September 8, 2015


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September TREC Newsletter

Read all the latest news from TREC.

New article by Dr. James Dearing
Influence networks among substance abuse treatment clinics: implications for the dissemination of innovations.
Non UofA Access
K. Johnson, A. Quanbeck, A. Maus, D. H. Gustafson and J. W. Dearing.
Transl Behav Med 2015 Sep;5(3):260-268

Understanding influence networks among substance abuse treatment clinics may speed the diffusion of innovations. The purpose of this study was to describe influence networks in Massachusetts, Michigan, New York, Oregon, and Washington and test two expectations, using social network analysis: (1) Social network measures can identify influential clinics; and (2) Within a network, some weakly connected clinics access out-of-network sources of innovative evidence-based practices and can spread these innovations through the network. A survey of 201 clinics in a parent study on quality improvement provided the data. Network measures and sociograms were obtained from adjacency matrixes created by UCINet. We used regression analysis to determine whether network status relates to clinics’ adopting innovations. Findings suggest that influential clinics can be identified and that loosely linked clinics were likely to join the study sooner than more influential clinics but were not more likely to have improved outcomes than other organizations. Findings identify the structure of influence networks for SUD treatment organizations and have mixed results on how those structures impacted diffusion of the intervention under study. Further study is necessary to test whether use of knowledge of the network structure will have an effect on the pace and breadth of dissemination of innovations.

New article by Dr. Susan Slaughter
What is the extent and quality of documentation and reporting of fidelity to implementation strategies: a scoping review
S Slaughter, J Hill, & E Snelgrove-Clarke.
Implementation Science 2015;10(1):129

Implementation fidelity is critical to the internal and external validity of implementation research. Much of what is written about implementation fidelity addresses fidelity of evidence-informed interventions rather than fidelity of implementation strategies. The documentation and reporting of fidelity to implementation strategies requires attention. Therefore, in this scoping review, we identify the extent and quality of documentation and reporting of fidelity of implementation strategies that were used to implement evidence-informed interventions.METHODS:A six-stage methodological framework for scoping studies guided our work. Studies were identified from the outputs of the Effective Practice and Organization of Care (EPOC) review group within the Cochrane Database of Systematic Reviews. EPOC’s primary focus, implementation strategies influencing provider behavior change, optimized our ability to identify articles for inclusion. We organized the retrieved articles from the systematic reviews by journal and selected the three journals with the largest number of retrieved articles. Using a data extraction tool, we organized retrieved article data from these three journals. In addition, we summarized implementation strategies using the EPOC categories. Data extraction pertaining to the quality of reporting the fidelity of implementation strategies was facilitated with an “Implementation Strategy Fidelity Checklist” based on definitions adapted from Dusenbury et al. We conducted inter-rater reliability checks for all of the independently scored articles. Using linear regression, we assessed the fidelity scores in relation to the publication year.RESULTS:Seventy-two implementation articles were included in the final analysis. Researchers reported neither fidelity definitions nor conceptual frameworks for fidelity in any articles. The most frequently employed implementation strategies included distribution of education materials (n=35), audit and feedback (n=32), and educational meetings (n=25). Fidelity of implementation strategies was documented in 51 (71%) articles. Inter-rater reliability coefficients of the independent reviews for each component of fidelity were as follows: adherence=0.85, dose=0.89, and participant responsiveness=0.96. The mean fidelity score was 2.6 (SD=2.25). We noted a statistically significant decline in fidelity scores over time.CONCLUSIONS:In addition to identifying the under-reporting of fidelity of implementation strategies in the health literature, we developed and tested a simple checklist to assess the reporting of fidelity of implementation strategies. More research is indicated to assess the definitions and scoring schema of this checklist. Careful reporting of details about fidelity of implementation strategies will make an important contribution to implementation science.

AIHS launches two Alberta SPOR SUPPORT Unit platforms

The Alberta Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit is a virtual network of services, expertise and resources to increase the quantity and quality of patient-oriented research in Alberta. For an overview please click here.
The Alberta SPOR SUPPORT Unit offers 4 different types of support for projects meeting the criteria. The criteria are projects must:
-Be conducted in Alberta or the Northwest Territories
-Be patient-Oriented
-Involve end-users
-Have potential for impact on the patient or system

CMA: A Policy Framework to Guide a National Seniors Strategy for Canada

The CMA developed the strategy based on their and Canadian Nurses Association’s principles as well as consultation with 35 stakeholder organizations. The key pillars of the strategy include:
-Wellness and prevention;
-Primary care;
-Home care and community support;
-Acute and specialty care;
-Long-term care; and,
-Palliative care.

World Alzheimer Report 2015: The Global Impact of Dementia

The World Alzheimer Report 2015, The Global Impact of Dementia: An analysis of prevalence, incidence, cost and trends updates ADI’s global dementia data. By carrying out a full update of previous systematic reviews, the report makes key recommendations to provide a global framework for action on dementia. The report also includes a systematic review of the evidence for and against recent trends in the prevalence and incidence of dementia over time, as well as an analysis of the broader societal impact of dementia.

Resource recommended by Dr. Carole Estabrooks
Article collection on Stepped Wedge Randomized Controlled Trials
Trials

There is often a tension between policy makers wishing to implement a novel intervention and researchers wanting time to do a controlled evaluation. One trial design that can address this tension is the stepped wedged randomized trial. In a stepped wedge trial, all groups or clusters of participants eventually receive the intervention, but the implementation is staggered in a random fashion allowing a robust evaluation to take place. Recently there has been an upsurge in interest in the design, which is not yet well understood. This series of papers reviews previous stepped wedge studies and explores key issues of design, forming a comprehensive overview of the current state of knowledge of the design.

Abstracts

CALL FOR ABSTRACTS:
Cultures of Harm in Institutions of Care: Historical & Contemporary Perspectives
15-16 April Birkbeck, University of London
DEADLINE 20 September

This two-day conference will explore the shifting political, socio-economic, cultural and medical influences that have formed and perpetuated cultures of harm from the eighteenth century to the present day around the world. We are particularly interested in the production of harmful practices – physical, sexual and psychological violence directed by one person or group against another – in therapeutic and caring environments. These might include hospitals and infirmaries, psychiatric facilities, religious institutions, care homes, children’s homes and educational establishments, as well as infirmaries and medical spaces in prisons and correctional institutions, military barracks, camps and workhouses.

CALL FOR ABSTRACTS:
21st Annual International Scientific Symposium on Improving the Quality and Value of Health Care
7 December Orlando, Florida
DEADLINE Wednesday 9 September

Ideal abstract submissions may include results of studies that apply improvement or implementation methods to improve health or health care at a local, regional, or national scale. These may include analytic, time-series, statistical process control, qualitative, and mixed-method studies. We are also interested in method or measurement development work that aims to advance the field more generally.

CALL FOR ABSTRACTS:
Margaret Scott Wright Research & Innovation Day
6 November Westin, Edmonton
DEADLINE 18 September

Join your clinical, student and Faculty colleagues for the new joint MSW Research & Innovation Day annual research conference, to explore how nurses can work together to mentor each other, strengthen our links, and improve our care, scholarship and practice for our patients.

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Grants & Awards

TVN-Mitacs Accelerate Internships
September 2015 – Open Call for Expression of Interest

Canada’s premier applied research internship program
-Seeking ways to leverage your R&D budget?
-Have a research or business challenge that requires outside expertise?
-Want to connect with highly-trained potential employees?
Engage top graduate students and postdoctoral fellows to address your unique business research challenges, and benefit from mentored insight and expertise. Matching funds from Mitacs provide cost-effective, low-risk Accelerate research partnerships.

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Publications

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

KT

The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice.
Non UofA Access
H. E. Breimaier, B. Heckemann, R. J. Halfens and C. Lohrmann.
BMC Nurs 2015 Aug 12;14:43-015-0088-4. eCollection 2015

Implementing clinical practice guidelines (CPGs) in healthcare settings is a complex intervention involving both independent and interdependent components. Although the Consolidated Framework for Implementation Research (CFIR) has never been evaluated in a practical context, it appeared to be a suitable theoretical framework to guide an implementation process. The aim of this study was to evaluate the comprehensiveness, applicability and usefulness of the CFIR in the implementation of a fall-prevention CPG in nursing practice to improve patient care in an Austrian university teaching hospital setting. METHODS: The evaluation of the CFIR was based on (1) team-meeting minutes, (2) the main investigator’s research diary, containing a record of a before-and-after, mixed-methods study design embedded in a participatory action research (PAR) approach for guideline implementation, and (3) an analysis of qualitative and quantitative data collected from graduate and assistant nurses in two Austrian university teaching hospital departments. The CFIR was used to organise data per and across time point(s) and assess their influence on the implementation process, resulting in implementation and service outcomes. RESULTS: Overall, the CFIR could be demonstrated to be a comprehensive framework for the implementation of a guideline into a hospital-based nursing practice. However, the CFIR did not account for some crucial factors during the planning phase of an implementation process, such as consideration of stakeholder aims and wishes/needs when implementing an innovation, pre-established measures related to the intended innovation and pre-established strategies for implementing an innovation. For the CFIR constructs reflecting & evaluating and engaging, a more specific definition is recommended. The framework and its supplements could easily be used by researchers, and their scope was appropriate for the complexity of a prospective CPG-implementation project. The CFIR facilitated qualitative data analysis and provided a structure that allowed project results to be organised and viewed in a broader context to explain the main findings. CONCLUSIONS: The CFIR was a valuable and helpful framework for (1) the assessment of the baseline, process and final state of the implementation process and influential factors, (2) the content analysis of qualitative data collected throughout the implementation process, and (3) explaining the main findings.

