April 20, 2015


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Announcements

New TREC Article
The Influence of Organizational Context on Best Practice Use by Care Aides in Residential Long-Term Care Settings
Non UofA Access
Estabrooks CA, Squires JE, Hayduk L, Morgan D, Cummings GG, Ginsburg L, et al.
Journal of the American Medical Directors Association

This study assessed individual and organizational context (work environment) factors that influence use of best practices by care aides (nursing assistants) in nursing homes. Little scientific attention has been focused on understanding best practice use in nursing homes and almost none on care aides. Setting and participants A total of 1262 care aides in 25 nursing homes in the 3 Canadian prairie provinces. Care aides are unregulated workers who provide 80% of direct care to residents in Canadian nursing homes. Method We used hierarchical linear modeling to (1) assess the amount of variance in use of best practices, as reported by care aides, that could be attributed to individual or organizational factors, and (2) identify predictors of best practices use by care aides. Results At the individual level, statistically significant predictors of instrumental use of best practices included sex, age, shift worked, job efficacy, and belief suspension. At the unit level, significant predictors were social capital, organizational slack (staffing and time), number of informal interactions, and unit type. At the facility level, ownership model and province were significant. Significant predictors of conceptual use of best practices at the individual level included English as a first language, job efficacy, belief suspension, intent to use research, adequate knowledge, and number of information sources used. At the unit level, significant predictors were evaluation (feedback mechanisms), structural resources, and organizational slack (time). At the facility level, province was significant. The R2 was 18.3% for instrumental use of best practices and 43.4% for conceptual use. Unit level factors added a substantial amount of explained variance whereas facility level factors added relatively little explained variance. Conclusions Our study suggests that context plays an important role in care aides’ use of best practices in nursing homes. Individual characteristics played a more prominent role than contextual factors in predicting conceptual use of best practices.

TREC on CTV’s Alberta Prime Time

Carole spoke about TREC and its findings in a segment called “Improving pain management for seniors”

Addressing Dementia The OECD Response
2015

The OECD recommended higher priority being given to:
-Timely diagnosis.
-Models of care which promote more independence, dignity and social interaction.
-Improving access to palliative care outside of hospitals, allowing people with dementia end-of-life care with dignity in a place of their choosing.
-Better handling of ethical issues behind the involvement of people with pre-symptomatic dementia in clinical trials.
-New models of consent which address concerns about privacy / confidentiality.

Abstracts

CALL FOR PAPERS:
Narrative Inquiry in Bioethics: A Journal of Qualitative Research

1. Qualitative and Mixed Methods Research Articles. NIB welcomes submitted papers that report on qualitative and mixed methods research studies, including ethnographic, interview, focus group, observational, mixed methods, and related studies in the areas of bioethics, human research ethics, or health care ethics. A variety of approaches to inquiry are welcome, including narrative, phenomenological, grounded theory, ethnographic, and case study approaches.
2. Case Studies. Case study articles are stand-alone articles that include an in-depth description and analysis of one or more instructive cases from health care that involve an ethical problem. NIB welcomes case studies on a variety of subjects including clinical care of patients, institutional undertakings, and policy initiatives. Case studies should be rich in description and should contain an analysis of the case that explores how the ethical challenges might best be addressed and what can be learned from the case.

CALL FOR RESEARCH METHOD CASES:
Write a Research Methods Case and publish it with SAGE

SAGE Research Methods Cases are an online collection of over 500 case studies.
-Written to provide short, useable examples of both quantitative and qualitative methods and research in action
-Aims to put methods in a real research context
How do I write a case?
Writing a case is easy – just tell us about your research experience! We want you to write a short, accessible description of a research project that you have carried out. Through reading your case a student will learn how to carry out a research project, choose and use methods and recognise the challenges and rewards of research in the real world.
What are the benefits to me of writing a case?
A year of free access to all the content and tools on SAGE Research Methods (giving you access to 700 research methods books!).
We will link from your case study to any related published research – driving traffic towards your papers and publications.
By writing a case you benefit from an additional publication from your existing research, and an opportunity to reflect on your own research practice. All while helping in the development of this unique pedagogical tool.

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Grants & Awards

CIHR Call for Proposals: Joint Programming Initiative “More Years, Better Lives”
DEADLINE 2 June

The objective of this call is to support innovative and interdisciplinary research into the drivers to, and constraints on, extending working life. Research is expected to cross the traditional boundaries of Government departments and occupational sectors and to examine the implications of extending working life for older workers (50+), new labour markets, health, wellbeing and intergenerational equity. In this context, this call invites proposals for funding research into one or more of four broad topics:
Modern work factors
Longer working life & Inequality
Health challenges
Caring responsibilities

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Publications

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

KT

The significance of ‘facilitator as a change agent’ – organisational learning culture in aged care home settings.
Non UofA Access
Grealish L, Henderson A, Quero F, Phillips R, Surawski M.
Journal of clinical nursing 2015 Apr;24(7-8):961-969

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.

Systematic review of instruments for measuring nurses’ knowledge, skills and attitudes for evidence-based practice.
Non UofA Access
Leung K, Trevena L, Waters D.
Journal of advanced nursing 2014 Oct;70(10):2181-2195

To identify, appraise and describe the characteristics of instruments for measuring evidence-based knowledge, skills and/or attitudes in nursing practice. BACKGROUND: Evidence-based practice has been proposed for optimal patient care for more than three decades, yet competence in evidence-based practice knowledge and skills among nurse clinicians remains difficult to measure. There is a need to identify well-validated and reliable instruments for assessing competence for evidence-based practice in nursing. DESIGN: Psychometric systematic review. DATA SOURCES: The MEDLINE, EMBASE, CINAHL, ERIC, CDSR, All EBM reviews and PsycInfo databases were searched from 1960-April 2013; with no language restrictions applied. REVIEW METHODS: Using pre-determined inclusion criteria, three reviewers independently identified studies for full-text review, extracting data and grading instrument validity using a Psychometric Grading Framework. RESULTS: Of 91 studies identified for full-text review, 59 met the inclusion criteria representing 24 different instruments. The Psychometric Grading Framework determined that only two instruments had adequate validity – the Evidence Based Practice Questionnaire measuring knowledge, skills and attitudes and another un-named instrument measuring only EBP knowledge and attitudes. Instruments used in another nine studies were graded as having ‘weak’ validity and instruments in the remaining 24 studies were graded as ‘very weak’. CONCLUSION: The Evidence Based Practice Questionnaire was assessed as having the highest validity and was the most practical instrument to use. However, the Evidence Based Practice Questionnaire relies totally on self-report rather than direct measurement of competence suggesting a need for a performance-based instrument for measuring evidence-based knowledge, skills and attitudes in nursing. © 2014 John Wiley & Sons Ltd.

Factors influencing implementation dose and fidelity thereof and related student outcomes of an evidence-based national HIV prevention program
Wang B, Stanton B, Deveaux L, Poitier M, Lunn S, Koci V, et al.
Implementation Science 2015;10(1):44

Teachers’ implementation of evidence-based prevention programs in schools is inconsistent. Using data gathered from the national implementation among grade six students in The Bahamas of an evidence-based HIV intervention [Focus on Youth in the Caribbean (FOYC)], this study examines differences in the degree of implementation (“dose”) and adherence to the core activities (“fidelity of implementation”) by teachers according to theoretically and historically relevant teachers’ characteristics, attitudes, and experiences pre-intervention and post-intervention. The relationship of implementation dose and implementation fidelity is assessed according to student outcomes. Methods Beginning in 2008, the Bahamian Ministry of Education (MOE) included FOYC in the grade six curriculum nationwide. Consistent with standard practice, teachers were offered MOE training workshops in FOYC prior to delivery. The MOE conducted an anonymous curricular assessment among the grade six students at the beginning and end of the school year. Teachers agreeing to participate in the research component were asked to complete a pre-implementation and post-implementation assessment of attitudes and prior experiences. Results Teachers taught 15.6 out of 30 core activities, 24 out of the 46 total activities, and 4.6 out of 8 sessions on average. Three teachers’ implementation groups were identified: 1) High Implementation Group (31.7% of the teachers), characterized by high levels of implementation dose and fidelity of implementation; 2) Moderate Implementation Group (52.8%), showing moderate levels of implementation dose but high levels of fidelity of implementation; and 3) Low Implementation Group (15.6%), with low levels of implementation dose and fidelity of implementation. Low Implementation Group teachers compared to teachers in the two higher performing groups had less training in interactive teaching, limited prior exposure to the FOYC curriculum, incomplete attendance at FOYC training workshops, and low levels of comfort in teaching FOYC lessons. Students taught by teachers in the Low Implementation Group demonstrated poorer outcomes relevant to the four student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection if they were to have sex). Conclusions Both implementation dose and implementation fidelity are related to student outcomes. Teachers at risk for limited implementation can be identified pre-intervention, thus opening the possibility for focused pre-intervention training.

Perceptions of national guidelines and their (non) implementation in mental healthcare: a deductive and inductive content analysis
Sandstrom B, Willman A, Svensson B, Borglin G.
Implementation Science 2015;10(1):43

National guidelines are being produced at an increasing rate, and politicians and managers are expected to promote these guidelines and their implementation in clinical work. However, research seldom deals with how decision-makers can perceive these guidelines or their challenges in a cultural context. Therefore, the aim of this study was twofold: to investigate how well Promoting Action on Research Implementation in Health Services (PARIHS) reflected the empirical reality of mental healthcare and to gain an extended understanding of the perceptions of decision-makers operating within this context, in regard to the implementation of evidence-based guidelines. Methods The study took place in the southeast of Sweden and employed a qualitative design. The data were collected through 23 interviews with politicians and managers working either in the county council or in the municipalities. The transcribed text was analysed iteratively and in two distinct phases, first deductively and second inductively by means of qualitative content analysis. Results Our deductive analysis showed that the text strongly reflected two out of three categorisation matrices, i.e. evidence and context representing the PARIHS framework. However, the key element of facilitation was poorly mirrored in the text. Results from the inductive analysis can be seen in light of the main category sitting on the fence; thus, the informants’ perceptions reflected ambivalence and contradiction. This was illustrated by conflicting views and differences in culture and ideology, a feeling of security in tradition, a certain amount of resistance to change and a lack of role clarity and clear directions. Together, our two analyses provide a rich description of an organisational culture that is highly unlikely to facilitate the implementation of the national guidelines, together with a distrust of the source behind such guidelines, which stands in stark contrast to the high confidence in the knowledge of experienced people in authority within the organisational context. Conclusions Our findings have highlighted that, regardless of by whom guidelines are released, they are not likely to be utilised or implemented if those who are responsible for implementing them do not trust the source. This aspect (i.e. contextual trust) is not covered by PARIHS.

