insights from your peers.
Find out what’s happening behind the scenes to optimize clinical research in Alberta.

Online

SEDL’s Center on Knowledge Translation for Disability and Rehabilitation Research (KTDRR): Vocational Rehabilitation Counselors’ Use of Evidence-Based Practices Involving Motivational Interviewing
Thursday 4 September 13:00 MT

The Center on Knowledge Translation for Disability and Rehabilitation Research is collaborating with the American Institutes for Research to support webcasts and a community of practice to examine issues around implementing evidence-based practice into vocational rehabilitation (VR). This webcast follows the thread of the relationship between research and practice as it relates to the use of “motivational interview (MI)” techniques by VR counselors. Motivational interviewing refers to an approach developed by clinical psychologists in the early 1980s (developed in part by Professors William R. Miller and and Stephen Rollnick) and evolved from experience in the treatment of problem drinking.

CIHR & SEDL: Innovative KT Strategies: A Four-Part Webcast Series
August 20, 21, 27, 28
Yes, you’ve missed some of these but they’re archived on YouTube–just follow the links

August 20 13:00-13:45 MT KT 101: Knowledge Translation Initiatives at CIHR
August 21 13:00-13:45 MT Ethics in Research: A Scientific Lifecycle Approach
August 27 13:00-13:45 MT Citizen and Patient Engagement
August 28 13:00-14:15 MT Evidence Informed Policy Making: A CIHR – Knowledge Translation Approach

CLSA Webinar: Aging Today – Opportunities for Tomorrow
Thursday 11 September 11:00-12:00 MT

Dr. Pianosi is an Associate Professor and the past chair of the Gerontology Department at Huntington/Laurentian University. She holds a PhD in Psycho-Gerontology from Germany and has completed two M.A. programs (in Human Development and in Psycho-Gerontology). She is a Credentialed Professional Gerontologist (C.P.G.) with the National Association for Professional Gerontologists and a certified coach for Gentle Persuasive Approaches in Dementia Care. Dr. Pianosi is the chair of the Ontario Interdisciplinary Council for Aging and Health and an executive board member of the Seniors Health Knowledge Network (SHKN).

How to Present Complex Information Simply through Stories
On demand webinar

Join Roger Courville, Chief “Aha!” Guy at TheVirtualPresenter.com, for a fast-paced and practical session on how to tell a clear, compelling story that both informs and inspires.
-3 steps for transforming facts into messages
-How to design a flow that keeps the audience engaged
-4 tips for creating visuals that stand out
-A killer idea for making infographics work in online presentations

AcademyHealth: Analytical Methods for Learning Health Systems
Tuesday 9 September 11:00-12:30 MT

Learning healthcare systems use routinely collected electronic health data (EHD) – known as “observational data” – to advance knowledge and support continuous learning within comparative effectiveness research and patient-centered outcomes research. Despite the increasing sophistication of analytics and data, analysts are still unable to confidently infer causal relationships from observational data. However, effective framing of research questions, careful study design, and appropriate analytical methods can improve these inferences and the utility of EHD. This webinar will discuss approaches to using observational data to improve performance in learning healthcare systems, including how to frame research questions effectively and how to apply study design and analytical methods to ensure rigorous results.

KT Canada Webinar: Use of KT models in the development of a Research Program
Thursday September 11 10:00-11:00 MT

Learning Objectives:
To understand how KT models can be used to guide research projects and a program of research
To understand how to engage knowledge users in unique KT studies
To understand how both integrated and end of grant KT was used to meet the needs of knowledge users in the Intellectual and Developmental Disability Sector.

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Courses

Online

Advances and New Capabilities in PLS Path Modeling
Five Consecutive Wednesdays 10 September-8 October
09:30-12:00 and 17:30-20:00 MT Cost $345

In recent years, there have been many new PLS path modeling techniques and capabilities published in the literature. PLS algorithm alternatives, including consistent PLS, quadratic PLS, and non-linear PLS; consistent bootstrapping, bias-corrected and accelerated bootstrapping; and prediction-oriented and genetic algorithm latent segmentation approaches, are just a few. Others include: advances to goodness-of-fit measures; orthogonalized interaction variables; the conditional process analyses of direct, indirect and total mediating and moderating effects. However, although validated in the literature, the widespread use of these many new and advanced techniques to analyze latent variable research data with path models has been impeded by the lack of available PLS path modeling software tools that actually implement these capabilities. Now these tools exist and are available. This live 5-session course (see detailed course agenda near bottom of page), presented online and available world-wide to anyone with an Internet connection, instructs with respect to the relevant concepts and practical use of these modern path modeling techniques. Researchers who are knowledgable about these approaches, and who have the requisite software tools to perform these analyses, will have a competitive advantage in analyzing and disseminating related data analyses into the literature through their published journal articles.