A qualitative study on barriers to evidence-based practice in patient counseling and advocacy in Germany.
Non UofA Access
S. Altin, A. Passon, S. Kautz-Freimuth, B. Berger and S. Stock.
BMC Health Serv Res 2015 Aug 11;15:317-015-0979-9

BACKGROUND: Despite the attempt to integrate evidence-based practice (EBP) in patient counseling and advocacy, there is limited knowledge on the status quo of this process in the German health care system. Our objective was to identify important determinants influencing the application of EBP in the counseling and advocacy setting in Germany. METHODS: We carried out a qualitative study performing semi-structured expert interviews and one group discussion among n = 9 patient counselors (PCs) and patient advocates (PAs) identified via expert recommendations and by contacting relevant institutions. The interview manual was developed on the basis of a literature review on barriers/facilitators of EBP in health care delivery and a preamble oriented pyramid discussion with a multidisciplinary team. Interviews were analyzed using the Grounded Theory method. A paradigm was developed to present the interrelations between hindering and facilitating factors for EBP and the attitude towards the utilization of EBP among PAs and PCs. RESULTS: Findings from nine face-to-face interviews and one group discussion demonstrate that by now PCs and PAs do not recognize EBP as a tool to facilitate the professionalization of patient counselors and advocates. This result is due to individual and institutional barriers such as cognitive-behavioral, professional, attitude related as well as resource and system barriers. PCs and PAs have predominantly critical attitudes towards EBP caused by a lack of trust in its reliability and by concerns regarding unfavorable effects EBP may have on the relationship with the patient and on the cooperation with physicians. A missing infrastructure of needs-based EBP training programs also discourages PCs and PAs from engaging in EBP. Despite the numerous hindering factors, there is also a growing awareness that EBP could help to improve patient counseling and advocacy. To facilitate EBP in future, needs-based training programs and health policy interventions that support interdisciplinary collaboration are required. CONCLUSION: Although EBP among PCs and PAs is gaining importance, it is still less likely to be recognized as helpful and its application faces various barriers. More needs-based EBP training programs and health policy interventions to decrease barriers and foster interdisciplinary collaboration are necessary.

Evidence-Informed Health Policymaking in Canada: Past, Present and Future. Canada-flat-icon
Non UofA Access
J. A. Boyko.
J Evid Based Med 2015 Aug 14

Evidence-informed health policymaking (EIHP) is becoming a necessary means to achieving health system reform. Although Canada has a rich and well documented history in the field of evidence-based medicine, a concerted effort to capture Canada’s efforts to support EIHP in particular has yet to be realized. This paper reports on the development of EIHP in Canada, including promising approaches being used to support the use of evidence in policymaking about complex health systems issues. In light of Canada’s contributions, this paper suggests that scholars in Canada will continue engaging in the field of EIHP through further study of interventions underway, as well as by sharing knowledge within and beyond Canada’s borders about approaches that support EIHP. This article is protected by copyright. All rights reserved.

Evidence-based practice beliefs and implementation before and after an initiative to promote evidence-based nursing in an ambulatory oncology setting.
Non UofA Access
M. Underhill, K. Roper, M. L. Siefert, J. Boucher and D. Berry.
Worldviews Evid Based Nurs 2015 Apr;12(2):70-78

BACKGROUND: The purpose of evidence-based practice (EBP) in nursing is to improve patient outcomes, providing the best and most up-to-date care practices. In 2011, a nurse-led committee convened to develop an institute-wide initiative to promote EBP with oncology nurses at the Dana-Farber Cancer Institute. AIMS: Compare and describe oncology nurse beliefs and perceived implementation of EBP and explore beliefs and implementation before and after implementing an institutional EBP initiative. METHODS: Based on the Advancing Research and Clinical practice through close Collaboration (ARCC) Model, the Evidence-Based Practice Beliefs (EBP-B) and Implementation (EBP-I) scales were distributed to all Dana-Farber Cancer Institute registered and advanced practice nurses through an online survey in 2011 (T1) and again in 2013 (T2) after the implementation of an institute-wide nursing EBP initiative (orientation, poster presentations, education). Descriptive and correlation statistics were completed on total scores and demographics. Differences in beliefs and implementation scores based on demographics were analyzed with Mann-Whitney U tests. Open-ended item responses at each time point (T) were summarized for EBP barriers and promoters. FINDINGS: Thirty-two percent (n = 112 at T1; n = 113 at T2) of 350 nurses began the survey. A history of formal EBP education and nurse role were associated with higher EBP-B and EBP-I scores (p < .05). Highest level of education was significantly correlated with both EBP-B (r = .25; p = .03) and EBP-I (r = .32; p = .01). Narrative responses to open-ended questions described perceived personal and environmental barriers to engaging in EBP. LINKING EVIDENCE TO ACTION: Although no significant differences were noted in beliefs and implementation after the EBP initiative, nurses reported valuing EBP. Respondents acknowledged a lack of full preparation in the EBP process to engage in and implement EBP consistently. Nurse role, formal EBP education, and highest level of education were associated with perceptions of EBP beliefs and implementation. Nurses should be provided the mentorship and support to obtain continuing education about how to engage in EBP and about implementing EBP change.

Characteristics and determinants of knowledge transfer policies at universities and public institutions in medical research-protocol for a systematic review of the qualitative research literature.
Non UofA Access
R. Jahn, O. Muller and K. Bozorgmehr.
Syst Rev 2015 Aug 19;4:110-015-0094-3

BACKGROUND: Universities, public institutions, and the transfer of knowledge to the private sector play a major role in the development of medical technologies. The decisions of universities and public institutions regarding the transfer of knowledge impact the accessibility of the final product, making it easier or more difficult for consumers to access these products. In the case of medical research, these products are pharmaceuticals, diagnostics, or medical procedures. The ethical dimension of access to these potentially lifesaving products is apparent and distinguishes the transfer of medical knowledge from the transfer of knowledge in other areas. While the general field of technology transfer from academic and public to private actors is attracting an increasing amount of scholarly attention, the specifications of knowledge transfer in the medical field are not as well explored. This review seeks to provide a systematic overview and analysis of the qualitative literature on the characteristics and determinants of knowledge transfer in medical research and development. METHODS: The review systematically searches the literature for qualitative studies that focus on knowledge transfer characteristics and determinants at medical academic and public research institutions. It aims at identifying and analyzing the literature on the content and context of knowledge transfer policies, decision-making processes, and actors at academic and public institutions. The search strategy includes the databases PubMed, Web of Science, ProQuest, and DiVa. These databases will be searched based on pre-specified search terms. The studies selected for inclusion in the review will be critically assessed for their quality utilizing the Qualitative Research Checklist developed by the Clinical Appraisal Skills Programme. Data extraction and synthesis will be based on the meta-ethnographic approach. DISCUSSION: This review seeks to further the understanding of the kinds of transfer pathways that exist in medical knowledge transfer as well as what factors lead to the adoption of one pathway over another. The aim is to provide evidence for political and academic actors designing policies for the translation of medical knowledge and public-private cooperation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015014241

Characterising an implementation intervention in terms of behaviour change techniques and theory: the ‘Sepsis Six’ clinical care bundle.
Non UofA Access
S. Steinmo, C. Fuller, S. P. Stone and S. Michie.
Implement Sci 2015 Aug 8;10(1):111-015-0300-7

BACKGROUND: Sepsis is a major cause of death from infection, with a mortality rate of 36 %. This can be halved by implementing the ‘Sepsis Six’ evidence-based care bundle within 1 h of presentation. A UK audit has shown that median implementation rates are 27-47 % and interventions to improve this have demonstrated minimal effects. In order to develop more effective implementation interventions, it is helpful to obtain detailed characterisations of current interventions and to draw on behavioural theory to identify mechanisms of change. The aim of this study was to illustrate this process by using the Behaviour Change Wheel; Behaviour Change Technique (BCT) Taxonomy; Capability, Opportunity, Motivation model of behaviour; and Theoretical Domains Framework to characterise the content and theoretical mechanisms of action of an existing intervention to implement Sepsis Six. METHODS: Data came from documentary, interview and observational analyses of intervention delivery in several wards of a UK hospital. A broad description of the intervention was created using the Template for Intervention Description and Replication framework. Content was specified in terms of (i) component BCTs using the BCT Taxonomy and (ii) intervention functions using the Behaviour Change Wheel. Mechanisms of action were specified using the Capability, Opportunity, Motivation model and the Theoretical Domains Framework. RESULTS: The intervention consisted of 19 BCTs, with eight identified using all three data sources. The BCTs were delivered via seven functions of the Behaviour Change Wheel, with four (‘education’, ‘enablement’, ‘training’ and ‘environmental restructuring’) supported by the three data sources. The most frequent mechanisms of action were reflective motivation (especially ‘beliefs about consequences’ and ‘beliefs about capabilities’) and psychological capability (especially ‘knowledge’). CONCLUSIONS: The intervention consisted of a wide range of BCTs targeting a wide range of mechanisms of action. This study demonstrates the utility of the Behaviour Change Wheel, the BCT Taxonomy and the Theoretical Domains Framework, tools recognised for providing guidance for intervention design, for characterising an existing intervention to implement evidence-based care.

Leadership in evidence-based practice: a systematic review
Non UofA Access
U. Reichenpfader, S. Carlfjord, P. Nilsen.
Leadership in Health Services 2015 10/05; 2015/09

Purpose We aimed to systematically review published empirical research on leadership as a determinant for the implementation of evidence-based practice (EBP) and to investigate leadership conceptualization and operationalization in this field. Design/methodology/approach A systematic review with narrative synthesis was conducted. Relevant electronic bibliographic databases and reference lists of pertinent review articles were searched. To be included, a study had to involve empirical research and refer to both leadership and EBP in health care. Study quality was assessed with a structured instrument based on study design. Findings A total of 17 studies were included. Leadership was mostly viewed as a modifier for implementation success, acting through leadership support. Yet, there was definitional imprecision as well as conceptual inconsistency and studies seemed to inadequately address situational and contextual factors. Although referring to an organizational factor, the concept was mostly analyzed at the individual or group level. Research limitations/implications The concept of leadership in implementation science seems to be not fully developed. It is unclear whether attempts to tap the concept of leadership in available instruments truly capture and measure the full range of the diverse leadership elements at various levels. Research in implementation science would benefit from a better integration of research findings from other disciplinary fields. Once a more mature concept has been established, researchers in implementation science could proceed to further elaborate operationalization and measurement. Originality/value Although the relevance of leadership in implementation science has been acknowledged, the conceptual base of leadership in this field has received only limited attention.