Applying normalization process theory to understand implementation of a family violence screening and care model in maternal and child health nursing practice: a mixed method process evaluation of a randomised controlled trial
Hooker L, Small R, Humphreys C, Hegarty K, Taft A.
Implementation Science 2015;10(1):39

In Victoria, Australia, Maternal and Child Health (MCH) services deliver primary health care to families with children 0–6 years, focusing on health promotion, parenting support and early intervention. Family violence (FV) has been identified as a major public health concern, with increased prevalence in the child-bearing years. Victorian Government policy recommends routine FV screening of all women attending MCH services. Using Normalization Process Theory (NPT), we aimed to understand the barriers and facilitators of implementing an enhanced screening model into MCH nurse clinical practice. Methods NPT informed the process evaluation of a pragmatic, cluster randomised controlled trial in eight MCH nurse teams in metropolitan Melbourne, Victoria, Australia. Using mixed methods (surveys and interviews), we explored the views of MCH nurses, MCH nurse team leaders, FV liaison workers and FV managers on implementation of the model. Quantitative data were analysed by comparing proportionate group differences and change within trial arm over time between interim and impact nurse surveys. Qualitative data were inductively coded, thematically analysed and mapped to NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) to enhance our understanding of the outcome evaluation. Results MCH nurse participation rates for interim and impact surveys were 79% (127/160) and 71% (114/160), respectively. Twenty-three key stakeholder interviews were completed. FV screening work was meaningful and valued by participants; however, the implementation coincided with a significant (government directed) change in clinical practice which impacted on full engagement with the model (coherence and cognitive participation). The use of MCH nurse-designed FV screening/management tools in focussed women’s health consultations and links with FV services enhanced the participants’ work (collective action). Monitoring of FV work (reflexive monitoring) was limited. Conclusions The use of theory-based process evaluation helped identify both what inhibited and enhanced intervention effectiveness. Successful implementation of an enhanced FV screening model for MCH nurses occurred in the context of focussed women’s health consultations, with the use of a maternal health and wellbeing checklist and greater collaboration with FV services. Improving links with these services and the ongoing appraisal of nurse work would overcome the barriers identified in this study.

Osteoporosis Prescribing in Long-Term Care: Impact of a Provincial Knowledge Translation Strategy Canada-flat-icon
Non UofA Access
Kennedy CC, Ioannidis G, Thabane L, Adachi JD, O’Donnell D, Giangregorio LM, et al.
Canadian journal on aging 2015 Apr 8:1-12

This study described prescribing trends before and after implementing a provincial strategy aimed at improving osteoporosis and fracture prevention in Ontario long-term care (LTC) homes. Data were obtained from a pharmacy provider for 10 LTC homes in 2007 and 166 homes in 2012. We used weighted, multiple linear regression analyses to examine facility-level changes in vitamin D, calcium, and osteoporosis medication prescribing rates between 2007 and 2012. After five years, the estimated increase in vitamin D, calcium, and osteoporosis medication prescribing rates, respectively, was 38.2 per cent (95% confidence interval [CI]: 29.0, 47.3; p < .001), 4.0 per cent (95% CI: -3.9, 12.0; p = .318), and 0.2 per cent (95% CI: -3.3, 3.7; p = .91). Although the study could not assess causality, findings suggest that wide-scale knowledge translation activities successfully improved vitamin D prescribing rates, although ongoing efforts are needed to target homes with low uptake.

10 years of mindlines: a systematic review and commentary
Wieringa S, Greenhalgh T.
Implementation Science 2015;10(1):45

In 2004, Gabbay and le May showed that clinicians generally base their decisions on mindlines—internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines. We considered how the concept of mindlines has been taken forward since. Methods We searched databases from 2004 to 2014 for the term ‘mindline(s)’ and tracked all sources citing Gabbay and le May’s 2004 article. We read and re-read papers to gain familiarity and developed an interpretive analysis and taxonomy by drawing on the principles of meta-narrative systematic review. Results In our synthesis of 340 papers, distinguished between authors who used mindlines purely in name (‘nominal’ view) sometimes dismissing them as a harmful phenomenon, and authors who appeared to have understood the term’s philosophical foundations. The latter took an ‘in-practice’ view (studying how mindlines emerge and spread in real-world settings), a ‘theoretical and philosophical’ view (extending theory) or a ‘solution focused’ view (exploring how to promote and support mindline development). We found that it is not just clinicians who develop mindlines: so do patients, in face-to-face and (potentially) online communities. Theoretical publications on mindlines have continued to challenge the rationalist assumptions of evidence-based medicine (EBM). Conventional EBM assumes a single, knowable reality and seeks to strip away context to generate universal predictive rules. In contrast, mindlines are predicated on a more fluid, embodied and intersubjective view of knowledge; they accommodate context and acknowledge multiple realities. When considering how knowledge spreads, the concept of mindlines requires us to go beyond the constraining notions of ‘dissemination’ and ‘translation’ to study tacit knowledge and the interactive human processes by which such knowledge is created, enacted and shared. Solution-focused publications described mindline-promoting initiatives such as relationship-building, collaborative learning and thought leadership. Conclusions The concept of mindlines challenges the naïve rationalist view of knowledge implicit in some EBM publications, but the term appears to have been misunderstood (and prematurely dismissed) by some authors. By further studying mindlines empirically and theoretically, there is potential to expand EBM’s conceptual toolkit to produce richer forms of ‘evidence-based’ knowledge. We outline a suggested research agenda for achieving this goal.

Integrating the Illness Beliefs Model in Clinical Practice: A Family Systems Nursing Knowledge Utilization Model. Canada-flat-icon
Non UofA Access
Duhamel F, Dupuis F, Turcotte A, Martinez AM, Goudreau J.
Journal of family nursing 2015 Apr 2

To promote the integration of Family Systems Nursing (FSN) in clinical practice, we need to better understand how nurses overcome the challenges of FSN knowledge utilization. A qualitative exploratory study was conducted with 32 practicing female nurses from hospital and community settings who had received FSN intervention training and skill development based on the Illness Beliefs Model and the Calgary Family Assessment and Intervention Models. The participants were interviewed about how they utilized FSN knowledge in their nursing practice. From the data analysis, a FSN Knowledge Utilization Model emerged that involves three major components: (a) nurses’ beliefs in FSN and in their FSN skills, (b) nurses’ knowledge utilization strategies to address the challenges of FSN practice, and (c) FSN positive outcomes. The FSN Knowledge Utilization Model describes a circular, incremental, and iterative process used by nurses to integrate FSN in daily nursing practice. Findings point to a need for re-evaluation of educational and management strategies in clinical settings for advancing the practice of FSN. © The Author(s) 2015.

The effectiveness of toolkits as knowledge translation strategies for integrating evidence into clinical care: a systematic review. Canada-flat-icon
Non UofA Access
Yamada J, Shorkey A, Barwick M, Widger K, Stevens BJ.
BMJ open 2015 Apr 13;5(4):e006808-2014-006808

The aim of this systematic review was to evaluate the effectiveness of toolkits as a knowledge translation (KT) strategy for facilitating the implementation of evidence into clinical care. Toolkits include multiple resources for educating and/or facilitating behaviour change. DESIGN: Systematic review of the literature on toolkits. METHODS: A search was conducted on MEDLINE, EMBASE, PsycINFO and CINAHL. Studies were included if they evaluated the effectiveness of a toolkit to support the integration of evidence into clinical care, and if the KT goal(s) of the study were to inform, share knowledge, build awareness, change practice, change behaviour, and/or clinical outcomes in healthcare settings, inform policy, or to commercialise an innovation. Screening of studies, assessment of methodological quality and data extraction for the included studies were conducted by at least two reviewers. RESULTS: 39 relevant studies were included for full review; 8 were rated as moderate to strong methodologically with clinical outcomes that could be somewhat attributed to the toolkit. Three of the eight studies evaluated the toolkit as a single KT intervention, while five embedded the toolkit into a multistrategy intervention. Six of the eight toolkits were partially or mostly effective in changing clinical outcomes and six studies reported on implementation outcomes. The types of resources embedded within toolkits varied but included predominantly educational materials. CONCLUSIONS: Future toolkits should be informed by high-quality evidence and theory, and should be evaluated using rigorous study designs to explain the factors underlying their effectiveness and successful implementation. Published by the BMJ Publishing Group Limited.

What’s in a mechanism? Development of a key concept in realist evaluation
Dalkin S, Greenhalgh J, Jones D, Cunningham B, Lhussier M.
Implementation Science 2015;10(1):49

The idea that underlying, generative mechanisms give rise to causal regularities has become a guiding principle across many social and natural science disciplines. A specific form of this enquiry, realist evaluation is gaining momentum in the evaluation of complex social interventions. It focuses on ‘what works, how, in which conditions and for whom’ using context, mechanism and outcome configurations as opposed to asking whether an intervention ‘works’. Realist evaluation can be difficult to codify and requires considerable researcher reflection and creativity. As such there is often confusion when operationalising the method in practice. This article aims to clarify and further develop the concept of mechanism in realist evaluation and in doing so aid the learning of those operationalising the methodology. Discussion Using a social science illustration, we argue that disaggregating the concept of mechanism into its constituent parts helps to understand the difference between the resources offered by the intervention and the ways in which this changes the reasoning of participants. This in turn helps to distinguish between a context and mechanism. The notion of mechanisms ‘firing’ in social science research is explored, with discussions surrounding how this may stifle researchers’ realist thinking. We underline the importance of conceptualising mechanisms as operating on a continuum, rather than as an ‘on/off’ switch. Summary The discussions in this article will hopefully progress and operationalise realist methods. This development is likely to occur due to the infancy of the methodology and its recent increased profile and use in social science research. The arguments we present have been tested and are explained throughout the article using a social science illustration, evidencing their usability and value.

Translating Evidence-Based Dementia Caregiving Interventions into Practice: State-of-the-Science and Next Steps
Non UofA Access
Gitlin LN, Marx K, Stanley IH, Hodgson N.
The Gerontologist 2015 04/01;55(2):210-226

Over the past 3 decades, more than 200 dementia caregiver interventions have been tested in randomized clinical trials and found to be efficacious. Few programs have been translated for delivery in various service contexts, and they remain inaccessible to the 15+ million dementia family caregivers in the United States. This article examines translational efforts and offers a vision for more rapid advancement in this area. We summarize the evidence for caregiver interventions, review published translational efforts, and recommend future directions to bridge the research-practice fissure in this area. We suggest that as caregiver interventions are tested external to service contexts, a translational phase is required. Yet, this is hampered by evidentiary gaps, lack of theory to understand implementation challenges, insufficient funding and unsupportive payment structures for sustaining programs. We propose ways to advance translational activities and future research with practical applications.

Systematic implementation of evidence-based practice in a clinical nursing setting: a participatory action research project.
Non UofA Access
Friesen-Storms JH, Moser A, van der Loo S, Beurskens AJ, Bours GJ.
Journal of clinical nursing 2015 Jan;24(1-2):57-68

To describe the process of implementing evidence-based practice in a clinical nursing setting. BACKGROUND: Evidence-based practice has become a major issue in nursing, it is insufficiently integrated into daily practice and its implementation is complex. DESIGN: Participatory action research. METHODS: The main participants were nurses working in a lung unit of a rural hospital. A multi-method process of data collection was used during the observing, reflecting, planning and acting phases. Data were continuously gathered during a 24-month period from 2010 to 2012, and analysed using an interpretive constant comparative approach. Patients were consulted to incorporate their perspective. RESULTS: A best-practice mode of working was prevalent on the ward. The main barriers to the implementation of evidence-based practice were that nurses had little knowledge of evidence-based practice and a rather negative attitude towards it, and that their English reading proficiency was poor. The main facilitators were that nurses wanted to deliver high-quality care and were enthusiastic and open to innovation. Implementation strategies included a tailored interactive outreach training and the development and implementation of an evidence-based discharge protocol. The academic model of evidence-based practice was adapted. Nurses worked according to the evidence-based practice discharge protocol but barely recorded their activities. Nurses favourably evaluated the participatory action research process. CONCLUSIONS: Action research provides an opportunity to empower nurses and to tailor evidence-based practice to the practice context. Applying and implementing evidence-based practice is difficult for front-line nurses with limited evidence-based practice competencies. RELEVANCE TO CLINICAL PRACTICE: Adaptation of the academic model of evidence-based practice to a more pragmatic approach seems necessary to introduce evidence-based practice into clinical practice. The use of scientific evidence can be facilitated by using pre-appraised evidence. For clinical practice, it seems relevant to integrate scientific evidence with clinical expertise and patient values in nurses’ clinical decision-making at the individual patient level. © 2014 John Wiley & Sons Ltd.