KT Canada: Introductory Course on Systematic Reviews and Meta-Analyses
8 September-5 December $1600

This is an introductory course on systematic reviews and meta-analyses and will be delivered online. It is co-taught by Andrea Tricco (MSc, PhD), Monika Kastner (PhD) and Sharon Straus (MD, MSc). The overall course objective is to teach about systematic reviews in general, as well as how to go about doing a systematic review. This information will be used by the students to conduct a systematic review in the topic of their choice, with guidance from the course instructors.

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News

CBC The Current: Diagnosis Dementia Canada-flat-icon

From beginning stages of the disease to life in a care facility, The Current brings you stories of Canadians living with dementia and the people who love and care for them.

Special measures scheme for failing care homes (UK)

Care homes and home care providers treating vulnerable and old people without dignity and respect will be put on an ‘unprecedented turn-around programme’, Health Secretary Jeremy Hunt announced in Parliament. The move comes alongside evidence that a special measures scheme introduced in failing hospitals in the wake of the scandal at Mid Staffs has triggered ‘transformational improvements in services’. From October, the 25,000 care home and homecare services in England will face a new inspection and rating regime that will ‘shine a light on poor care to drive up standards’.

Care home resident numbers remain static despite elderly population rise (UK)

Despite an 11% rise in the number of people aged over 65 between 2001 and 2011 in England and Wales, the number of care home residents has hardly changed. According to figures from the Office for National Statistics (ONS) around 291,000 people were living in care homes in 2011, which is only 1,000 more than a decade earlier.

Care Coordination for Older Americans Act of 2014 (US)

On July 24, Rep. Allyson Schwartz (D-PA) introduced the Care Coordination for Older Americans Act of 2014 (H.R. 5200), legislation that would focus on improved care coordination for older adults. If passed, the bill would:
-Include care coordination in the Declaration of Objectives of the Older American Act.
-Direct the collaboration among states, Aging and Disability Resource Centers, Area Agencies on Aging, service providers, healthcare providers and medical entities.
-Instruct the state agency and Area Agencies on Aging (AAA’s) to promote the development and implementation of care coordination plans that address the needs of older individuals with multiple chronic illnesses.

Québec Home Care in Trouble Canada-flat-icon

Quebec tabled legislation to provide additional $100 million per year, but health critics say the program is failing those most in need

Dutch model offers new approach to home care

Since its development in 2006, the Buurtzorg or “neighbourhood care” model has attracted the interest of more than 25 countries including the National Health Service in England. Sweden, Japan and the US state of Minnesota have already begun introducing Buurtzorg nurse-led teams in their jurisdictions.

Dementia is ‘one of greatest enemies of humanity’ – David Cameron (UK)

A “big, bold global push” is needed to beat dementia, David Cameron has told a summit in London. He pledged to accelerate progress on dementia drugs, by increasing funding and making new drugs more accessible.

International nurses must now apply to National Nursing Assessment Service Canada-flat-icon

Effective August 12, 2014, to become a nurse in Canada (except Quebec and Territories), all internationally educated nurse (IEN) applicants must first apply to the National Nursing Assessment Service (NNAS) for document evaluation and verification.

B.C. invests in first-in-Canada community-care licensing program Canada-flat-icon

“With the growing seniors’ population in B.C. and a number of child-care facilities, there is an increasing need for residential facilities and community-care licensing inspectors to ensure that facilities provide the best and safest care,” said Health Minister Terry Lake. “Investing in the certification of these inspectors now is a proactive step towards filling a future need in our communities. While this is not an overnight change, it will sustain training, consistency of practice and accountability over the coming years.”

Alberta Clinical Research Consortia Newsletter Canada-flat-icon

Articles include: Internal Costing Template, ACRC Clinical Research Conference, Community of Experts, and an Update on Adding Clarity to Health Canada guidelines.

Supporting Ontario’s unpaid caregivers Canada-flat-icon

Many caregivers experience significant distress associated with caring for a loved one. However, while her husband’s condition poses many challenges, Anne feels confident that she will be able to continue to care for him at home, thanks in large part to the support she receives from the Alzheimer society.

Businesses risk losing billions unless they adapt: report reveals the future cost of dementia (UK)

Public Health England (PHE) and Alzheimer’s Society, who recently joined forces to launch the Dementia Friends campaign, release a new report on the future financial implications to the nation’s businesses of dementia, and call on employers to adapt their working environment to support the increasing numbers affected by the condition.

England records rise in dementia diagnoses (UK)

The number of people in England diagnosed with dementia has risen by 62% over seven years.

Hospital failure regime extended to care homes (UK)

A system of special measures designed to improve failing hospitals in England is to be extended to care homes, the government has announced.

Where Are the Nurses? (US)

They’re called “nursing homes,” so most of us assume that they have nurses — registered nurses — on the premises. But not all the time. In some facilities, not even most of the time.