Exploring the influence of context in a community-based facilitation intervention focusing on neonatal health and survival in Vietnam: a qualitative study.
Non UofA Access
D. M. Duong, A. Bergstrom, L. Wallin, H. T. Bui, L. Eriksson and A. C. Eldh.
BMC Public Health 2015 Aug 22;15(1):814-015-2142-2

BMC Public Health 2015 Aug 22;15(1):814-015-2142-2
BACKGROUND: In the Neonatal health – Knowledge into Practice (NeoKIP) trial in Vietnam, local stakeholder groups, supported by trained laywomen acting as facilitators, promoted knowledge translation (KT) resulting in decreased neonatal mortality. In general, as well as in the community-based NeoKIP trial, there is a need to further understand how context influences KT interventions in low- and middle-income countries (LMICs). Thus, the objective of this study was to explore the influence of context on the facilitation process in the NeoKIP intervention. METHODS: A secondary content analysis was performed on 16 Focus Group Discussions with facilitators and participants of the stakeholder groups, applying an inductive approach to the content on context through naive understanding and structured analysis. RESULTS: The three main-categories of context found to influence the facilitation process in the NeoKIP intervention were: (1) Support and collaboration of local authorities and other communal stakeholders; (2) Incentives to, and motivation of, participants; and (3) Low health care coverage and utilization. In particular, the role of local authorities in a KT intervention was recognized as important. Also, while project participants expected financial incentives, non-financial benefits such as individual learning were considered to balance the lack of reimbursement in the NeoKIP intervention. Further, project participants recognized the need to acknowledge the needs of disadvantaged groups. CONCLUSIONS: This study provides insight for further understanding of the influence of contextual aspects to improve effects of a KT intervention in Vietnam. We suggest that future KT interventions should apply strategies to improve local authorities’ engagement, to identify and communicate non-financial incentives, and to make disadvantaged groups a priority. Further studies to evaluate the contextual aspects in KT interventions in LMICs are also needed.

Implementation of Safe Patient Handling in the U.S. Veterans Health System: A Qualitative Study of Internal Facilitators’ Perceptions.
Non UofA Access
C. A. Elnitsky, G. Powell-Cope, K. L. Besterman-Dahan, D. Rugs and P. M. Ullrich.
Worldviews Evid Based Nurs 2015 Aug;12(4):208-216

BACKGROUND: Although the literature has noted the positive effects of facilitation in implementation research, little is known about what facilitators do or how they increase adoption of a program. The purpose of this study was to understand internal facilitation activities in implementing a national safe patient handling program from the perspective of facility coordinators who implemented the program. METHODS: Using a qualitative descriptive design, data were collected in five focus groups at two international Safe Patient Handling and Mobility Conferences. Participants were 38 facility coordinators implementing a safe patient handling program in the Department of Veterans Affairs medical centers throughout the United States. Data were analyzed using direct content analysis to gather descriptions of internal facilitation. RESULTS: The internal facilitation process involved engaging multiple disciplines and levels of leadership for implementation. Fifty-four facilitation activities were identified, including five activities not currently listed in an existing taxonomy. Key characteristics and skills of facilitators included persistence, credibility and clinical experience, and leadership and project management experience. Themes were mapped onto an existing framework and taxonomy of facilitation activities. LINKING EVIDENCE TO ACTION: Internal facilitation is both an implementation intervention and a process involving a wide range of activities. The findings provide an understanding of what internal facilitators are doing to support practice changes and the characteristics and skills of internal facilitators that are likely to result in long-term organizational change. Five recommendations for action address organizations, senior leaders, and internal facilitators.

What research tells us about knowledge transfer strategies to improve public health in low-income countries: a scoping review. Canada-flat-icon
Non UofA Access
S. Siron, C. Dagenais and V. Ridde.
Int J Public Health 2015 Aug 23

OBJECTIVES: This study describes the current state of research on knowledge transfer strategies to improve public health in low-income countries, to identify the knowledge gaps on this topic. METHODS: In this scoping review, a descriptive and systematic process was used to analyse, for each article retained, descriptions of research context and methods, types of knowledge transfer activities and results reported. RESULTS: 28 articles were analysed. They dealt with the evaluation of transfer strategies that employed multiple activities, mostly targeting health professionals and women with very young children. Most often these studies used quantitative designs and measurements of instrumental use with some methodological shortcomings. Results were positive and suggested recommendations for improving professional practices, knowledge and health-related behaviours. The review highlights the great diversity of transfer strategies used, strategies and many conditions for knowledge use. CONCLUSIONS: The review provides specific elements for understanding the transfer processes in low-income countries and highlights the need for systematic evaluation of the conditions for research results utilization.

Making the connection-factors influencing implementation of evidence supported and non-evaluated lifestyle interventions in healthcare: a multiple case study.
Non UofA Access
I. van de Glind, M. Heinen, W. Geense, I. Mesters, M. Wensing and T. van Achterberg.
Health Educ Res 2015 Aug;30(4):521-541

Many implementation barriers relate to lifestyle interventions (LIs) being developed by scientists. Exploring whether implementation of non-evaluated LIs is less complicated, might offer insight how to improve the use of effective interventions. This study aimed to identify influencing factors for implementation and compare factors between evidence supported and non-evaluated LIs. Evidence-supported (n = 7) and non-evaluated LIs (n = 7) in hospitals, general practices and community care organizations were included as cases. Semi-structured interviews (n = 46) were conducted. Additionally, documents (n = 207) were collected describing intervention, implementation process, and policy. We used a stepwise approach to inductively identify factors, organize them by diffusion phase, and an existing framework. A total of 37 factors were identified. ‘Dissemination’ factors were mainly observed in evidence-supported LIs. ‘Compatibility to existing structures’ (‘adoption’), ‘funding’ and ‘connection to existing care processes’ (‘implementation’) was factors identified in all cases. ‘Quality control’ and ‘ongoing innovation’ (‘maintenance’) were reported in evidence-supported interventions. In all domains of the framework factors were observed. Factors identified in this study are in line with the literature. The findings do not support the assumption that implementation of non-evaluated LIs is perceived as less complex.

Putting Health Impact Assessment into practice through the lenses of diffusion of innovations theory: a review
Non UofA Access
T Byambaa, C Janes, T Takaro, & K Corbett.
Environ Dev Sustainability 2015 02/01;17(1):23-40.

This paper looks into the applicability of diffusion of innovation (DoI) theory and the implementation of a Health Impact Assessment (HIA) approach, focusing mainly on the resource extraction sector in low- and middle-income countries (LMICs). The paper begins with a review of DoI theory and discusses how HIA adoption in a LMIC context might be understood from the perspective of DoI theory. It then asks whether knowledge translation theories and approaches might be relevant to DoI, and if so, how. Based on the findings of the literature review and practical applications of DoI theory in HIA implementation, this paper is concluded by arguing that DoI is useful as an overarching theoretical framework to plan and implement adoption strategies and activities, to identify potential challenges.

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Health Care Administration and Organization

Qualifications for nurses for the care of patients with dementia and support to their caregivers: A pilot evaluation of the dementia care management curriculum.
Non UofA Access
A. Dreier, J. R. Thyrian, T. Eichler and W. Hoffmann.
Nurse Educ Today 2015 Jul 31

BACKGROUND: A substantial increase of people with dementia (PwD) is predicted for the future. Nurses are taking over important tasks to support PwD, which requires a specialized qualification. OBJECTIVES: The aim was to identify points for revision and to further improve the Dementia Care Manager (DCM) curriculum as a basis for probable qualification of nurses caring for PwD. DESIGN: We conducted a summative evaluation study to revise the first version of the DCM curriculum. SETTING: The study was conducted in the primary health care setting. PARTICIPANTS: Nurses and lecturers of the first theoretical and practical implementation were involved. METHODS: Questionnaire-based interviews with nurses and lecturers after every module during the theoretical qualification. Besides, nurses rated the curriculum after the end of the theoretical part and evaluated the DCM tasks and the usefulness of the curriculum contents after the practical phase in questionnaire-based interviews. Descriptive statistics were used for analysis. RESULTS: A total of five nurses and 33 lecturers participated in the first theoretical and practical implementation of the DCM qualification. Generally, nurses and lecturers assessed the curriculum contents as “very important” or “important.” In particular, the job-related issues, the variety of course topics and the close combination of theory and practice were highly valued. The practical implementation of the DCM was rated predominantly as “important” by nurses for the delivery of care for PwD. To optimize the theoretical DCM curriculum, participants suggested increasing the number of lessons for two of the modules (gerontopsychiatry, interdisciplinary case reviews). Furthermore, nurses preferred a longer practical phase, whereas some lecturers called for larger group sizes of participants. CONCLUSIONS: The DCM qualification enhances nurses’ competencies to care for PwD. The curriculum regards an interprofessional, cooperative team approach as the potential to improve health care supply for demented people and to better support their caregivers.

Home nurses’ turnover intentions: the impact of informal supervisory feedback and self-efficacy.
Non UofA Access
T. Van Waeyenberg, A. Decramer and F. Anseel.
J Adv Nurs 2015 Aug 13

AIM: To examine how home nurses’ turnover intentions are affected by the quality and frequency of supervisory feedback and by their own self-efficacy. BACKGROUND: Little is known about effective retention strategies for the growing home healthcare sector that struggles to retain an adequate workforce. While the work environment and supervisors have been found to play a key-role in nurses’ turnover intentions, home nurses mostly work autonomously and apart from their supervisors. These circumstances require a customized approach and need to be understood to ensure high-quality home health care. DESIGN: We used a correlational, cross-sectional survey design. METHOD: A convenience sample of 312 home nurses was selected from a division of a large home health care organization in Flanders, Belgium. Data were collected in 2013 using structured questionnaires and analysed using descriptive statistics, structural equation modelling and relative weight analysis. RESULTS: The quality of feedback was related to lower levels of turnover intentions. This relationship was fully mediated by home nurses’ self-efficacy. Frequent favourable feedback was directly related to lower turnover intentions while the relationship between frequent unfavourable feedback and turnover intentions was conditional on home nurses’ level of self-efficacy. CONCLUSION: This study contributes to our understanding of home nurses’ turnover intentions and the role of informal supervisory feedback and home nurses’ self-efficacy.