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Health Care Administration and Organization

“Careworkers don’t have a voice:” Epistemological violence in residential care for older people. Canada-flat-icon
Non UofA Access
Banerjee A, Armstrong P, Daly T, Armstrong H, Braedley S.
Journal of aging studies 2015 Apr;33:28-36

Drawing on feminist epistemologies, this paper attends to the way the reductionist assumptions have shaped the organization of nursing home carework in manners that are insufficient to the needs of relational care. This paper is informed by a study involving nine focus groups and a survey of Canadian residential care workers (141 RNs, 139 LPNs and 415 frontline careworkers). Four major themes were identified. Reductionist assumptions contributed to routinized, task-based approaches to care, resulting in what careworkers termed “assembly line care.” Insufficient time and emphasis on the relational dimensions of care made it difficult to “treat residents as human beings.” Accountability, enacted as counting and documenting, led to an “avalanche of paperwork” that took time away from care. Finally, hierarchies of knowledge contributed to systemic exclusions and the perception that “careworkers’ don’t have a voice.” Careworkers reported distress as a result of the tensions between the organization of work and the needs of relational care. We theorize these findings as examples of “epistemological violence,” a concept coined by Vandana Shiva (1988) to name the harm that results from the hegemony of reductionist assumptions. While not acting alone, we argue that reductionism has played an important role in shaping the context of care both at a policy and organizational level, and it continues to shape the solutions to problems in nursing home care in ways that pose challenges for careworkers. We conclude by suggesting that improving the quality of both work and care will require respecting the specificities of care and its unique epistemological and ontological nature. Copyright © 2015 Elsevier Inc.

Physicians in Nursing Homes: Effectiveness of Physician Accountability and Communication.
Non UofA Access
Lima JC, Intrator O, Wetle T.
Journal of the American Medical Directors Association 2015 Apr 6

The objective of this study was to develop a measure of the perceptions of nursing home (NH) directors of nursing (DONs) on the adequacy of physician care and to examine its variation as well as its construct validity. DESIGN: A nationwide cross-sectional study with primary data collection. SETTING: A total of 2043 NHs surveyed between August 2009 and April 2011. PARTICIPANTS: DONs and NH administrators responded to questions pertaining to their perceptions of the care provided by physicians in their NH. MEASUREMENTS: Ten items were used to create 3 domains: medical staff attentiveness, physician communication, and staff concerns about physician practice. These were combined into an overall summary score measure called “Effectiveness of Physician Accountability and Communication” (EPAC). EPAC construct validity was ascertained from other DON questions and from a complementary survey of NH administrators. RESULTS: The established EPAC score is the first measure to capture specific components of the adequacy of physician care in NHs. EPAC exhibited good construct validity: more effective practices were correlated with greater physician involvement in discussions of do-not-resuscitate orders, the frequency with which the medical director checked on the medical care delivered by the attending physician, the tightness of the NH’s control of its physician resources, and the DON’s perception of whether or not avoidable hospitalizations and emergency room visits could be reduced with greater physician attention to resident needs. CONCLUSION: As increased attention is given to the quality of care provided to vulnerable elders, effective measures of processes of care are essential. The EPAC measure provides an important new metric that can be used in these efforts. The goal is that future studies could use EPAC and its individual domains to shed light on the manner through which physician presence is related to resident outcomes in the NH setting. Copyright © 2015 AMDA

A Systematic Review of Measurement Properties of Instruments Assessing Presenteeism.
Ospina M, B., Dennett L, Waye A, Jacobs P, Thompson A, H.
American Journal of Managed Care 2015 02;21(2):e171-85

Presenteeism (decreased productivity while at work) is reported to be a major occupational problem in many countries. Challenges exist for identifying the optimal approach to measure presenteeism. Evidence of the relative value of presenteeism instruments to support their use in primary studies is needed. Objectives To assess and compare the measurement properties (ie, validity, reliability, responsiveness) and the quality of the evidence of presenteeism instruments. Study Design Systematic review. Methods Comprehensive searches of electronic databases were conducted up to October 2012. Twenty-three presenteeism instruments were examined. Methodological quality was appraised with the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist. A best-evidence synthesis approach was used in the analysis. Results The titles and abstracts of 1767 articles were screened, with 289 full-text articles reviewed for eligibility. Of these, 40 studies assessing the measurement properties of presenteeism instruments were identified. The 3 presenteeism instruments with the strongest level of evidence on more than 1 measurement property were the Stanford Presenteeism Scale, 6-item version (content validity, internal consistency, construct validity, convergent validity, and responsiveness); the Endicott Work Productivity Scale (internal consistency, convergent validity, and responsiveness); and the Health and Work Questionnaire (HWQ; internal consistency and structural validity). Only the HWQ was assessed for criterion validity, with unknown quality of the evidence. Conclusions Most presenteeism instruments have been examined for some form of validity; evidence for criterion validity is virtually absent. The selection of instruments for use in primary studies depends on weak forms of validity. Further research should focus on the goal of a comprehensive evaluation of the psychometric properties of existing tests of presenteeism, with emphasis on criterion validity.

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Health Care Innovation and Quality Assurance

Clinical Burden, Quality of Care, Organizational Context: Different Lenses to Optimize Care for Older People. Canada-flat-icon
Non UofA Access
Wong RY.
Journal of the American Medical Directors Association 2015 Mar 31.

For many practitioners in geriatrics, the primary mission in caring for frail older people (especially those with dementia) is to optimize their quality of life. This is often achieved, at least in part, by reducing their clinical symptom burden, which is particularly relevant in end-of-life care. Although recent advances have focused on improving the pharmacologic and nonpharmacologic modalities of symptom reduction at the level of an individual patient, we must remember that a system-based approach to improve the quality-of-care provision can have a larger impact on groups of patients, and when such quality improvement results in an organizational or contextual change, the impact can become more sustainable over time.

Quality improvement in nursing homes: testing of an alarm elimination program.
Non UofA Access
Crogan NL, Dupler AE.
Journal of nursing care quality 2014 Jan-Mar;29(1):60-65

Falls are the most common cause of injury deaths and nonfatal injuries in older adults. In an effort to detect a resident’s movement, many nursing homes use bed or chair alarms to alert staff that the resident may get up and possibly fall. However, there is little evidence that bed or chair alarms prevent falls, and mounting evidence that alarms can impede the functional status and negatively impact feelings of dignity among older adults in nursing homes. The purpose of this article was to describe the development and pilot testing of an alarm elimination program for nursing homes. A program aimed at decreasing or eliminating the use of alarms may enhance quality of life of older adults in nursing homes.

Process Evaluation of a Quality Improvement Project to Decrease Hospital Readmissions From Skilled Nursing Facilities.
Non UofA Access
Meehan TP S, Qazi DJ, Van Hoof TJ, Ho SY, Eckenrode S, Spenard A, et al.
Journal of the American Medical Directors Association 2015 Mar 29

To describe and evaluate the impact of quality improvement (QI) support provided to skilled nursing facilities (SNFs) by a Quality Improvement Organization (QIO). DESIGN: Retrospective, mixed-method, process evaluation of a QI project intended to decrease preventable hospital readmissions from SNFs. SETTING: Five SNFs in Connecticut. PARTICIPANTS: SNF Administrators, Directors of Nursing, Assistant Directors of Nursing, Admissions Coordinators, Registered Nurses, Certified Nursing Assistants, Receptionists, QIO Quality Improvement Consultant. INTERVENTION: QIO staff provided training and technical assistance to SNF administrative and clinical staff to establish or enhance QI infrastructure and implement an established set of QI tools [Interventions to Reduce Acute Care Transfers (INTERACT) tools]. MEASUREMENTS: Baseline SNF demographic, staffing, and hospital readmission data; baseline and follow-up SNF QI structure (QI Committee), processes (general and use of INTERACT tools), and outcome (30-day all-cause hospital readmission rates); details of QIO-provided training and technical assistance; QIO-perceived barriers to quality improvement; SNF leadership-perceived barriers, accomplishments, and suggestions for improvement of QIO support. RESULTS: Success occurred in establishing QI Committees and targeting preventable hospital readmissions, as well as implementing INTERACT tools in all SNFs; however, hospital readmission rates decreased in only 2 facilities. QIO staff and SNF leaders noted the ongoing challenge of engaging already busy SNF staff and leadership in QI activities. SNF leaders reported that they appreciated the training and technical assistance that their institutions received, although most noted that additional support was needed to bring about improvement in readmission rates. CONCLUSION: This process evaluation documented mixed clinical results but successfully identified opportunities to improve recruitment of and provision of technical support to participating SNFs. Recommendations are offered for others who wish to conduct similar projects. Copyright © 2015 AMDA

A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework
Moullin J, Sabater-Hernandez D, Fernandez-Llimos F, Benrimoj S.
Health Research Policy and Systems 2015;13(1):16

Implementation science and knowledge translation have developed across multiple disciplines with the common aim of bringing innovations to practice. Numerous implementation frameworks, models, and theories have been developed to target a diverse array of innovations. As such, it is plausible that not all frameworks include the full range of concepts now thought to be involved in implementation. Users face the decision of selecting a single or combining multiple implementation frameworks. To aid this decision, the aim of this review was to assess the comprehensiveness of existing frameworks. Methods A systematic search was undertaken in PubMed to identify implementation frameworks of innovations in healthcare published from 2004 to May 2013. Additionally, titles and abstracts from Implementation Science journal and references from identified papers were reviewed. The orientation, type, and presence of stages and domains, along with the degree of inclusion and depth of analysis of factors, strategies, and evaluations of implementation of included frameworks were analysed. Results Frameworks were assessed individually and grouped according to their targeted innovation. Frameworks for particular innovations had similar settings, end-users, and ‘type’ (descriptive, prescriptive, explanatory, or predictive). On the whole, frameworks were descriptive and explanatory more often than prescriptive and predictive. A small number of the reviewed frameworks covered an implementation concept(s) in detail, however, overall, there was limited degree and depth of analysis of implementation concepts. The core implementation concepts across the frameworks were collated to form a Generic Implementation Framework, which includes the process of implementation (often portrayed as a series of stages and/or steps), the innovation to be implemented, the context in which the implementation is to occur (divided into a range of domains), and influencing factors, strategies, and evaluations. Conclusions The selection of implementation framework(s) should be based not solely on the healthcare innovation to be implemented, but include other aspects of the framework’s orientation, e.g., the setting and end-user, as well as the degree of inclusion and depth of analysis of the implementation concepts. The resulting generic structure provides researchers, policy-makers, health administrators, and practitioners a base that can be used as guidance for their implementation efforts.