Nearly one third of older people with care needs do not receive crucial help (UK)

New research from Age UK reveals that nearly 900,000 (870, 000) older people between 65 and 89 now have unmet needs for social care[i]. The research uncovers the fact that nearly a third (31.1 per cent) of people who have difficulty in carrying out some essential activities of daily life do not receive any help formally from care workers or informally from family, friends or neighbours and are left to struggle alone. These are older people who require help with everyday tasks such as getting out of bed, washing, using the toilet or eating.

New registry of caregivers with history of abuse of adults in their care signed into law in Kentucky (US)

A new Kentucky law creating a caregiver misconduct registry will help families and employers in the adult care profession learn if an applicant has a record of substantiated adult maltreatment.

Virtual reality allows nurses to experience life with dementia Canada-flat-icon

New technology is giving Saint John nurses a feel for what it’s like to live with dementia by allowing them to experience the disease using virtual reality. The Virtual Dementia Tour is a sensitivity program designed to help simulate what it’s like to live with dementia.

Canadian Medical Association wants seniors’ care on federal agenda Canada-flat-icon

For the second year running, but bolstered by a new survey, Canada’s doctors are calling for a national seniors’ health care strategy. “Federal should worry about this if they want to stay federal politicians,” Canadian Medical Association President Dr. Lopoliticiansuis Hugo Francescutti told CMAJ.

Care home and social care regulation in Northern Ireland subject to full review

Claire Keatinge, the Older People’s Commissioner for Northern Ireland, has admitted there are ‘fundamental failings’ that need to be addressed in order for care regulation to effectively safeguard service users.

Care homes face nurse recruitment ‘crisis,’ claims forum (UK)

Urgent action is needed to attract more nurses into Wales’ independent care sector so it can relieve pressure on hospital bed use, says a campaigner.

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Resources

AHRQ Systematic Review Data Repository

In an effort to reduce the burden of conducting systematic reviews, the Evidence-based Practice Center (EPC) at Tufts Medical Center, with support from the Agency for Healthcare Research and Quality (AHRQ), has developed a collaborative, Web-based repository of systematic review data. The Systematic Review Data Repository (SRDR) is a powerful and easy-to-use tool for the extraction and management of data for systematic review or meta-analysis. It is also an open and searchable archive of systematic reviews and their data. This resources is free but requires registration.

Online Globe & Mail available for free through UofA’s libraries
Must be affiliated with the University.

Follow the instructions to access this paper on your computer, tablet, or smartphone.

Toolkit for Person-Centeredness in Assisted Living – An Informational Guide and Questionnaires of Person-Centered Practices in Assisted Living (PC-PAL)

Initially released for use in June 2014, the Toolkit for Person-Centeredness in Assisted Living was developed through a close partnership between the University of North Carolina at Chapel Hill and the national Center for Excellence in Assisted Living (CEAL), along with assisted living providers, residents, family members, and organizational representatives. Available for free download, the Toolkit includes questionnaires to be completed by assisted living residents and staff, and simple, easy-to-follow instructions for scoring and interpreting the results. The questionnaires measure Person-Centered Practices in Assisted Living, and are called the PC-PAL. Unlike earlier tools, the PC-PAL questionnaires are based on research evidence and have been rigorously tested for ease of use and statistical validity.

RNAO Best Practices: Care Transitions Canada-flat-icon

Best practice guidelines are systematically developed statements to assist nurses and clients make decisions about appropriate health care (Field & Lohr, 1990). This guideline provides evidence-based recommendations for nurses and other members of the interprofessional teamG who are assessing and managing clients undergoing a care transition.

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Opportunities

TVN Request for Proposal Canada-flat-icon
DEADLINE 3 September

TVN is seeking an organization to design and implement an environmental scan that systematically examines the care of the seriously ill, frail elderly nearing end of life. Through this scan TVN will quantitate the health care environment and the health care that this population receives in Canada. This environmental scan will also help identify health care resource utilization which may ultimately be used by policy and decision makers to better utilize and marshal health care resources.

Senior Research Fellow/Research Fellow in Healthcare Modelling
University of Southampton, Southampton UK
DEADLINE 1 September

Southampton Health Technology Assessments Centre (SHTAC) is an NIHR centre of excellence for health technology assessment and health services research with an influential role in determining national health policy through its research programme. SHTAC has expertise in health economics/modelling, evidence synthesis, information science and epidemiology. As part of an expanding research programme, SHTAC is looking to strengthen its multi-disciplinary research team with two new posts. We are looking for people to join a cohesive research team working on economic evaluations and evidence synthesis/primary research to address major policy questions concerning the use of drugs, devices, procedures, diagnostics, public health programmes and other health interventions. You will also work with colleagues on a programme of research on methodological developments related to health technology assessment.

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