Evaluating the Veterans Health Administration’s Staffing Methodology Model: A Reliable Approach.
Non UofA Access
B. Taylor, N. Yankey, C. Robinson, et al.
Nurs Econ 2015 Jan-Feb;33(1):36-40, 66

All Veterans Health Administration facilities have been mandated to use a standardized method of determining appropriate direct-care staffing by nursing personnel. A multi-step process was designed to lead to projection of full-time equivalent employees required for safe and effective care across all inpatient units. These projections were intended to develop appropriate budgets for each facility. While staffing levels can be increased, even in facilities subject to budget and personnel caps, doing so requires considerable commitment at all levels of the facility. This commitment must come from front-line nursing personnel to senior leadership, not only in nursing and patient care services, but throughout the hospital. Learning to interpret and rely on data requires a considerable shift in thinking for many facilities, which have relied on historical levels to budget for staffing, but which does not take into account the dynamic character of nursing units and patient need.

Measurement of Nursing’s Complex Health Care Work: Evolution of the Science For Determining the Required Staffing For Safe and Effective Patient Care.
Non UofA Access
K. Malloch.
Nurs Econ 2015 Jan-Feb;33(1):20-25

The availability of technology to monitor and manage data increases our ability to better understand the processes and outcomes needed for patient care. It is important to remember this work requires not only the science of data management, but also the art of integrating the multiple variables involved in the dynamic of safe staffing. Fasoli and Haddock (2010) provided an excellent summary of the literature. Nurse leaders must be open to new additions to this work and the possibility that the essential ingredient of the gold standard for patient classification systems (PCS) might still be missing. The goal of a new approach to determine time for nurse work was to advance the science of PCS from the perspective of the characteristics identified by Fasoli and Haddock.

Coming to grips with challenging behaviour: a cluster randomised controlled trial on the effects of a new care programme for challenging behaviour on burnout, job satisfaction and job demands of care staff on dementia special care units.
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S. A. Zwijsen, D. L. Gerritsen, J. A. Eefsting, M. Smalbrugge, C. M. Hertogh and A. M. Pot.
Int J Nurs Stud 2015 Jan;52(1):68-74

BACKGROUND: Caring for people with dementia in dementia special care units is a demanding job. Challenging behaviour is one of the factors influencing the job satisfaction and burnout of care staff. A care programme for the challenging behaviour of nursing home residents with dementia might, next to diminishing the challenging behaviour of residents, improve job satisfaction and reduce the care staff’s feelings of burnout. OBJECTIVES: To determine the effects of a care programme for the challenging behaviour of nursing home residents with dementia on the burnout, job satisfaction and job demands of care staff. DESIGN: The care programme was implemented according to a stepped wedge design in which care units were randomly divided over five groups with different time points of starting with implementation. SETTING: 17 Dutch dementia special care units. PARTICIPANTS: Care staff members of the 17 units. INTERVENTION: The care programme consists of an education package and of various structured assessment tools that guide professionals through the multidisciplinary detection, analysis, treatment and evaluation of treatment of challenging behaviour. METHODS: Burnout, job satisfaction and job demands were measured before implementation, halfway through the implementation process and after all the care units had implemented the care programme. Burnout was measured with the Dutch version of the Maslach burnout inventory (UBOS-C, three subscales); job satisfaction and job demands were measured with subscales of the Leiden Quality of Work Questionnaire. Mixed model analyses were used to determine effects. Care staff could not be blinded for the intervention. RESULTS: Of the 1441 questionnaires, 645 were returned (response 45%, 318 control measurements, 327 intervention measurements) by 380 unique care staff members. Significant effects were found on job satisfaction (0.93, 95% CI 0.48-1.38). On the other outcomes, no significant changes in the scores were found. CONCLUSION: Positive effects of using the Grip on Challenging behaviour care programme were found on job satisfaction, without an increase in job demands.

Verbal and nonverbal indicators of quality of communication between care staff and residents in ethnoculturally and linguistically diverse long-term care settings. Canada-flat-icon
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J. Small, S. M. Chan, E. Drance, et al.
J Cross Cult Gerontol 2015 Sep;30(3):285-304

Linguistic and ethnocultural diversity in long-term residential care is a growing trend in many urban settings. When long-term care staff and residents do not share the same language or ethnocultural background, the quality of their communication and care are jeopardized. There is very little research addressing how staff and residents communicate when they experience a mismatch in their language and ethnocultural backgrounds. Thus, the goals of the present study were to 1) document the verbal and nonverbal behaviours used by staff and residents in diverse interactions, and 2) identify and account for behaviours that either promoted or detracted from positive communication by drawing on principles from ‘Communication Accommodation Theory’. Two long-term care facilities in British Columbia Canada were selected due to the diverse linguistic and ethnocultural backgrounds of their staff and residents. Twenty-seven staff and 27 residents consented to being video-recorded during routine activities (e.g., mealtimes, recreational activities). The recorded observations were transcribed, translated, and coded using qualitative descriptive and interpretive analyses. A number of verbal and nonverbal behaviours were identified and interpreted in relation to whether they promoted or detracted from positive communication. The findings point to considering a variety of proactive strategies that staff and administrators could employ to effectively accommodate to language and ethnocultural diversity in long-term care practice.

The Relationship of Workplace Culture With Nursing-Sensitive Organizational Factors.
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N. Hahtela, B. McCormack, E. Paavilainen, P. Slater, M. Helminen and T. Suominen.
J Nurs Adm 2015 Jul-Aug;45(7-8):370-376

OBJECTIVE: The aim of this study is to explore the relations of workplace culture on nursing-sensitive organizational factors. BACKGROUND: The need for standardized and valid measures for nursing-sensitive organizational outcomes has already been recognized in the literature. METHODS: A cross-sectional questionnaire survey of 21 inpatient acute care units in 9 organizations at the municipal primary healthcare level was conducted. Participants included licensed practical nurses, registered nurses, and nurse managers. RESULTS: Workplace culture, especially the overarching factor of stress, correlated with the use of supplemental nursing staff and patients’ length of stay. CONCLUSION: It is essential to find and test workplace-sensitive indicators so that managers will have a wider range of methods to plan and evaluate nursing outcomes.

Nurses’ sensemaking of contradicting logics: An underexplored aspect of organisational work in nursing homes
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M. Kristiansen, A. Obstfelder, A.T. Lotherington.
Scandinavian Journal of Management 2015 9;31(3):330-337

Organisational work, understood as the practices by which care services are organised, is often referred to as the glue in healthcare organisations. In response to healthcare reforms, organisational work in Norwegian nursing homes has undergone extensive changes. With increased standardisation and efficiency demands, new managerial logic often stands in stark contrast to traditional professional logic. Although organisational work is essential for all action in care, there is a lack of research on how contradicting logics influence organisational work in nursing homes. In this study, we combine the institutional logic perspective with sensemaking to demonstrate how nurses create new patterns and routines in organisational work. Our analysis indicates that contradicting logics create incongruous events that nurses attempt to clarify through sensemaking. To illustrate nurses’ sensemaking, we rely on new theoretical developments from the institutional logic perspective. The study contributes with a new understanding of nurses’ organisational work in nursing homes. In addition, by combining the institutional logic perspective with sensemaking, the study adds to previous knowledge in the institutional literature by demonstrating how sensemaking enables contradicting logics to co-exist.

Physicians in Nursing Homes: Effectiveness of Physician Accountability and Communication.
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J. C. Lima, O. Intrator and T. Wetle.
J Am Med Dir Assoc 2015 Sep 1;16(9):755-761

OBJECTIVES: 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.

“It is meaningful; I feel that I can make a difference” -A qualitative study about GPs’ experiences of work at nursing homes in Sweden.
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B. B. Bolmsjo, E. L. Strandberg, P. Midlov and A. Brorsson.
BMC Fam Pract 2015 Aug 28;16(1):111-015-0326-6

BACKGROUND: Swedish nursing homes (NH) have limited capacity. As a result elderly people living in NH represent the part of the elderly population in most need of care. In Sweden a General Practitioner (GP) is usually responsible for the medical care of all subjects living in a NH. The residents in NH seldom have adequate pharmacological treatment according to diagnosis and often have polypharmacy and/or inappropriate medical treatment regarding concerns of declining renal function. What prevents optimal care for the elderly is multifaceted, but there is limited research on how GPs experience their work with the elderly in NH in Sweden. This study aims to illuminate the GPs’ work with the elderly in NH to provide input on how the care can be improved, as well as to identify potential obstacles for good quality of care. METHODS: This qualitative study is based on individual semi-structured interviews with 12 GPs and a follow-up focus group discussion with six of the interviewed GPs. The interviews were analysed with systematic text condensation, with the process leading to identify categories and themes. Thereafter, the themes were discussed among six of the participating GPs in a focus group interview. RESULTS: Two main themes were identified: concern for the patient and sustainable working conditions. The principal focus for the GPs was to contribute to the best possible quality of life for the patients. The GPs described discordance between the demand from staff for medications and the patients’ actual need of care. GPs found their work with NH enjoyable. Even though the patients at the NH often suffered from multiple illnesses, which could lead to difficult decisions being made, the doctors felt confident in their role by having a holistic view of the patient in tandem with reliable support from the nurse at the NH. CONCLUSION: Working with NH patients was considered important and meaningful, with the GPs striving for the patient’s well-being with special consideration to the continuum of ageing. A continuous and well-functioning relationship between the GP and the nurse was crucial for the patients well-being.

CIHI Regulated Nurses, 2014 Canada-flat-icon
2015

This report highlights current trends in nursing practice across a variety of demographic, education, mobility and employment characteristics. The report highlights data from three groups of regulated nursing professionals in Canada:
-registered nurses (RNs, including nurse practitioners or NPs)
-licensed practical nurses (LPNs) and
-registered psychiatric nurses (RPNs).