Person-centered Climate Questionnaire-Patient in English: A psychometric evaluation study in long-term care settings.
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Yoon JY, Roberts T, Grau B, Edvardsson D.
Archives of Gerontology and Geriatrics 2015 Apr 6

There is increasing evidence that person-centered care improves nursing home residents’ quality of life. Despite the clear focus of person-centered care on enhancing care for residents and engaging residents in care, there are few options available for measuring person-centered care from the perspective of the elder residents. OBJECTIVE: The aim of this study was to assess the psychometric properties of the English version of the Person-centered Climate Questionnaire-Patient (PCQ-P) in U.S. long-term care settings. METHODS: A total of 189 older adults from six nursing homes in the Midwestern United States were included. Convergent validity and known-group comparison were examined for construct validity. Exploratory factor analysis and second-order confirmatory factor analysis were utilized to examine the factor structure. Reliability was tested using Cronbach’s alpha values for internal consistency. RESULTS: This study demonstrated a substantial convergent validity of the PCQ-P in English as higher scores correlated significantly with higher resident life satisfaction (r=0.459), and the satisfactory construct validity as evidenced by a significantly higher mean PCQ-P score from residents in higher quality nursing homes. Factor analysis demonstrated that the PCQ-P had three factors (hospitality, safety, and everydayness) in U.S. nursing home residents. The PCQ-P showed satisfactory internal consistency reliability (α=0.89). CONCLUSION: The English version of the PCQ-P is a valid and reliable tool to directly measure the perceptions of the person-centered climate in the U.S nursing homes. The simple and straightforward PCQ-P items are easy to administer to nursing home residents. Consequently, clinical staff can utilize the PCQ-P to assess the unit climate, and evaluate outcomes of person-centered interventions. Copyright © 2015 Elsevier Ireland

Creating peer groups for assessing and comparing nursing home performance.
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Byrne MM, Daw C, Pietz K, Reis B, Petersen LA.
The American Journal of Managed Care 2013 Nov;19(11):933-939

Publicly reported performance data for hospitals and nursing homes are becoming ubiquitous. For such comparisons to be fair, facilities must be compared with their peers. OBJECTIVES: To adapt a previously published methodology for developing hospital peer groupings so that it is applicable to nursing homes and to explore the characteristics of “nearest-neighbor” peer groupings. STUDY DESIGN: Analysis of Department of Veterans Affairs administrative databases and nursing home facility characteristics. METHODS: The nearest-neighbor methodology for developing peer groupings involves calculating the Euclidean distance between facilities based on facility characteristics. We describe our steps in selection of facility characteristics, describe the characteristics of nearest-neighbor peer groups, and compare them with peer groups derived through classical cluster analysis. RESULTS: The facility characteristics most pertinent to nursing home groupings were found to be different from those that were most relevant for hospitals. Unlike classical cluster groups, nearest neighbor groups are not mutually exclusive, and the nearest-neighbor methodology resulted in nursing home peer groupings that were substantially less diffuse than nursing home peer groups created using traditional cluster analysis. CONCLUSION: It is essential that healthcare policy makers and administrators have a means of fairly grouping facilities for the purposes of quality, cost, or efficiency comparisons. In this research, we show that a previously published methodology can be successfully applied to a nursing home setting. The same approach could be applied in other clinical settings such as primary care.

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Research Practice and Methodology

Inclusion of quasi-experimental studies in systematic reviews of health systems research.
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Rockers PC, Rottingen JA, Shemilt I, Tugwell P, Barnighausen T.
Health policy (Amsterdam, Netherlands) 2015 Apr;119(4):511-521

Systematic reviews of health systems research commonly limit studies for evidence synthesis to randomized controlled trials. However, well-conducted quasi-experimental studies can provide strong evidence for causal inference. With this article, we aim to stimulate and inform discussions on including quasi-experiments in systematic reviews of health systems research. We define quasi-experimental studies as those that estimate causal effect sizes using exogenous variation in the exposure of interest that is not directly controlled by the researcher. We incorporate this definition into a non-hierarchical three-class taxonomy of study designs – experiments, quasi-experiments, and non-experiments. Based on a review of practice in three disciplines related to health systems research (epidemiology, economics, and political science), we discuss five commonly used study designs that fit our definition of quasi-experiments: natural experiments, instrumental variable analyses, regression discontinuity analyses, interrupted times series studies, and difference studies including controlled before-and-after designs, difference-in-difference designs and fixed effects analyses of panel data. We further review current practices regarding quasi-experimental studies in three non-health fields that utilize systematic reviews (education, development, and environment studies) to inform the design of approaches for synthesizing quasi-experimental evidence in health systems research. Ultimately, the aim of any review is practical: to provide useful information for policymakers, practitioners, and researchers. Future work should focus on building a consensus among users and producers of systematic reviews regarding the inclusion of quasi-experiments.Copyright © 2015 Elsevier Ireland Ltd.

The rise of multiple imputation: a review of the reporting and implementation of the method in medical research
Hayati Rezvan P, Lee KJ, Simpson JA.
BMC medical research methodology 2015 01;15(1):30-30

Missing data are common in medical research, which can lead to a loss in statistical power and potentially biased results if not handled appropriately. Multiple imputation (MI) is a statistical method, widely adopted in practice, for dealing with missing data. Many academic journals now emphasise the importance of reporting information regarding missing data and proposed guidelines for documenting the application of MI have been published. This review evaluated the reporting of missing data, the application of MI including the details provided regarding the imputation model, and the frequency of sensitivity analyses within the MI framework in medical research articles. Methods A systematic review of articles published in the Lancet and New England Journal of Medicine between January 2008 and December 2013 in which MI was implemented was carried out. Results We identified 103 papers that used MI, with the number of papers increasing from 11 in 2008 to 26 in 2013. Nearly half of the papers specified the proportion of complete cases or the proportion with missing data by each variable. In the majority of the articles (86%) the imputed variables were specified. Of the 38 papers (37%) that stated the method of imputation, 20 used chained equations, 8 used multivariate normal imputation, and 10 used alternative methods. Very few articles (9%) detailed how they handled non-normally distributed variables during imputation. Thirty-nine papers (38%) stated the variables included in the imputation model. Less than half of the papers (46%) reported the number of imputations, and only two papers compared the distribution of imputed and observed data. Sixty-six papers presented the results from MI as a secondary analysis. Only three articles carried out a sensitivity analysis following MI to assess departures from the missing at random assumption, with details of the sensitivity analyses only provided by one article. Conclusions This review outlined deficiencies in the documenting of missing data and the details provided about imputation. Furthermore, only a few articles performed sensitivity analyses following MI even though this is strongly recommended in guidelines. Authors are encouraged to follow the available guidelines and provide information on missing data and the imputation process.

Improving participation rates by providing choice of participation mode: two randomized controlled trials
Hayati Rezvan P, Lee KJ, Simpson JA.
BMC medical research methodology 2015 01;15(1):30-30

Low participation rates reduce effective sample size, statistical power and can increase risk for selection bias. Previous research suggests that offering choice of participation mode can improve participation rates. However, few head-to-head trials compared choice of participation mode using telephone interviews and postal questionnaires as modes of interest. Aiming to explore effects of choice of participation, two randomized controlled trials were performed comparing participation rates of patients provided with and without choice of participation mode, using interviews and questionnaires as participation modes. Methods Two trials were embedded in a larger study on cardiovascular risk management in primary care. Patients with a chronic cardiovascular condition recruited for the larger study were invited to participate in an additional survey on social networks, using invitations with and without choice of participation mode. Primary outcome was participation rate. Other outcomes of interest were participation rate conditional on willingness to participate, and initial willingness to participate. In trial 1 we compared outcomes after choice of participation mode (interview or questionnaire) with invitations for participation in a telephone interview. In Trial 2 results for choice of participation mode were compared with postal questionnaires. Results In Trial 1 no differences were found in participation rates (65% vs 66%, p = 0.853) although conditional participation rate was highest for interviews (90% vs 72%, p < .01). Initial willingness to participate was higher when choice of participation mode was provided (90% versus 73%, p < .01). In Trial 2 participation rate and conditional participation rate was higher when choice of participation mode was provided (59% vs 46%, p < .01 and 66% vs 53%, p < .01, respectively). No differences were found for initial willingness to participate (90% vs 86%, p = 0.146). Conclusion Offering choice of participation mode had benefit on participation rates compared to invitations to participate in questionnaires, but not when compared to invitations to participate in telephone interviews.

Time to rethink the systematic review catechism? Moving from ‘what works’ to ‘what happens’
Petticrew M.
Systematic Reviews 2015;4(1):36

Systematic review methods are developing rapidly, and most researchers would recognise their key methodological aspects, such as a closely focussed question, a comprehensive search, and a focus on synthesising ‘stronger’ rather than ‘weaker’ evidence. However, it may be helpful to question some of these underlying principles, because while they work well for simpler review questions, they may result in overly narrow approaches to more complex questions and interventions. This commentary discusses some core principles of systematic reviews, and how they may require further rethinking, particularly as reviewers turn their attention to increasingly complex issues, where a Bayesian perspective on evidence synthesis, which would aim to assemble evidence – of different types, if necessary – in order to inform decisions’, may be more productive than the ‘traditional’ systematic review model. Among areas identified for future research are the examination of publication bias in qualitative research; research on the efficiency and potential biases of comprehensive searches in different disciplines; and the use of Bayesian methods in evidence synthesis. The incorporation of a systems perspective into systematic reviews is also an area which needs rapid development.

A narrative review of research impact assessment models and methods
Milat A, Bauman A, Redman S.
Health Research Policy and Systems 2015;13(1):18

Research funding agencies continue to grapple with assessing research impact. Theoretical frameworks are useful tools for describing and understanding research impact. The purpose of this narrative literature review was to synthesize evidence that describes processes and conceptual models for assessing policy and practice impacts of public health research. Methods The review involved keyword searches of electronic databases, including MEDLINE, CINAHL, PsycINFO, EBM Reviews, and Google Scholar in July/August 2013. Review search terms included ‘research impact’, ‘policy and practice’, ‘intervention research’, ‘translational research’, ‘health promotion’, and ‘public health’. The review included theoretical and opinion pieces, case studies, descriptive studies, frameworks and systematic reviews describing processes, and conceptual models for assessing research impact. The review was conducted in two phases: initially, abstracts were retrieved and assessed against the review criteria followed by the retrieval and assessment of full papers against review criteria. Results Thirty one primary studies and one systematic review met the review criteria, with 88% of studies published since 2006. Studies comprised assessments of the impacts of a wide range of health-related research, including basic and biomedical research, clinical trials, health service research, as well as public health research. Six studies had an explicit focus on assessing impacts of health promotion or public health research and one had a specific focus on intervention research impact assessment. A total of 16 different impact assessment models were identified, with the ‘payback model’ the most frequently used conceptual framework. Typically, impacts were assessed across multiple dimensions using mixed methodologies, including publication and citation analysis, interviews with principal investigators, peer assessment, case studies, and document analysis. The vast majority of studies relied on principal investigator interviews and/or peer review to assess impacts, instead of interviewing policymakers and end-users of research. Conclusions Research impact assessment is a new field of scientific endeavour and there are a growing number of conceptual frameworks applied to assess the impacts of research.