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Health Care Innovation and Quality Assurance

Beyond metrics? Utilizing ‘soft intelligence’ for healthcare quality and safety.
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G. P. Martin, L. McKee and M. Dixon-Woods.
Soc Sci Med 2015 Jul 31;142:19-26

Formal metrics for monitoring the quality and safety of healthcare have a valuable role, but may not, by themselves, yield full insight into the range of fallibilities in organizations. ‘Soft intelligence’ is usefully understood as the processes and behaviours associated with seeking and interpreting soft data-of the kind that evade easy capture, straightforward classification and simple quantification-to produce forms of knowledge that can provide the basis for intervention. With the aim of examining current and potential practice in relation to soft intelligence, we conducted and analysed 107 in-depth qualitative interviews with senior leaders, including managers and clinicians, involved in healthcare quality and safety in the English National Health Service. We found that participants were in little doubt about the value of softer forms of data, especially for their role in revealing troubling issues that might be obscured by conventional metrics. Their struggles lay in how to access softer data and turn them into a useful form of knowing. Some of the dominant approaches they used risked replicating the limitations of hard, quantitative data. They relied on processes of aggregation and triangulation that prioritised reliability, or on instrumental use of soft data to animate the metrics. The unpredictable, untameable, spontaneous quality of soft data could be lost in efforts to systematize their collection and interpretation to render them more tractable. A more challenging but potentially rewarding approach involved processes and behaviours aimed at disrupting taken-for-granted assumptions about quality, safety, and organizational performance. This approach, which explicitly values the seeking out and the hearing of multiple voices, is consistent with conceptual frameworks of organizational sensemaking and dialogical understandings of knowledge. Using soft intelligence this way can be challenging and discomfiting, but may offer a critical defence against the complacency that can precede crisis.

A qualitative study on the ethics of transforming care: examining the development and implementation of Canada’s first mental health strategy Canada-flat-icon
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M. M. Park, R. Lencucha, C. Mattingly, H. Zafran and L. J. Kirmayer.
Implement Sci 2015 Aug 19;10(1):121-015-0297-y

BACKGROUND: The Mental Health Commission of Canada worked collaboratively with stakeholders to create a new framework for a federal mental health strategy, which is now mandated for implementation by 2017. The proposed strategies have been written into provincial health plans, hospital accreditation standards, and the annual objectives of psychiatric departments and community organizations. This project will explore the decision-making process among those who contributed to Canada’s first federal mental health policy and those implementing this policy in the clinical setting. Despite the centrality of ethical reasoning to the successful uptake of the recent national guidelines for recovery-oriented care, to date, there are no studies focused exclusively on the ethical tensions that emerged and continue to emerge during the creation and implementation of the new standards for recovery-oriented practice. METHODS/DESIGN: This two-year Canadian Institute of Health Research Catalyst Grant in Ethics (2015-2017) consists of three components. C-I, a retrospective, qualitative study consisting of document analysis and interviews with key policy-makers of the ethical tensions that arose during the development of Canada’s Mental Health Strategy will be conducted in parallel to C-II, a theory-based, focused ethnography of how mental health practitioners in a psychiatric setting reason about and act upon new standards in everyday practice. Case-based scenarios of ethical tensions will be developed from C-I/II and fed-forward to C-III: participatory forums with policy-makers, mental health practitioners, and other stakeholders in recovery-oriented services to collectively identify and prioritize key ethical concerns and generate action steps to close the gap between the policy-making process and its implementation at the local level. DISCUSSION: Policy-makers and clinicians make important everyday decisions that effect the creation and implementation of new practice standards. Particularly, there is a need to understand how ethical dilemmas that arise during this decision-making process and the reasoning and resources they use to resolve these tensions impact on the implementation process. This catalyst grant in ethics will (1) introduce a novel line of inquiry focusing on the ethical tensions that arose in the development of Canada’s first mental health strategy, while (2) intensifying our focus on the ethical aspects of moving policy into action.

The Relationship Between Registered Nurses and Nursing Home Quality: An Integrative Review (2008-2014).
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M. E. Dellefield, N. G. Castle, K. S. McGilton and K. Spilsbury.
Nurs Econ 2015 Mar-Apr;33(2):95-108, 116

Nursing home care is expensive; second only to acute hospital care for inpatient Medicare costs. The increased focus on costs of care accrued by Medicare beneficiaries in nursing homes presents a valuable opportunity for registered nurses (RNs) to further demonstrate quantitatively the value they add to the capacity of the nursing home nursing skill mix to provide cost-effective and efficient quality care. Most of the studies included in this review consistently reported that higher RN staffing and higher ratios of RNs in the nursing skill mix are related to better NH quality. Concerns about the costs of employing more highly skilled RNs and directors of nursing that have the potential to positively influence members of the nursing skill mix will continue to influence nursing home industry hiring practices. For both the advancement of nursing as an applied science and the benefit of society at large, nursing researchers are challenged to better demonstrate how the increased presence of a RN on each shift has the potential to enhance the cost effectiveness, efficiency, and quality of nursing homes.

Better Care, Better Quality: Reducing Avoidable Hospitalizations of Nursing Home Residents.
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M. J. Rantz, M. K. Flesner, J. Franklin, et al.
J Nurs Care Qual 2015 Oct-Dec;30(4):290-297.

This study explores staff perceptions in a nursing home that successfully achieved 4 key project goals for the first 2 years of Missouri Quality Initiative. Goals were to (1) reduce potentially avoidable hospital transfers; (2) reduce polypharmacy and antipsychotic medication use among nursing home residents; (3) increase goals of care discussions and completion of AD; and (4) introduce secure communications for electronic transfer of resident health information among health care providers, nursing homes, and hospitals. To successfully achieve these goals, the APRN needed to become an integral part of the nursing home, fit into its culture, and have leadership support for MOQI.

Organization of nursing and quality of care for veterans at the end of life.
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A. Kutney-Lee, C. W. Brennan, M. Meterko and M. Ersek.
J Pain Symptom Manage 2015 Mar;49(3):570-577

CONTEXT: The Veterans Health Administration (VA) has improved the quality of end-of-life (EOL) care over the past several years. Several structural and process variables are associated with better outcomes. Little is known, however, about the relationship between the organization of nursing care and EOL outcomes. OBJECTIVES: To examine the association between the organization of nursing care, including the nurse work environment and nurse staffing levels, and quality of EOL care in VA acute care facilities. METHODS: Secondary analysis of linked data from the Bereaved Family Survey (BFS), electronic medical record, administrative data, and the VA Nursing Outcomes Database. The sample included 4908 veterans who died in one of 116 VA acute care facilities nationally between October 2010 and September 2011. Unadjusted and adjusted generalized estimating equations were used to examine associations between nursing and BFS outcomes. RESULTS: BFS respondents were 17% more likely to give an excellent overall rating of the quality of EOL care received by the veteran in facilities with better nurse work environments (P </= 0.05). The nurse work environment also was a significant predictor of providers listening to concerns and providing desired treatments. Nurse staffing was significantly associated with an excellent overall rating, alerting of the family before death, attention to personal care needs, and the provision of emotional support after the patient’s death. CONCLUSION: Improvement of the nurse work environment and nurse staffing in VA acute care facilities may result in enhanced quality of care received by hospitalized veterans at the EOL.

Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients.
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E. C. Wick, D. J. Galante, D. B. Hobson, et al.
J Am Coll Surg 2015 Sep;221(3):669-677

BACKGROUND: The goals of quality improvement are to partner with patients and loved ones to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste, yet few programs have successfully worked on of all these in concert. STUDY DESIGN: We evaluated implementation of a pathway designed to improve patient outcomes, value, and experience in colorectal surgery. The pathway expanded on pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, from senior leaders (chief financial officer and senior vice president for patient safety and quality) to frontline staff. It included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia with thoracic epidurals or transversus abdominus plane blocks, a restricted intravenous fluids protocol, early mobilization, and resumption of oral intake. Eleven months of pre- and post-pathway outcomes, including length of stay (LOS), National Surgical Quality Improvement Program surgical site infection (SSI), venous thromboembolism, and urinary tract infection rates, patient experience, and variable direct costs were compared. RESULTS: Three hundred ten patients underwent surgery in the baseline period, the mean LOS was 7 days, and the mean SSI rate was 18.8%. There were 330 patients who underwent surgery on the pathway, the LOS was 5 days, and the rate of SSI was 7.3%. Patient experience improved and variable direct costs decreased. CONCLUSIONS: Our trust-based accountability model, which included both senior hospital leadership and frontline providers, provided an enabling structure to rapidly implement an integrated recovery pathway and quickly improve outcomes, value, and experience of patients undergoing colorectal surgery. The study findings have significant implications for spreading surgical quality improvement work.

Long-Term Clinical Outcomes from a Randomized Controlled Trial of Two Implementation Strategies to Promote Collaborative Care Attendance in Community Practices.
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A. M. Kilbourne, D. E. Goodrich, K. M. Nord, et al.
Adm Policy Ment Health 2015 Sep;42(5):642-653

This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement.
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C. J. Crnich, R. Jump, B. Trautner, P. D. Sloane and L. Mody.
Drugs Aging 2015 Aug 28

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.

The effect of a care bundle on nursing staff when caring for the dying.
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K. Clark, T. Curry and N. Byfieldt.
Int J Palliat Nurs 2015 Aug 2;21(8):392-398

Background Most Australians die in acute hospital settings. Despite this, hospitals remain ill-equipped to care for dying patients with hospital deaths not uncommonly perceived as distressing by both patients and their families. As a quality improvement project, a care bundle for the dying was developed and piloted on two medical wards. The aim of this study was to examine whether or not the quality initiative had any effect on the ward nurse’s attitudes and self-assessed competency to care for dying patients. Methods A pre- and post-survey using self-administered questionnaires were given to nursing staff who voluntarily completed these before and after implementation of the caring for the dying bundle. Results Over the 6 months the bundle was piloted, 74.5% of people who died did so with the bundle in place. While this was seen as clinically useful by nearly half the nurses who responded, there was not a significant change in the staff’s attitudes or self-assessed competency to care for dying patients. There was a minor change in the Thanatophobia Scale (pre 18.2: SD+/-9.0 versus post 16.8: SD 7.8; P=0.53), the Self-efficacy in Palliative Care Scale for communication (pre 47.4: SD +/-17.4 versus post 54.7:SD+/-17.9; P=0.11) and patient management respectively (pre 54.3: SD +/-12.9 versus 59.1: SD +/-12.6; P=0.15). Discussion This work highlighted that at least in the short term, that a quality initiative had only a modest impact on nursing attitudes to caring for dying patients. However, as a collection of clinical tools grouped as a care bundle, a proportion of nursing staff acknowledged this initiative as useful. Conclusion Further research is required to understand if such an initiative approach may, in the long term, positively impacts attitude. This is highly relevant given the increasing numbers of people likely to die in acute care.

Managing Responsive Behaviours: A Wicked Problem Addressed through a Grassroots Approach Canada-flat-icon
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Suzette Brémault-Phillips, Steven Friesen, Lynne Moulton, Tamara Germani, Maxi Miciak, Jasneet Parmar and,Laura G.
Healthcare Quarterly 2015 07/30;18(2):31-34

Challenging responsive behaviours, such as aggression, wandering and social inappropriateness, exhibited by persons with neurological, mental health or developmental disorders are of increasing concern across Canada. These behaviours can cause distress or catastrophic outcomes for the person, others in care, caregivers and healthcare providers, and result in extensive resource utilization. The objective of this paper is to discuss the role and impact of a unique, grassroots provincial initiative aimed at networking among healthcare providers, decision-makers and caregivers across government ministries and service-provider agencies. This collaboration provides a model for informing service provision and policy development across multiple stakeholders.

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Research Practice and Methodology

Development of an algorithm to provide awareness in choosing study designs for inclusion in systematic reviews of healthcare interventions: a method study
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F. Peinemann and J. Kleijnen.
BMJ Open 2015 Aug 19;5(8):e007540-2014-007540

OBJECTIVES: To develop an algorithm that aims to provide guidance and awareness for choosing multiple study designs in systematic reviews of healthcare interventions. DESIGN: Method study: (1) To summarise the literature base on the topic. (2) To apply the integration of various study types in systematic reviews. (3) To devise decision points and outline a pragmatic decision tree. (4) To check the plausibility of the algorithm by backtracking its pathways in four systematic reviews. RESULTS: (1) The results of our systematic review of the published literature have already been published. (2) We recaptured the experience from our four previously conducted systematic reviews that required the integration of various study types. (3) We chose length of follow-up (long, short), frequency of events (rare, frequent) and types of outcome as decision points (death, disease, discomfort, disability, dissatisfaction) and aligned the study design labels according to the Cochrane Handbook. We also considered practical or ethical concerns, and the problem of unavailable high-quality evidence. While applying the algorithm, disease-specific circumstances and aims of interventions should be considered. (4) We confirmed the plausibility of the pathways of the algorithm. CONCLUSIONS: We propose that the algorithm can assist to bring seminal features of a systematic review with multiple study designs to the attention of anyone who is planning to conduct a systematic review. It aims to increase awareness and we think that it may reduce the time burden on review authors and may contribute to the production of a higher quality review.

Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): a tool for critical appraisal of quality improvement intervention publications.
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S. Hempel, P. G. Shekelle, J. L. Liu, et al.
BMJ Qual Saf 2015 Aug 26

OBJECTIVE: Valid, reliable critical appraisal tools advance quality improvement (QI) intervention impacts by helping stakeholders identify higher quality studies. QI approaches are diverse and differ from clinical interventions. Widely used critical appraisal instruments do not take unique QI features into account and existing QI tools (eg, Standards for QI Reporting Excellence) are intended for publication guidance rather than critical appraisal. This study developed and psychometrically tested a critical appraisal instrument, the QI Minimum Quality Criteria Set (QI-MQCS) for assessing QI-specific features of QI publications. METHODS: Approaches to developing the tool and ensuring validity included a literature review, in-person and online survey expert panel input, and application to empirical examples. We investigated psychometric properties in a set of diverse QI publications (N=54) by analysing reliability measures and item endorsement rates and explored sources of disagreement between reviewers. RESULTS: The QI-MQCS includes 16 content domains to evaluate QI intervention publications: Organisational Motivation, Intervention Rationale, Intervention Description, Organisational Characteristics, Implementation, Study Design, Comparator Description, Data Sources, Timing, Adherence/Fidelity, Health Outcomes, Organisational Readiness, Penetration/Reach, Sustainability, Spread and Limitations. Median inter-rater agreement for QI-MQCS items was kappa 0.57 (83% agreement). Item statistics indicated sufficient ability to differentiate between publications (median quality criteria met 67%). Internal consistency measures indicated coherence without excessive conceptual overlap (absolute mean interitem correlation=0.19). The critical appraisal instrument is accompanied by a user manual detailing What to consider, Where to look and How to rate. CONCLUSIONS: We developed a ready-to-use, valid and reliable critical appraisal instrument applicable to healthcare QI intervention publications, but recognise scope for continuing refinement.

Statistical process control and interrupted time series: a golden opportunity for impact evaluation in quality improvement.
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A. Fretheim and O. Tomic.
BMJ Qual Saf 2015 Aug 27.

Statistical process control (SPC) and interrupted time series (ITS) designs are two closely related methodologies in the field of quality improvement. In both approaches, data are organised in time series and presented using time series plots. Both SPC and ITS use data to assess whether observed changes reflect random variation or ‘real’ change. SPC is a popular method in quality improvement in the health sector worldwide, with scores of time series data collected. These data represent a golden but largely lost opportunity for learning and improving quality of care.

The advantage of short paper titles
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A Letchford, HS Moat, T Preis.
Royal Society Open Science 2015 The Royal Society;2(8)

Vast numbers of scientific articles are published each year, some of which attract considerable attention, and some of which go almost unnoticed. Here, we investigate whether any of this variance can be explained by a simple metric of one aspect of the paper’s presentation: the length of its title. Our analysis provides evidence that journals which publish papers with shorter titles receive more citations per paper. These results are consistent with the intriguing hypothesis that papers with shorter titles may be easier to understand, and hence attract more citations.

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Aging

The Effect of Depressive Symptoms and Antidepressant Use on Subsequent Physical Decline and Number of Hospitalizations in Nursing Home Residents: A 9-Year Longitudinal Study.
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H. Luo, J. Y. Tang, G. H. Wong, et al.
J Am Med Dir Assoc 2015 Jul 31

To investigate whether depressive symptoms and antidepressant use at baseline predict the subsequent decline in physical functioning and number of hospitalizations in nursing home residents. DESIGN: Observational study based on Minimum Data Set (MDS) 2.0. SETTING: Six nursing homes in Hong Kong. PARTICIPANTS: All nursing home residents (n = 1076) assessed with the MDS 2.0 in 2005 followed until 2013. MEASUREMENTS: Outcome variables included annual performance in activities of daily living (ADLs) and number of hospitalizations within 90 days before each assessment. The presence of depressive symptoms at baseline was measured by the Resident Assessment Protocol triggered from the MDS 2.0 assessment. Records of antidepressant use and other control variables were exacted directly from the MDS 2.0 assessment. RESULTS: The presence of baseline depressive symptoms did not have significant association with baseline ADLs and number of hospitalizations according to the multilevel mixed-effect model. However, it was associated with a faster deterioration of physical functioning (coefficient 0.03; 95% confidence interval [CI] 0.00-0.07) and an increase in the number of hospitalizations (coefficient 0.05; 95% CI 0.03-0.07). No significant difference between elders using antidepressants and elders who were free from depressive symptoms was observed. If depressive symptoms were presented but antidepressants were not used, a much sharper decline was evident (coefficient 0.06; 95% CI 0.02-0.09). CONCLUSIONS: This study provided evidence that the presence of depressive symptoms is associated with more utilization of health care services. However, the use of antidepressants may play a significant role in altering the trajectory. The presence of depressive symptoms is a worrisome but treatable condition. Effective intervention/treatment should be called on.

As they see it: A qualitative study of how older residents in nursing homes perceive their care needs.
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Y. H. Chuang, J. A. Abbey, Y. C. Yeh, I. J. Tseng and M. F. Liu.
Collegian 2015;22(1):43-51

OBJECTIVES: Meeting care needs of nursing home residents is a significant element in providing the best quality care. A literature review revealed that there is poor understanding of the care needs of older residents from their own viewpoints within a nursing home context. Therefore, this study aimed to explore the older nursing home residents’ care needs from their own perspectives. METHODS: This was a qualitative study. In-depth interviews were conducted by a purposive sample of 18 nursing home residents with a mean age of 80.7 years in Taiwan. All data was transcribed and coded for emerging themes. RESULTS: A qualitative data analysis generated six themes including the body, economics, environment, mind, preparation for death, and social support, referred to subsequently as BEEMPS. CONCLUSIONS: These findings can provide nursing home managers with information on how to improve nursing home care protocols to accommodate residents’ expressed needs and also inform healthcare professionals about the care needs of older residents, thus fostering better care.

Secondary Analysis of Office of Inspector General’s Pressure Ulcer Data: Incidence, Avoidability, and Level of Harm.
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J. M. Levine and K. M. Zulkowski.
Adv Skin Wound Care 2015 Sep;28(9):420-428

PURPOSE: To provide information about a secondary analysis of pressure ulcer data regarding incidence, avoidability, and level of harm. TARGET AUDIENCE: This continuing activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Summarize the data provided in the Office of Inspector General (OIG) study regarding incidence of pressure ulcers (PrUs) found in hospitals and skilled nursing facilities (SNFs).2. Identify the classification systems used that designate levels of harm to patients and the avoidability of PrUs. OBJECTIVE: To investigate in greater detail the government data on pressure ulcer (PrU) incidence, avoidability, and level of harm. DESIGN: The authors performed a secondary analysis of PrU data published in 2 studies by the Office of Inspector General (OIG) on adverse events in hospitals and skilled nursing facilities (SNFs). SETTING: Acute care hospitals and Medicare-certified SNFs across the United States. PATIENTS: The hospital sample included 780 Medicare beneficiaries randomly selected from 999,645 discharges during October 2008. The SNF population included 653 Medicare beneficiaries randomly selected from 100,771 patients whose stay began within 1 day of hospital discharge, who had a length of stay of 35 days or less, and whose stay ended in August 2011. MAIN OUTCOME MEASURES: Pressure ulcer incidence with stage, location, avoidability, and level of harm using the Modified National Coordinating Council for Medication Errors Reporting and Prevention Index. MAIN RESULTS: The PrU incidence in hospitals was 2.9%, and the incidence in SNFs was 3.4%. Most PrUs were Stages I and II, with 78.3% in hospitals and 54.5% in SNFs. The avoidability of PrUs was similar in both locations, with 39.1% unavoidable in hospitals and 40.9% unavoidable in SNFs. All hospital-acquired PrUs and 90.9% of SNF-acquired PrUs were designated level E on the National Coordinating Council for Medication Errors Reporting and Prevention Index, indicating a temporary harm event. CONCLUSIONS: The OIG studies captured few Stage III PrUs and no Stage IV PrUs, and they underestimate the level of harm generated from PrUs in hospitals and SNFs. The studies offer a structured algorithm for avoidability determination, but lack measures of reliability and validity. Nonetheless, the high rate of unavoidable ulcers leads to questions on the reliability of PrUs as a quality indicator. There are several weaknesses in OIG methodology with regard to PrUs; however, its structured algorithm can be viewed as a starting point for future studies of PrU avoidability.