Evaluation as evolution: a Darwinian proposal for health policy and systems research
Martiniuk A, Abimbola S, Zwarenstein M.
Health Research Policy and Systems 2015;13(1):15

Health systems are complex and health policies are political. While grand policies are set by politicians, the detailed implementation strategies which influence the shape and impact of these policies are delegated to technical personnel. This is an underappreciated opportunity for optimising health systems. We propose that selective ‘breeding’ through successive evaluations of and selection among implementation strategies is a metaphor that health system thinkers can use to improve health care. Discussion Similar to Darwinian evolution, the acceptance and accumulation of successful choices and the detection and discarding of unsuccessful ones would improve health systems in small and uncontroversial ways, over time. The effects of better implementation choices would be synergistic and cumulative, accumulating large impact (and lessons) from small changes. Just as with evolution of species, this means that even slight improvements over usual outcomes makes these numerous small choices as important a focus for system improvement as the overarching policy itself. Several alternative implementation approaches can be compared under real-world conditions in prospective head-to-head experimental and non-experimental explorations to understand whether and to what extent a strategy works and what works for whom, how, and under what circumstances in different locations. As in breeding or evolution, the best variants would spread to become the new, proven superior, implementation strategies for that policy in those settings. Conclusions Evolution does not produce a new species whole, in a single transaction. Instead it gathers new parts and powers over time as different combinations are tested through competition with one another, to survive and spread or become extinct. Without necessarily changing or challenging grand policies, extending this idea to health systems innovation can facilitate thinking around how local, small – but cumulative – improvements in implementation potentially contribute to a pattern of successive adaptation spreading within its viable niche and ultimately providing locally-derived, long-term improvements in health systems.

Recruitment of Mobility Limited Older Adults Into a Facility-Led Exercise-Nutrition Study: The Effect of Social Involvement
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Corcoran MP, Nelson ME, Sacheck JM, Reid KF, Kirn D, Fielding RA, et al.
The Gerontologist 2015 03/20

Older adults are among the most challenging population groups to enroll into health-related research. This article describes two methods used by investigators to recruit mobility limited older adults residing at assisted living or senior housing (SH) facilities into a facility-led exercise-nutrition research study. Design and Methods: Sedentary older adults were recruited from 42 different assisted living facilities (ALFs) or SH communities. Two different recruitment approaches were used: At 22 sites, investigators conducted heavily advertised informational sessions to recruit participants (Info only). At 20 locations, these sessions were preceded by attendance of a study team member at various activities offered by the facility over the preceding 2 weeks (activity attendance). Population reach, enrollment, personnel cost, and time required to recruit at least five participants at each facility was measured. Reasons for declining participation and withdrawal rate were also measured. Results: Sixty percent more residents elected to be screened for eligibility when study personnel attended an activity offered by the facility. Activity attendance resulted in significantly less time, costs, and participant withdrawals compared with facilities with no activity attendance. Implications: Study team member attendance at activities offered by senior living facilities reduces cost and duration of recruitment and improves study retention. Interventions targeting this demographic are likely to benefit from deliberately building trust and familiarity among the resident population at senior living communities as part of the recruitment process.

Using a population-based observational cohort study to address difficult comparative effectiveness research questions: the CEASAR study.
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Barocas DA, Chen V, Cooperberg M, Goodman M, Graff JJ, Greenfield S, et al.
Journal of comparative effectiveness research 2013 Jul;2(4):445-460

While randomized controlled trials represent the highest level of evidence we can generate in comparative effectiveness research, there are clinical scenarios where this type of study design is not feasible. The Comparative Effectiveness Analyses of Surgery and Radiation in localized prostate cancer (CEASAR) study is an observational study designed to compare the effectiveness and harms of different treatments for localized prostate cancer, a clinical scenario in which randomized controlled trials have been difficult to execute and, when completed, have been difficult to generalize to the population at large. METHODS: CEASAR employs a population-based, prospective cohort study design, using tumor registries as cohort inception tools. The primary outcome is quality of life after treatment, measured by validated instruments. Risk adjustment is facilitated by capture of traditional and nontraditional confounders before treatment and by propensity score analysis. RESULTS: We have accrued a diverse, representative cohort of 3691 men in the USA with clinically localized prostate cancer. Half of the men invited to participate enrolled, and 86% of patients who enrolled have completed the 6-month survey. CONCLUSION: Challenging comparative effectiveness research questions can be addressed using well-designed observational studies. The CEASAR study provides an opportunity to determine what treatments work best, for which patients, and in whose hands.

Exploring physician specialist response rates to web-based surveys Canada-flat-icon
Cunningham CT, Quan H, Hemmelgarn B, Noseworthy T, Beck CA, Dixon E, et al.
BMC Medical Research Methodology 2015 apr;15(1):32

Survey research in healthcare is an important tool to collect information about healthcare delivery, service use and overall issues relating to quality of care. Unfortunately, physicians are often a group with low survey response rates and little research has looked at response rates among physician specialists. For these reasons, the purpose of this project was to explore survey response rates among physician specialists in a large metropolitan Canadian city. Methods As part of a larger project to look at physician payment plans, an online survey about medical billing practices was distributed to 904 physicians from various medical specialties. The primary method for physicians to complete the survey was via the Internet using a well-known and established survey company (www.surveymonkey.com). Multiple methods were used to encourage survey response such as individual personalized email invitations, multiple reminders, and a draw for three gift certificate prizes were used to increase response rate. Descriptive statistics were used to assess response rates and reasons for non-response. Results Overall survey response rate was 35.0%. Response rates varied by specialty: Neurology/neurosurgery (46.6%); internal medicine (42.9%); general surgery (29.6%); pediatrics (29.2%); and psychiatry (27.1%). Non-respondents listed lack of time/survey burden as the main reason for not responding to our survey. Conclusions Our survey results provide a look into the challenges of collecting healthcare research where response rates to surveys are often low. The findings presented here should help researchers in planning future survey based studies. Findings from this study and others suggest smaller monetary incentives for each individual may be a more appropriate way to increase response rates.

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Aging

Depression, frailty, and all-cause mortality: a cohort study of men older than 75 years.
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Almeida OP, Hankey GJ, Yeap BB, Golledge J, Norman PE, Flicker L.
Journal of the American Medical Directors Association 2015 Apr 1;16(4):296-300

Depression is associated with increased mortality, but it is unclear if this relationship is truly causal. OBJECTIVES: To determine the relative mortality associated with past and current depression, taking into account the effect of frailty. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal cohort study of 2565 men aged 75 years or over living in metropolitan Perth, Western Australia, who completed the third wave of assessments of the Health In Men Study throughout 2008. MAIN OUTCOME AND MEASURES: All-cause mortality data were derived from Australian death records up to June 17, 2013. History of past depression and age of onset of symptoms were obtained from direct questioning and from electronic health record linkage. Diagnosis of current major depressive symptoms followed Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision guidelines. We considered that participants were frail if they showed evidence of impairment in 3 or more of the 5 domains on the fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) scale. Other measured factors included age, education, living arrangements, smoking and alcohol history, and physical activity. RESULTS: 558 participants died during mean period of follow-up of 4.2 ± 1.1 years. The annual death rate per thousand was 50 for men without depression, 52 for men with past depression, and 201 for men with major depressive symptoms at baseline. The crude mortality hazard was 4.26 (95% confidence interval = 2.98, 6.09) for men with depression at baseline compared with never depressed men, and 1.79 (95% confidence interval = 1.21, 2.62) after adjustment for frailty. Further decline in mortality hazard was observed after adjustment for other measured factors. CONCLUSIONS: Current, but not past, depression is associated with increased mortality, and this excess mortality is strongly associated with frailty. Interventions designed to decrease depression-related mortality in later life may need to focus on ameliorating frailty in addition to treating depression. Copyright © 2015 AMDA

Critical Decisions for Older People With Advanced Dementia: A Prospective Study in Long-Term Institutions and District Home Care.
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Toscani F, van der Steen JT, Finetti S, Giunco F, Pettenati F, Villani D, et al.
Journal of the American Medical Directors Association 2015 Apr 2

To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services. DESIGN: Prospective cohort study with a follow-up of 6 months. SETTING: Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy. PARTICIPANTS: Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥7) and expected survival ≥2 weeks. MEASUREMENTS: At baseline, the patients’ demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients’ general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤15 days). RESULTS: For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. CONCLUSIONS: Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life. Copyright © 2015 AMDA

Derivation of a frailty index from the interRAI acute care instrument
Hubbard RE, Peel NM, Samanta M, Gray LC, Fries BE, Mitnitski A, et al.
BMC Geriatrics 2015 03;15(1):27-27

A better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care. Methods 1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis. Results Variables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data. Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0–1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0. In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70 – 2.48]). Conclusions Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs. The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.

Agreement between administrative data and the Resident Assessment Instrument Minimum Dataset (RAI-MDS) for medication use in long-term care facilities: a population-based study
Lix LM, Yan L, Blackburn D, Hu N, Schneider-Lindner V, Shevchuk Y, et al.
BMC Geriatrics 2015 03;15(1):24-24

Prescription medication use, which is common among long-term care facility (LTCF) residents, is routinely used to describe quality of care and predict health outcomes. Data sources that capture medication information, which include surveys, medical charts, administrative health databases, and clinical assessment records, may not collect concordant information, which can result in comparable prevalence and effect size estimates. The purpose of this research was to estimate agreement between two population-based electronic data sources for measuring use of several medication classes among LTCF residents: outpatient prescription drug administrative data and the Resident Assessment Instrument Minimum Data Set (RAI-MDS) Version 2.0. Methods Prescription drug and RAI-MDS data from the province of Saskatchewan, Canada (population 1.1 million) were linked for 2010/11 in this cross-sectional study. Agreement for anti-psychotic, anti-depressant, and anti-anxiety/hypnotic medication classes was examined using prevalence estimates, Cohen’s κ, and positive and negative agreement. Mixed-effects logistic regression models tested resident and facility characteristics associated with disagreement. Results The cohort was comprised of 8,866 LTCF residents. In the RAI-MDS data, prevalence of anti-psychotics was 35.7%, while for anti-depressants it was 37.9% and for hypnotics it was 27.1%. Prevalence was similar in prescription drug data for anti-psychotics and anti-depressants, but lower for hypnotics (18.0%). Cohen’s κ ranged from 0.39 to 0.85 and was highest for the first two medication classes. Diagnosis of a mood disorder and facility affiliation was associated with disagreement for hypnotics. Conclusions Agreement between prescription drug administrative data and RAI-MDS assessment data was influenced by the type of medication class, as well as selected patient and facility characteristics. Researchers should carefully consider the purpose of their study, whether it is to capture medication that are dispensed or medications that are currently used by residents, when selecting a data source for research on LTCF populations.