Aged care residents in the emergency department: the experiences of relatives.
Non UofA Access
J. Morphet, K. Decker, K. Crawford, K. Innes, A. F. Williams and D. Griffiths.
J Clin Nurs 2015 Aug 12

AIMS AND OBJECTIVES: The aim of this study was to investigate the experiences of relatives who had a family member in an aged care facility subsequently transferred to an emergency department. BACKGROUND: The provision of timely and relevant patient information is vital for assessment and management of older patients presenting to the emergency department from aged care facilities. Older people are commonly accompanied by relatives who are an important resource for emergency department staff, providing medical information and assisting with treatment decisions. Investigating the experiences of relatives may provide key information to enable improvements in the delivery of emergency department care. DESIGN: This study used a descriptive qualitative design. METHODS: Semi-structured interviews were undertaken with 24 relatives of residents who were transferred from an aged care facility to an emergency department in Victoria, Australia in the previous three years. Inductive content analysis was used to analyse the transcripts. RESULTS: Relatives reflected on four main themes following their emergency department visit: The need for clear communication; The role of relatives in emergency department care; How older people are perceived in the health care system and an Ability to provide specialised care. CONCLUSIONS: Many people link their emergency department experience to the quality of communication with emergency department staff, and participants in this study felt satisfied with their visit when they were included in discussions about treatment, and their role was recognised by staff members. In contrast, participants were dissatisfied with the care provided to their family member when staff members failed to communicate with them, or recognise their role in the care of the family member. RELEVANCE TO CLINICAL PRACTICE: The findings of this study emphasise the importance of effective communication between emergency department staff and family members, in relation to treatment and end-of-life care.

Suicide Risk in Nursing Homes and Assisted Living Facilities: 2003-2011.
Non UofA Access
B. Mezuk, M. Lohman, M. Leslie and V. Powell.
Am J Public Health 2015 Jul;105(7):1495-1502

OBJECTIVES: We investigated the epidemiology of suicide among adults aged 50 years and older in nursing homes and assisted living facilities and whether anticipating transitioning into long-term care (LTC) is a risk factor for suicide. METHODS: Data come from the Virginia Violent Death Reporting System (2003-2011). We matched locations of suicides (n = 3453) against publicly available resource registries of nursing homes (n = 285) and assisted living facilities (n = 548). We examined individual and organizational correlates of suicide by logistic regression. We identified decedents anticipating entry into LTC through qualitative text analysis. RESULTS: Incidence of suicide was 14.16 per 100 000 in nursing homes and 15.66 in the community. Better performance on Nursing Home Compare quality metrics was associated with higher odds of suicide in nursing homes (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.21, 3.14). Larger facility size was associated with higher suicide risk in assisted living facilities (OR = 1.01; 95% CI = 1.00, 1.01). Text narratives identified 38 decedents anticipating transitioning into LTC and 16 whose loved one recently transitioned or resided in LTC. CONCLUSIONS: LTC may be an important point of engagement in suicide prevention.

How nursing home residents develop relationships with peers and staff: a grounded theory study.
Non UofA Access
T. Roberts and B. Bowers.
Int J Nurs Stud 2015 Jan;52(1):57-67

Social support and social relationships have been repeatedly identified as essential to nursing home resident quality of life. However, little is known about ways residents develop relationships with peers or staff. OBJECTIVE: This study was conducted to explore the ways resident develop relationships with peers and staff in nursing homes. DESIGN AND METHODS: Fifteen cognitively intact nursing home residents from two facilities were interviewed for this grounded theory study. Sampling, interviewing, and analysis occurred in a cyclical process with results at each stage of the study informing decisions about data collection and analysis in the next. Unstructured interviews and field observations were conducted. Data were analyzed with open, axial, and selective coding. RESULTS: Residents developed relationships with peers and staff largely as an unintended consequence of trying to have a life in the nursing home. Having a life was a two-step process. First, life motivations (Being Self and Creating a Positive Atmosphere) influenced resident preferences for daily activities and interaction goals and subsequently their strategies for achieving and establishing both. Second, the strategies residents used for achieving their required daily activities (Passing Time and Getting Needs Met) and interaction goals then influenced the nature of interaction and the subsequent peer or staff response to these interactions. Residents defined relationships as friendly or unfriendly depending on whether peers or staff responded positively or negatively. There was considerable overlap in the ways peer and staff relationships developed and the results highlight the role of peer and staff responsiveness in relationship development. IMPLICATIONS: The results provide possible explanations for the success of interventions in the literature designed to improve staff responsiveness to residents. The results suggest that adapting these kinds of interventions for use with peers may also be successful. The conceptual model also presents a number of opportunities for developing interventions for residents.

An elastic band exercise program for older adults using wheelchairs in Taiwan nursing homes: a cluster randomized trial.
Non UofA Access
K. M. Chen, C. H. Li, Y. H. Chang, H. T. Huang and Y. Y. Cheng.
Int J Nurs Stud 2015 Jan;52(1):30-38

BACKGROUND: The number of older adults using wheelchairs in nursing homes is over 50% of that population, and many of them use wheelchairs due to muscle weakness in the lower extremities. Muscles of older adults are trainable, and progressive resistance exercises using elastic bands can increase muscle strength in older adults. OBJECTIVES: To test the effectiveness of six-month Wheelchair-bound Senior Elastic Band exercises on the functional fitness of older adults in nursing homes. DESIGN: Cluster randomized trial. SETTINGS: Ten nursing homes, southern Taiwan. PARTICIPANTS: 127 participants were recruited, and 114 of them completed the study. Inclusion criteria were: (1) aged 65 and over, (2) using wheelchairs for mobility, (3) living in the facility for at least three months, (4) cognitively intact, and (5) heavily or moderate dependency in their activities of daily living. The mean age of the participants was 79.15 (7.03) years, and 98.20% of them had chronic illnesses. METHODS: Participants were randomly assigned to the experimental (five nursing homes, n=59) or the control (five nursing homes, n=55) group based on the nursing homes where they stayed. A 40-min Wheelchair-bound Senior Elastic Band exercise program was implemented three times per week for six months for the experimental group participants. The functional fitness (activities of daily living, lung capacity, body flexibilities, muscle power and endurance) of the participants was examined at baseline, after three months, and at the end of the six months study. The mixed-design, two-way analysis of variance was used to detect the interaction effects, and one-way repeated measures analysis of variance and analysis of covariance were performed to analyze the within-group and between-group differences. RESULTS: At the end of the six-month study, the Wheelchair-bound Senior Elastic Band group had better performances in all of the functional fitness indicators than the control group (all p<0.05). CONCLUSIONS: The Wheelchair-bound Senior Elastic Band exercises significantly improved the functional fitness of the older adults in wheelchairs. It is suggested that the program be incorporated as a part of daily activities for nursing home older adults in wheelchairs.

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia.
Non UofA Access
C. M. Callahan, W. Tu, K. T. Unroe, M. A. LaMantia, T. E. Stump and D. O. Clark.
J Am Geriatr Soc 2015 Aug;63(8):1495-1502

OBJECTIVES: To describe transitions in care for older adults with dementia identified from a nationally representative cohort and to describe transition rates in those with more-severe levels of cognitive and functional impairment. DESIGN: Longitudinal cohort study. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: HRS respondents aged 65 and older whose survey data were linked with Medicare claims from 1999 to 2008 (N = 16,186). MEASUREMENTS: Transitions in care between home, home with formal services, hospital, and nursing facility care; cognitive function; activities of daily living; and mortality. RESULTS: The 3,447 (21.3%) HRS subjects who were ever diagnosed with dementia experienced frequent transitions. Of subjects transitioning from a hospital stay, 52.2% returned home without home care services, and 33.8% transitioned to a nursing facility. Of subjects transitioning from a nursing facility, 59.2% transitioned to the hospital, and 25.3% returned home without services. There were 2,139 transitions to death, and 58.7% of HRS subjects with dementia died at home. Even in persons with moderate to severe dementia, multiple transitions in care were documented, including transitions from the hospital to home and back to the hospital. CONCLUSION: In this nationally representative sample of older adults, subjects diagnosed with dementia experience frequent transitions. Persons with dementia who are cared for at home and who transition back to home often have moderate to severe impairments in function and cognition.

Home healthcare teams’ assessments of pain in care recipients living with dementia: a Swedish exploratory study.
Non UofA Access
C. E. Karlsson, M. Ernsth Bravell, K. Ek and I. Bergh.
Int J Older People Nurs 2015 Sep;10(3):190-200

BACKGROUND: Pain assessment in people living with dementia is a challenge due to the complexity of pain and dementia and the difficulties in self-reporting. In home healthcare, nurses are frequently involved in pain assessment situations and there is a need to explore how home healthcare teams’ manage pain assessment in this setting. AIM: The study aimed to explore home healthcare teams’ experiences of pain assessment among care recipients with dementia. DESIGN: An exploratory qualitative design was used. METHODS: Open-ended individual interviews were conducted with thirteen registered nurses and ten nursing assistants, working in three different home healthcare teams in one municipality in western Sweden. Philosophical hermeneutics was utilised to interpret the home healthcare teams’ experiences. RESULTS: Four interpretations emerged: the need for trusting collaboration, the use of multiple assessment strategies, maintenance of staff continuity in care and assessment situations, and the need for extended time to assess pain. CONCLUSIONS: The home healthcare teams recognise pain assessment in people with dementia as involving a complex interaction of sensory, cognitive, emotional and behavioural components in which efforts to acquire understanding of behavioural changes mainly guides their assessments. The solid team coherence between registered nurses and nursing assistants aided the assessment procedure. To assess pain, the teams used multiple methods that complemented one another. However, no systematic routines or appropriate evidence-based pain tools were used. IMPLICATIONS FOR PRACTICE: The team members’concern for care recipients when assessing pain is evident and needs to be acknowledged by the organisation which is responsible for the quality of care. Future studies should focus on further exploration of nurses’ experiences with pain and dementia in home healthcare settings and address what nurses identify and how they deal with their findings. It is imperative to investigate how organisations and nurses can ensure best practices and how the implementation of evidence-based routines for assessing pain may aid in pain assessment situations.