What should we know about dementia in the 21st Century? A Delphi consensus study.
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Annear MJ, Toye C, McInerney F, Eccleston C, Tranter B, Elliott KE, et al.
BMC geriatrics 2015 Feb 6;15(1):5

Escalating numbers of people are experiencing dementia in many countries. With increasing consumer needs, there is anticipated growth in the numbers of people providing diagnostic evaluations, treatments, and care. Ensuring a consistent and contemporary understanding of dementia across all of these groups has become a critical issue. This study aimed to reach consensus among dementia experts from English speaking countries regarding essential and contemporary knowledge about dementia.MethodsAn online Delphi study was conducted to examine expert opinion concerning dementia knowledge with three rounds of data collection. A sample of dementia experts was selected by a panel of Australian experts, including a geriatrician and three professors of aged care. Purposive selection was initially undertaken with the sample expanded through snowballing. Dementia experts (N¿=¿19) included geriatricians, psychologists, psychiatrists, neuroscientists, dementia advocates, and nurse academics from the United Kingdom, United States, and Australia. In the first round, these participants provided open-ended responses to questions determining what comprised essential knowledge about dementia. In the second round, responses were summarised into 66 discrete statements that participants rated on the basis of importance. In the third round, a rank-ordered list of the 66 statements and a group median were provided and participants rated the statements again. The degree of consensus regarding importance ratings was determined by assessing median, interquartile range, and proportion of experts scoring above predetermined thresholds. Correlation scores were calculated for each statement after the final round to identify changes in statement scores.ResultsThe Delphi experts identified 36 statements about dementia that they considered essential to understanding the condition. Statements about care for a person experiencing dementia and their care giver represented the largest response category. Other statements, for which full or very high consensus was reached, related to dementia characteristics, symptoms and progression, diagnosis and assessment, and treatment and prevention.ConclusionsThese results summarise knowledge of dementia that is considered essential across expert representatives of key stakeholder groups from three countries. This information has implications for the delivery of care to people with the condition and the development of dementia education programs.

Predictors of caregiving satisfaction in informal caregivers of people with dementia.
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de Labra C, Millan-Calenti JC, Bujan A, Nunez-Naveira L, Jensen AM, Peersen MC, et al.
Archives of Gerontology and Geriatrics 2015 Mar 14

The prevalence of dementia is increasing and consequently the demands from families, institutions and healthcare system. Although a substantial amount of research on caregiving has emphasized the negative aspects of caregiving, specifically on caregiver burden and depression, less attention has been paid to the positive aspects of caregiving. The aim of the present work was to study the phenomenon of caregiving satisfaction in informal caregivers of people with dementia by assessing their likely predictors. METHODS: A stress process model was used to study caregiver’s satisfaction (measured using the Revised Caregiving Satisfaction Scale) on 101 informal caregivers of patients with dementia in relation to the caregiver’s background and context, stress-related factors, and mediators. RESULTS: The regression model has an adjusted R2 of 0.20, which indicates that having a consanguinity relationship with the care recipient, suffering from lower levels of subjective burden, and managing individuals with severe cognitive impairment are the most important predictors of higher caregiving satisfaction. CONCLUSION: Interventions focused on the enhancement of the caregiving satisfaction by increasing the understanding of the disease, should be especially addressed to caregivers without a consanguinity relationship and with high levels of subjective burden, and to those managing care recipients with mild or moderate stages of dementia. Copyright © 2015 Elsevier Ireland Ltd.

Comparison of sit-to-stand strategies used by older adults and people living with dementia.
Non UofA Access
Dolecka UE, Ownsworth T, Kuys SS.
Archives of Gerontology and Geriatrics 2015 Jan 5

Physiotherapists routinely retrain sit-to-stand (STS) during rehabilitation using strategies such as sliding forward, moving the feet backwards, leaning forward, and pushing through the armrests. It is unknown if people living with dementia use the same strategies as other older adults and if a table positioned in front alters their performance. Twenty participants 65 years or older (10 with Alzheimer’s disease or mixed dementia; 10 without dementia) performed six STS trials from a standard chair with armrests, including three trials without and three with a table in front. Trials were digitally recorded and the starting position and type and order of strategies used were rated by a blinded assessor. Starting position was similar between the groups. The most common strategy was leaning forward (119 out of 120 trials) while the least used was sliding forward (four out of 120 trials). People living with dementia used significantly more strategies (p=0.037), pushed through the armrests more than older adults (p=0.038) and moved feet backwards more frequently in trials without the table in front (p=0.010). Presence of the table had no significant effect on STS performance of older adults (p>0.317). Our results demonstrated that people living with dementia had a similar starting position but used more strategies to stand up, pushing through their arms more than older adults without dementia and moved their feet backwards more often when no table was in front. People living with dementia should be provided with chairs with armrests and space to move feet backwards. Crown Copyright © 2014.

Physical and Psychological Distress Are Related to Dying Peacefully in Residents with Dementia in Long-Term Care Facilities.
Non UofA Access
De Roo ML, Albers G, Deliens L, de Vet HC, Francke AL, Van Den Noortgate N, et al.
Journal of pain and symptom management 2015 Apr 3

Although dying peacefully is considered an important outcome of high-quality palliative care, large-scale quantitative research on dying peacefully and the factors associated with a peaceful death is lacking. OBJECTIVES: To gain insight into how many residents with dementia in long-term care facilities die peacefully, according to their relatives, and whether that assessment is correlated with observed physical and psychological distress. METHODS: This was a retrospective cross-sectional study of deceased nursing home residents in a representative sample of long-term care facilities in Flanders, Belgium (2010). Structured post-mortem questionnaires were completed by relatives of the resident, who were asked to what extent they agreed that the resident “appeared to be at peace” during the dying process. Spearman correlation coefficients gave the correlations between physical and psychological distress (as measured using the Symptom Management at the End of Life with Dementia and Comfort Assessment in Dying at the End of Life with Dementia scales) and dying peacefully (as measured using the Quality of Dying in Long Term Care instrument). RESULTS: The sample comprised 92 relatives of deceased residents with dementia. In 54% of cases, relatives indicated that the resident died peacefully. Weak to moderate correlations (0.2-0.57) were found between dying peacefully and physical distress in the last week of life. Regarding psychological distress, weak to moderate correlations were found for both the last week (0.33-0.44) and last month of life (0.28-0.47). CONCLUSION: Only half of the residents with dementia died peacefully as perceived by their relatives. Relatives’ assessment of whether death was peaceful is related to both physical and psychological distress. Further qualitative research is recommended to gain more in-depth insights into the aspects on which relatives base their judgment of dying peacefully. Copyright © 2015 American Academy of Hospice and Palliative Medicine

Effects of an Oral Nutritional Supplementation Plus Physical Exercise Intervention on the Physical Function, Nutritional Status, and Quality of Life in Frail Institutionalized Older Adults: The ACTIVNES Study.
Non UofA Access
Abizanda P, Lopez MD, Garcia VP, Estrella JD, da Silva Gonzalez A, Vilardell NB, et al.
Journal of the American Medical Directors Association 2015 Apr 2

The objective of this study was to assess the effects of a hyperproteic, hypercaloric oral nutritional supplement with prebiotic fiber, vitamin D, and calcium, plus a standardized physical intervention, in the functional status, strength, nutritional status, and quality of life of frail institutionalized older adults. DESIGN: Multicentric prospective observational study under usual clinical practice conditions. SETTING: Four nursing homes from Burgos (2), Albacete, and Madrid, Spain. PARTICIPANTS: Participants included 91 institutionalized older adults (age ≥70), able to walk 50 m, and meeting at least 3 of the Fried frailty phenotype criteria. INTERVENTION: Daily intake of two 200-mL bottles of an oral nutritional supplement, each bottle containing 300 kcal, 20 g protein, 3 g fiber, 500 IU vitamin D, and 480 mg calcium, plus a standardized physical exercise training consisting of flexibility, balance, and strengthening exercises for arms and legs, 5 days per week. MEASUREMENTS: Short Physical Performance Battery (SPPB), Short-Form-Late-Life Function and Disability Instrument (SF-LLFDI) function subscale, handgrip strength, EuroQoL-5 Dimensions visual analogic scale (EQ5DVAS), weight, body mass index (BMI), and Short-Form Mini Nutritional Assessment (MNA-SF) at baseline and 6 and 12 weeks. RESULTS: Forty-eight participants (52.7%) improved at least 1 point in the SPPB at week 6, and 44 (48.4%) did so at week 12; 39 participants (42.9%) improved at least 2 points in the SF-LLFDI at week 6, and 46 (50.5%) at week 12. Participants improved their quality of life measured with the EQ5DVAS by 6% (95% confidence interval [CI] 3%-10%) at week 6, and by 5% (95% CI 0%-10%) at week 12. They also improved their nutritional status (weight gain, BMI increase, and higher MNA-SF scores at 6- and 12-week follow-up). This improvement was higher in participants with more frailty criteria, lower functional level, lower vitamin D levels, and poorer nutritional status. CONCLUSION: A 12-week intervention with oral nutritional supplementation plus physical exercise improves function, nutritional status, and quality of life in frail institutionalized older adults. Copyright © 2015 AMDA

Maintaining dignity for residents of care homes: a qualitative study of the views of care home staff, community nurses, residents and their families.
Non UofA Access
Hall S, Dodd RH, Higginson IJ.
Geriatric nursing (New York, N.Y.) 2014 Jan-Feb;35(1):55-60

This study uses the Framework approach to qualitative analysis to explore and compare the views of residents in care homes for older people, their families and care providers on maintaining dignity. We interviewed 33 care home managers, 29 care assistants, 18 care home nurses, 10 community nurses, 16 residents and 15 members of residents’ families. The most prevalent themes were: “independence,” and “privacy”; followed by “comfort and care,” “individuality,” “respect,” “communication,” “physical appearance” and “being seen as human.” Residents and their families sometimes described incidents where a resident’s dignity had been compromised. How to help residents maintain dignity and focusing on fostering dignity, can be a starting point for improving the quality of care and quality of life of residents. It is, however, important to remove the gap between the rhetoric of dignity conserving care and the reality experienced by residents in these and other care settings. Copyright © 2014 Mosby, Inc.

Antibiotic Prescribing in Long-Term Care Facilities: A Meta-synthesis of Qualitative Research.
Non UofA Access
Fleming A, Bradley C, Cullinan S, Byrne S.
Drugs & aging 2015 Apr 2

The objective of this review was to synthesize the findings of qualitative studies investigating the factors influencing antibiotic prescribing in long-term care facilities (LTCFs). These findings will inform the development of future antimicrobial stewardship strategies (AMS) in this setting. METHODS: We searched Embase, PubMed, PsycInfo, Social Science Citations Index and Google Scholar for all qualitative studies investigating health care professionals’ views on antibiotic prescribing in LTCFs. The quality of the papers was assessed using the Critical Appraisal Skills Programme (CASP) assessment tool for qualitative research. Thematic synthesis was used to integrate the emergent themes into an overall analytical theme. RESULTS: The synthesis of eight qualitative studies indicated that health care professionals and administrators have identified factors that influence antibiotic prescribing in LTCFs. These factors include variations in knowledge and practice among health care professionals, and the LTCF context, which is unique given the complex patient population and restricted access to doctors and diagnostic tests. The social factors underpinning the interaction between nurses, residents’ families and doctors also influence decision making around antibiotic prescribing. The study also found that there is an acknowledged need for collaborative, evidence-based AMS specific to LTCFs, as antibiotic prescribing is heavily influenced by factors unique to this setting. CONCLUSION: This review highlighted the key contextual challenges for AMS in LTCFs. The findings provide an in-depth insight into the factors-such as the LTCF context, social factors, variability in knowledge and prescribing practices, and antimicrobial resistance-that impact on antibiotic prescribing and AMS strategies. These factors must be considered in order to ensure the feasibility and applicability of future AMS interventions.

Aging and place in long-term care settings: influences on social relationships.
Non UofA Access
Bonifas RP, Simons K, Biel B, Kramer C.
Journal of aging and health 2014 Dec;26(8):1320-1339

This article presents results of a qualitative research study that examined how living in a long-term care (LTC) home influences the quality of residents’ relationships with peers, family members, and outside friends. METHOD: Semistructured interviews using a phenomenological approach were conducted with 23 residents of a LTC home. Thematic analysis was employed to illuminate residents’ perspectives on the nature of social relationships in this setting. RESULTS: Four key themes were identified that highlight the role of place in social relationships. Residing in a LTC home influences the context of social interactions, impacts their quality and process, clusters individuals with health and functional declines that hinder socialization, and poses structural and cultural barriers that impede social interactions. Health and functional limitations posed the greatest challenge to socialization relative to characteristics of the facility itself. DISCUSSION: Residents’ insights emphasize how personal characteristics influence community culture and the experience of place. © The Author(s) 2014.

Bodily Pain Intensity in Nursing Home Residents With Pressure Ulcers: Analysis of National Minimum Data Set 3.0.
Non UofA Access
Ahn H, Stechmiller J, Fillingim R, Lyon D, Garvan C.
Research in nursing & health 2015 Apr 7

Clinical reports suggest that superficial pressure ulcers produce pain, but that pain decreases as the wound advances in stage. This study of the relationship between pressure ulcer stage and bodily pain intensity in nursing home residents was a secondary analysis of the national Minimum Data Set 3.0 assessment data in long-term care facilities, collected from nursing home residents at least 65 years of age. Data were examined from residents with pressure ulcers who completed a bodily pain intensity interview between January and March 2012 (N = 41,680) as part of the MDS comprehensive assessment. After adjusting for other variables (e.g., cognition, functional impairment, presence of comorbidities, use of scheduled pain medication, and sociodemographic variables), bodily pain intensity for those with more severe pressure ulcers in comparison to those with Stage I ulcers was higher by 11% (Stage II), 14% (Stage III), 24% (Stage IV), and 22% (suspected deep tissue injury). Because multivariate analysis showed that greater bodily pain intensity was associated with an advanced stage of pressure ulcer, health care providers should assess bodily pain intensity and order appropriate pain management for nursing home residents with pressure ulcers, particularly for those with advanced pressure ulcers who are vulnerable to greater bodily pain intensity. © 2015 Wiley Periodicals, Inc.

Prevalence and Factors Associated With Polypharmacy in Long-Term Care Facilities: A Systematic Review
Non UofA Access
Jokanovic N, Tan ECK, Dooley MJ, Kirkpatrick CM, Bell JS.
Journal of the American Medical Directors Association

The objective of the study was to investigate the prevalence of, and factors associated with, polypharmacy in long-term care facilities (LTCFs). Methods MEDLINE, EMBASE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from January 2000 to September 2014. Primary research studies in English were eligible for inclusion if they fulfilled the following criteria: (1) polypharmacy was quantitatively defined, (2) the prevalence of polypharmacy was reported or could be extracted from tables or figures, and (3) the study was conducted in a LTCF. Methodological quality was assessed using an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist. Results Forty-four studies met the inclusion criteria and were included. Polypharmacy was most often defined as 5 or more (n = 11 studies), 9 (n = 13), or 10 (n = 11) medications. Prevalence varied widely between studies, with up to 91%, 74%, and 65% of residents taking more than 5, 9, and 10 medications, respectively. Seven studies performed multivariate analyses for factors associated with polypharmacy. Positive associations were found for recent hospital discharge (n = 2 studies), number of prescribers (n = 2), and comorbidity including circulatory diseases (n = 3), endocrine and metabolic disorders (n = 3), and neurological motor dysfunctioning (n = 3). Older age (n = 5), cognitive impairment (n = 3), disability in activities of daily living (n = 3), and length of stay in the LTCF (n = 3) were inversely associated with polypharmacy. Conclusions The prevalence of polypharmacy in LTCFs is high, varying widely between facilities, geographical locations and the definitions used. Greater use of multivariate analysis to investigate factors associated with polypharmacy across a range of settings is required. Longitudinal research is needed to explore how polypharmacy has evolved over time.

Policy Recommendation: The National Center for Prevention of Resident-to-Resident Aggression in Dementia
Non UofA Access
Caspi E.
Journal of the American Medical Directors Association 2015/04.

Several research studies have shown that resident-to-resident aggression (RRA) in long-term care residences is a prevalent, concerning, but under-reported and understudied phenomenon with serious psychological and physical consequences for residents and staff members. In addition, numerous deaths subsequent to injury in RRA episodes have been reported in the media (as documented on the Archival Blog: The Center for Prevention of Aggression Between Residents with Dementia); Staff training programs in recognition, prevention, and de-escalation of RRA episodes are sorely needed.

Exercise programs for people with dementia. Canada-flat-icon
Non UofA Access
Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S.
The Cochrane database of systematic reviews 2015 Apr 15;4:CD006489

This is an update of our previous 2013 review. Several recent trials and systematic reviews of the impact of exercise on people with dementia are reporting promising findings. OBJECTIVES: Primary objectiveDo exercise programs for older people with dementia improve their cognition, activities of daily living (ADLs), neuropsychiatric symptoms, depression, and mortality? Secondary objectivesDo exercise programs for older people with dementia have an indirect impact on family caregivers’ burden, quality of life, and mortality?Do exercise programs for older people with dementia reduce the use of healthcare services (e.g. visits to the emergency department) by participants and their family caregivers? SEARCH METHODS: We identified trials for inclusion in the review by searching ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group’s Specialised Register, on 4 September 2011, on 13 August 2012, and again on 3 October 2013. SELECTION CRITERIA: In this review, we included randomized controlled trials in which older people, diagnosed with dementia, were allocated either to exercise programs or to control groups (usual care or social contact/activities) with the aim of improving cognition, ADLs, neuropsychiatric symptoms, depression, and mortality. Secondary outcomes related to the family caregiver(s) and included caregiver burden, quality of life, mortality, and use of healthcare services. DATA COLLECTION AND ANALYSIS: Independently, at least two authors assessed the retrieved articles for inclusion, assessed methodological quality, and extracted data. We analysed data for summary effects. We calculated mean differences or standardized mean difference (SMD) for continuous data, and synthesized data for each outcome using a fixed-effect model, unless there was substantial heterogeneity between studies, when we used a random-effects model. We planned to explore heterogeneity in relation to severity and type of dementia, and type, frequency, and duration of exercise program. We also evaluated adverse events. MAIN RESULTS: Seventeen trials with 1067 participants met the inclusion criteria. However, the required data from three included trials and some of the data from a fourth trial were not published and not made available. The included trials were highly heterogeneous in terms of subtype and severity of participants’ dementia, and type, duration, and frequency of exercise. Only two trials included participants living at home.Our meta-analysis revealed that there was no clear evidence of benefit from exercise on cognitive functioning. The estimated standardized mean difference between exercise and control groups was 0.43 (95% CI -0.05 to 0.92, P value 0.08; 9 studies, 409 participants). There was very substantial heterogeneity in this analysis (I² value 80%), most of which we were unable to explain, and we rated the quality of this evidence as very low. We found a benefit of exercise programs on the ability of people with dementia to perform ADLs in six trials with 289 participants. The estimated standardized mean difference between exercise and control groups was 0.68 (95% CI 0.08 to 1.27, P value 0.02). However, again we observed considerable unexplained heterogeneity (I² value 77%) in this meta-analysis, and we rated the quality of this evidence as very low. This means that there is a need for caution in interpreting these findings.In further analyses, in one trial we found that the burden experienced by informal caregivers providing care in the home may be reduced when they supervise the participation of the family member with dementia in an exercise program. The mean difference between exercise and control groups was -15.30 (95% CI -24.73 to -5.87; 1 trial, 40 participants; P value 0.001). There was no apparent risk of bias in this study. In addition, there was no clear evidence of benefit from exercise on neuropsychiatric symptoms (MD -0.60, 95% CI -4.22 to 3.02; 1 trial, 110 participants; P value .0.75), or depression (SMD 0.14, 95% CI -0.07 to 0.36; 5 trials, 341 participants; P value 0.16). We could not examine the remaining outcomes, quality of life, mortality, and healthcare costs, as either the appropriate data were not reported, or we did not retrieve trials that examined these outcomes. AUTHORS’ CONCLUSIONS: There is promising evidence that exercise programs may improve the ability to perform ADLs in people with dementia, although some caution is advised in interpreting these findings. The review revealed no evidence of benefit from exercise on cognition, neuropsychiatric symptoms, or depression. There was little or no evidence regarding the remaining outcomes of interest (i.e., mortality, caregiver burden, caregiver quality of life, caregiver mortality, and use of healthcare services).

IOM: Cognitive Aging: Progress in Understanding and Opportunities for Action (US)
2015

People forget things—a name, where they put their keys, a phone number—and yet what is dismissed as a minor inconvenience at 25 years of age, can evolve into a momentary anxiety at 35, and a major source of personal worry at ages 55 or 60. Forgetfulness at older ages is often equated with a decline in cognition—a public health issue that goes beyond memory lapses and one that can have significant impacts on independent living and healthy aging. The term “cognition” covers many mental abilities and processes including decision making, memory, attention, and problem-solving. At this point in time, when the older population is rapidly growing in the United States and across the globe, it is important to carefully examine what is known about cognitive aging, to identify the positive steps that can be taken to promote cognitive health, and then to take action to implement those changes by informing and activating the public, the health sector, nonprofit and professional associations, communities, the private sector, and government agencies. This Institute of Medicine (IOM) study examines cognitive aging, a natural process associated with advancing years. The IOM committee was charged with assessing the public health dimensions of cognitive aging with an emphasis on definitions and terminology, epidemiology and surveillance, prevention and intervention, education of health professionals, and public awareness and education.

Experiencing Integrated Care: Ontarians’ views of health care coordination and communication Canada-flat-icon
Health Quality Ontario 2015

Experiencing Integrated Care offers patients’ perspectives on key touch-points where patients are in transition from one health care provider to another and therefore, where care coordination and communication is needed, such as during a health care visit, between appointments or after a stay in hospital. Based on the 2014 Commonwealth Fund International Health Policy Survey of Older Adults, Experiencing Integrated Care compares Ontario’s performance with the other provinces in Canada and 10 other countries. The report focuses on responses to survey questions related to coordination of care between health providers and communication between providers and patients. Both care coordination and communication are aspects of health system integration, which is an important measure of how well our health system is performing.

Draft Report: Atypical Antipsychotic Use for the Behavioural and Psychological Symptoms of Dementia in the Elderly Canada-flat-icon
Ontario Drug Policy Research Network
March 2015

Concern has been raised regarding the high utilization of these medications in the elderly, in particular in long-term care facilities.1;2 Safety concerns, such as increased mortality, have been identified with the use of these medications in the elderly with dementia. As part of the formulary modernization review, an evaluation of atypical antipsychotics for the management of elderly patients with behavioural and psychological symptoms of dementia (BPSD) was undertaken to provide policy recommendations for these products in Ontario

Placement, Drugs and Therapy…We Can Do Better Canada-flat-icon
BC Office of the Seniors Advocate, 2015

This initial report is intended to inform the public of the existence of these data and to highlight three systemic issues that are of immediate concern to the Advocate:
1. Premature admissions to residential care of up to 15 percent of residents in care facilities;
2. The overuse of drugs in care facilities;
3. The lack of physiotherapy and recreational therapy in B.C. care facilities.

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Events

UofA

Research Data Management Week
4-8 May

New norms and practices are developing around the management of research data. Canada’s research councils are discussing the introduction of data management plans within their application processes. The University of Alberta’s Research Policy now addresses the stewardship of research records, with an emphasis on the long-term preservation of data. An increasing number of scholarly journals are requiring authors to provide access to the data behind their submissions for publication. Data repositories are being established in domains and institutions to support the sharing and preservation of data. The series of talks and workshops that have been organized will help you better prepare for this emerging global research data ecosystem.

Non UofA

Critical Intersections: Mild Cognitive Impairment, Aging and Dementia in Theory and Practice
7-8 May Peterborough ON

This symposium will bring together Canadian and international experts and public intellectuals to present and exchange current research on aging and dementia, with a focus on Mild Cognitive Impairment (MCI). Held at Trent University’s attractive and accessible Traill College, the meeting promises to be a unique and exciting opportunity to draw upon work in the arts and humanities, sciences and social sciences, and healthcare sectors to explore the meaning of MCI and dementia today and into the future.

Online

Driving and Dementia
The brainXchange & the Alzheimer Society of Canada
Wednesday 29 April 10:00-11:00 MT

Driving is an important activity for enabling participation in community life. Age-associate changes and medical conditions such as dementias can affect the ability to drive safely. This presentation will focus on the effects of Alzheimer’s disease and dementias on the ability to drive and on the evaluation process to assess fitness-to-drive. Supporting drivers who are no longer safe and their families will also be briefly addressed.

AHRQ Webinar Overcoming Barriers to Shared Decision Making
Monday 18 May 11:00 MT Free Pre-Registration Required

The webinar will address: (1) barriers to shared decision making from both the patient and provider perspectives; (2) strategies for overcoming these barriers in clinical practice; and (3) how identified barriers were considered during the development of the SHARE Approach to facilitate implementation of shared decision making.
Speakers:
France Légaré, M.D. Université Laval, Quebec
Mark Friedberg, M.D. Brigham and Women’s Hospital and Harvard Medical School, RAND Corporation; Assistant Professor of Medicine
Alaina Fournier, Ph.D. Agency for Healthcare Research and Quality
Moderator: Rebecca Burkholder, J.D. National Consumers League

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Courses

AIHS Scientist Knowledge Translation Training (SKTT) Program
7-8 May Edmonton AB

This highly-regarded, two-day workshop helps participants build essential skills in knowledge translation. Join trainers Dr. Melanie Barwick and Dr. Donna Lockett to:
• understand the theory behind knowledge translation
• understand evidence-based knowledge translation strategies and evaluation methods
• develop knowledge translation plans
• communicate research findings to multiple audiences including the media
• link with policy and decision-makers
This workshop is of interest to scientists, KT professionals, practitioners, educators, and decision makers in community-based organizations and government who wish to develop their knowledge translation (KT) skills. While the focus is on health, the course material is relevant to individuals working in all sectors.

AIHS Intensive Training Course on Implementing Health Research Impact Assessments
7-11 June Banff AB

Alberta Innovates – Health Solutions (AIHS) is pleased to host a unique intensive training course on implementing health research impact assessments in Banff, June 7 – 11, 2015. The hands-on, practical curriculum will focus on the health research and innovation system in Alberta and Canada, and is a collaborative event including many of our local partners in this ecosystem.

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News

How ‘Design Thinking’ is Paving the Way for Change at PHC’S Residential Care Sites (US)

How can we improve residential care and ensure sustainability while caring for an increasing proportion of residents with complex mental health issues, in aging infrastructure? We don’t know yet, but we’re finding out.

Many With Alzheimer’s Aren’t Told of Diagnosis by Doctor (US)

Doctors are not telling a majority of their patients diagnosed with Alzheimer’s that they have the degenerative brain disease.

Some residential care seniors could be living independently, says B.C. Seniors Advocate Isobel Mackenzie Canada-flat-icon

A new report by B.C.’s Seniors Advocate says too many elderly seniors are living in residential care who could be living independently. “If you are not in need of that level of care, it can be a rather uninspiring experience to live in such a restricted community, which is what you need when you are providing the safety for higher acute clients,” said Isobel Mackenzie.

Gary Teare named CEO of Saskatchewan’s Health Quality Council Canada-flat-icon

Following an extensive national executive search, Gary Teare has been announced as the new CEO of Saskatchewan’s Health Quality Council (HQC). “I am extremely happy that Gary Teare will be our next CEO. The board did a thorough search across Canada. We interviewed and considered a strong group of candidates from Saskatchewan and beyond,” said Dr. Susan Shaw, HQC’s board chair.

Is the NHS getting safer? (UK)

This overview considers how the NHS has performed over the current parliament in relation to patient safety. We look at data relating to reported incidents and harm, episodes of care free of certain types of harm, and patient and staff perceptions of safety.

Nova Scotia plans to unveil nursing strategy in May Canada-flat-icon

The province says there are 135 vacant nursing positions in Nova Scotia right now.

National Partnership to Improve Dementia Care in Nursing Homes (US)

The Centers for Medicare and Medicaid Services (CMS) is partnering with federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers to improve comprehensive dementia care. CMS and its partners are committed to finding new ways to implement practices that enhance the quality of life for people with dementia, protect them from substandard care and promote goal-directed, person-centered care for every nursing home resident. The Partnership promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training and revised surveyor guidance.

WHO Statement on Public Disclosure of Clinical Trial Results

The World Health Organisation (WHO) made it unambiguously that researchers have an ethical imperative to make results from all clinical trials – including past trials – publicly available. Its Statement on Public Disclosure of Clinical Trials Results:
-says results from clinical trials should be publicly reported within 12 months of the trial’s end,
-calls for results from previously unpublished trials to be made publicly available, and
-calls on organisations and governments to implement measures to achieve this.

Fifty shades of rejection Canada-flat-icon

Guest blogger Jan Klimas asks, why can’t rejection letters be a bit more helpful with their feedback?

Fewer nurses providing more care in UK

The RCN report, Frontline First: The fragile frontline finds that there are fewer nurses than in 2010 and that an already over-stretched workforce is being forced to carry out even more work, with serious implications for patient care and staff welfare.

Implementation Science reappraises its journal mission and scope

Emerging issues and developments include the following:
-Extension of our field of interest, which predominantly has been evidence-based healthcare practice, to include evidence-based population health;
-Recognition of a continuum between studies of clinical or population interventions and studies of implementation interventions, and the need to clarify boundaries for journal scope;
-Prioritisation of studies which make substantial, rather than marginal, contributions to the field of implementation research.

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Resources

A guide to economic assessment in nursing

This guide to economic assessment in nursing supports the work of the Royal College of Nursing (RCN) and OPM, who are working together to provide training in how to perform economic assessments and use economic evidence to demonstrate the value of nurse-led innovation. It is a collection of articles that explain some of the principles of economic assessment and describe the most common approaches in the context of nurse-led service innovation.

Writing Academic Book Reviews

Although the journal article manuscript rather than the academic book is the coin of the realm in the academic nursing’s knowledge economy, nurses do write books and books are written for nurses, which means that readers need book reviews, typically in scholarly or professional journals. How do you secure the opportunity to write a book review? How does one structure a book review?

IHI: How do you use a driver diagram?

If you’re embarking on an improvement project, it’s common to want to start testing changes right away. You have an aim, and you want to achieve it! But how do you know the change you are making will help you achieve your aim? Enter the driver diagram. A driver diagram, explains Don Goldmann, MD, IHI’s Chief Medical and Scientific officer, is a “simple, visual, somewhat intuitive display to help you understand where you’re going with your work.”

The nuts and bolts of peer review: what are the benefits for an early career researcher?

Peer review likely isn’t daunting to the academic veteran. But for PhD students, early career researchers and other novice academics, submitting your first peer review can be terrifying. Commenting, giving advice, suggesting changes, and questioning. Re-thinking, over-thinking, spending days going over your own comments! For the ECR anything new is daunting.

EvidenceNetwork.ca Canada-flat-icon

The Evidence Network of Canadian Health Policy, commonly known as EvidenceNetwork.ca is a non-partisan, web-based project funded by the Canadian Institutes of Health Research, Research Manitoba and a partnership with the George and Fay Yee Centre for Healthcare Innovation to make the latest evidence on controversial health policy issues available to the media. The project links journalists with health policy experts to provide access to credible, evidence-based information, and creates original OpEds, articles, infographics, posters and videos on health policy topics for publication in the mainstream media.

Long Term Care Toolkit: Teamwork

Teamwork is an important aspect of any workplace. In healthcare, effective teamwork is paramount to ensure quality of patient care. In long-term care these can be interdisciplinary teams of varied size. The Minnesota Alliance for Patient Safety has developed a toolkit specifically geared towards long-term care of strategies with corresponding potential tools and resources that can be used to improve teamwork amongst health care providers. Many of the elements of the toolkit come from the TeamSTEPPS program, a teamwork system developed by the Agency for Healthcare Research and Quality (AHRQ) the United States.

Hospice enabled dementia care – the first steps
Hospice UK

A guide to help hospices establish care for people with dementia, their families and carers.

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Opportunities

Post-doctoral Fellow in Knowledge Translation Canada-flat-icon
Arthritis Research Canada, UBC Vancouver BC
The position will be open until filled

The Arthritis Research Canada is seeking a Post-Doctoral Fellow for a 1-year position to assist in leading a series of projects to study a counseling intervention using wearable devices to change patient’s physical activity behaviours. These projects are guided by the Knowledge-to-Action process and a team of patient partners. Under the supervision of Dr. Linda Li, the candidate will have an opportunity to develop a subproject to study patient engagement in research.

Knowledge Broker (0.5 FTE) Canada-flat-icon
Canadian Consortium on Neurodegeneration in Aging (CCNA), Halifax, NS
DEADLINE 23 April

The CCNA is seeking a highly motivated individual to help implement the organization’s knowledge translation and exchange (KTE) strategy. Reporting to the KTE Program Lead, the Knowledge Broker will help initiate, develop and implement knowledge translation strategies to make research evidence from the CCNA available and accessible to a variety of stakeholders, including healthcare practitioners, policy and decision-makers, persons with lived experience and their advocates, as well as to the general public.

Grant Associated Research Faculty Position Canada-flat-icon
Canadian Centre for Applied Research in Cancer Control (ARCC) Vancouver BC
Open until position is filled.

Applications are invited from candidates with outstanding credentials and an excellent track record of research productivity to join our team of world-class scientists at the BC Cancer Agency (BCCA) for the Canadian Centre for Applied Research in Cancer Control (ARCC). ARCC is an innovative pan-Canadian research centre whose mission is to improve cancer control and the delivery of care through interdisciplinary leadership in health economics, services, policy, and ethics research, education and knowledge translation. Applicants at the Scientist (equivalent to a university Assistant Professor) level are invited to apply.

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