Managing pain medications in long-term care: nurses’ views. Canada-flat-icon
Non UofA Access
S. Kaasalainen, G. Agarwal, L. Dolovich, K. Brazil and A. Papaioannou.
Br J Nurs 2015 May 14-27;24(9):484, 486-9

The purpose of this study was to explore nurses’ perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents’ pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses’ perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

The effect of conservative treatment of urinary incontinence among older and frail older people: a systematic review.
Non UofA Access
K. Stenzelius, U. Molander, J. Odeberg, et al.
Age Ageing 2015 Sep;44(5):736-744

BACKGROUND: urinary incontinence (UI) is a common symptom among older people, with a higher prevalence among frail older persons living in nursing homes. Despite consequences such as reduced health and quality of life, many older people do not seek help for their symptoms, resulting in missed opportunity for treatment. OBJECTIVE: the aim of this study was to investigate the evidence and the effect of conservative treatment of UI and the quality of life among older and frail older persons. METHODS: a systematic review of randomised controlled studies and prospective, non-randomised studies was conducted, evaluating interventions of conservative treatment of UI in an older population (65 years or older). A total of 23 studies fulfilled the inclusion criteria and 9 were of high or moderate quality. Fourteen studies were of low quality and were therefore excluded from the analysis. RESULTS: documented and effective conservative treatments are available even for older persons with UI. Pelvic muscle exercise, physical training in combination with ADL, prompted voiding and attention training, and help to toilet are important treatments. In some studies, however, the evidence of effectiveness is limited. CONCLUSIONS: this systematic review concludes that there are conservative treatments for UI for older and frail older persons that reduce leakage and increase quality of life. There is however a need for further high-quality studies.

Development and Psychometric Properties of the Family Distress in Advanced Dementia Scale.
Non UofA Access
J. L. Givens, R. N. Jones, K. M. Mazor, H. G. Prigerson and S. L. Mitchell.
J Am Med Dir Assoc 2015 Sep 1;16(9):775-780

OBJECTIVE: The majority of scales to measure family member distress in dementia are designed for community settings and do not capture the unique burdens of the nursing home (NH) environment. We report the psychometric properties of a new Family Distress in Advanced Dementia Scale for use in the NH setting. DESIGN, SETTING, PARTICIPANTS: Cross-sectional questionnaire of 130 family member health care proxies of NH residents with advanced dementia in 31 Boston-area NHs. METHODS: Thirty-one initial items were evaluated, measuring the frequency over the past 3 months of sources of distress. Exploratory factor analysis identified domains of distress; Cronbach’s alpha was computed for each domain. Associations between the domains and other measures were evaluated using Pearson correlation coefficients, including measures of depression (PHQ-9), satisfaction with care (Satisfaction with Care at the End-of-Life in Dementia [SWC-EOLD]), and caregiver burden (Zarit Burden Interview short version). RESULTS: Factor analysis suggested 3 domains: emotional distress (9 items), dementia preparedness (5 items), and NH relations (7 items). Cronbach’s alpha coefficients were 0.82, 0.75, and 0.83 respectively. The PHQ-9 correlated most strongly with the emotional distress factor (r = 0.34), the SWC-EOWD correlated most strongly with the NH relations factor (r = 0.35), as did the Zarit Burden Scale (r = 0.50). CONCLUSIONS: The Family Distress in Advanced Dementia Scale encompasses 3 domains of distress. This scale represents a much needed tool to assess distress among family members of NH residents with advanced dementia and provides a metric to evaluate interventions in the population.

Transitioning From Community-Based to Institutional Long-term Care: Comparing 1915(c) Waiver and PACE Enrollees
Non UofA Access
M. Segelman, X. Cai, C. van Reenen and H. Temkin-Greener.
Gerontologist 2015 Aug 18

PURPOSE OF THE STUDY: To compare the risk of long-term nursing home (NH) admission and the level of functional and cognitive impairment at the time of long-term NH admission in the Program of All-Inclusive Care for the Elderly (PACE) and in 1915(c) aged and aged and disabled waiver programs. DESIGN AND METHODS: Cohorts of new waiver and PACE enrollees in 12 states were identified (in 2005-2007) and followed (through 2009) using the Medicaid Analytic Extract and the Minimum Data Set. Individual-level outcomes of interest were time from waiver or PACE enrollment to long-term (90+ days) NH admission and functional (29-point activities of daily living [ADL]) and cognitive (7-point Cognitive Performance Scale [CPS]) impairment at NH admission. An overall measure of impairment was also created and categorized as low (ADL /= 17 or CPS >/= 3). The key independent variable was enrollment in PACE versus waiver program. County-level covariates were included. Analyses employed multivariable models including competing risk proportional hazard and linear and logistic regressions. RESULTS: Compared with waiver enrollees, PACE enrollees had 31% lower risk of long-term NH admission (p /= 17 or CPS >/= 3). The key independent variable was enrollment in PACE versus waiver program. County-level covariates were included. Analyses employed multivariable models including competing risk proportional hazard and linear and logistic regressions. RESULTS: Compared with waiver enrollees, PACE enrollees had 31% lower risk of long-term NH admission (p /= 4) cognitive impairment (p < .001) and 45% higher odds of having overall high impairment (p = .003). IMPLICATIONS: PACE may be more effective than 1915(c) aged and aged and disabled waiver programs in reducing long-term NH use and may be particularly well suited to supporting cognitively impaired individuals, enabling them to remain in the community longer.

Sequence of Functional Loss and Recovery in Nursing Homes.
Non UofA Access
C. R. Levy, M. Zargoush, A. E. Williams, et al.
Gerontologist 2015 Aug 18

PURPOSE OF THE STUDY: This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery. DESIGN AND METHODS: We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits. RESULTS: The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments. IMPLICATIONS: Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.

Does the Volume of Post-Acute Care Affect Quality of Life in Nursing Homes?
Non UofA Access
K. Abrahamson, T. P. Shippee, C. Henning-Smith and V. Cooke.
J Appl Gerontol 2015 Aug 24

Although short-stay, post-acute nursing home stays are increasing, little is known about the impact of volume of post-acute care on quality of life (QOL) within nursing homes. We analyzed data from the 2010 Minnesota QOL and Consumer Satisfaction survey (N = 13,433 residents within 377 facilities) and federal Minimum Data Set to determine the influence of living in a facility with an above-average proportion of post-acute care residents on six domains of resident QOL. In bivariate analyses, an above-average proportion of Medicare-funded post-acute care had a significant negative influence on four domains (mood, environment, food, engagement) and overall facility QOL. However, when resident and facility covariates were added to the model, only the food domain remained significant. Although the challenges of caring for residents with a diverse set of treatment and caregiving goals may negatively affect overall facility QOL, negative impacts are moderated by individual resident and nursing home characteristics.

Physical Frailty and Cognitive Functioning in Depressed Older Adults: Findings From the NESDO Study.
Non UofA Access
M. H. Arts, R. M. Collard, H. C. Comijs, et al.
J Am Med Dir Assoc 2015 Sep 1

OBJECTIVES: Cognitive frailty has recently been defined as the co-occurrence of physical frailty and cognitive impairment. Late-life depression is associated with both physical frailty and cognitive impairment, especially processing speed and executive functioning. The objective of this study was to investigate the association between physical frailty and cognitive functioning in depressed older persons. DESIGN: Baseline data of a depressed cohort, participating in the Netherlands Study of Depression in Older persons (NESDO). SETTING: Primary care and specialized mental health care. PARTICIPANTS: A total of 378 patients (>/=60 years) with depression according to DSM-IV criteria and a MMSE score of 24 points or higher. MEASUREMENTS: The physical frailty phenotype as well as its individual criteria (weight loss, weakness, exhaustion, slowness, low activity). Cognitive functioning was examined in 4 domains: verbal memory, working memory, interference control, and processing speed. RESULTS: Of the 378 depressed patients (range 60-90 years; 66.1% women), 61 were classified as robust (no frailty criteria present), 214 as prefrail (1 or 2 frailty criteria present), and 103 as frail (>/=3 criteria). Linear regression analyses, adjusted for confounders, showed that the severity of physical frailty was associated with poorer verbal memory (ss = -0.13, P = .039), slower processing speed (ss = -0.20, P = .001), and decreased working memory (ss = -0.18, P = .004), but not with changes in interference control (ss = 0.04, P = .54). CONCLUSION: In late-life depression, physical frailty is associated with poorer cognitive functioning, although not consistently for executive functioning. Future studies should examine whether cognitive impairment in the presence of physical frailty belongs to cognitive frailty and is indeed an important concept to identify a specific subgroup of depressed older patients, who need multimodal treatment strategies integrating physical, cognitive, and psychological functioning.

A cost-effectiveness analysis of two different repositioning strategies for the prevention of pressure ulcers.
Non UofA Access
G. Marsden, K. Jones, J. Neilson, L. Avital, M. Collier and G. Stansby.
J Adv Nurs 2015 Aug 27

AIMS: To assess the cost effectiveness of two repositioning strategies and inform the 2014 National Institute for Health and Care Excellence clinical guideline recommendations on pressure ulcer prevention. BACKGROUND: Pressure ulcers are distressing events, caused when skin and underlying tissues are placed under pressure sufficient to impair blood supply. They can have a substantial impact on quality of life and have significant resource implications. Repositioning is a key prevention strategy, but can be resource intensive, leading to variation in practice. This economic analysis was conducted to identify the most cost-effective repositioning strategy for the prevention of pressure ulcers. DESIGN: The economic analysis took the form of a cost-utility model. METHODS: The clinical inputs to the model were taken from a systematic review of clinical data. The population in the model was older people in a nursing home. The economic model was developed with members of the guideline development group and included costs borne by the UK National Health Service. Outcomes were expressed as costs and quality adjusted life years. CONCLUSION: Despite being marginally more clinically effective, alternating 2 and 4 hourly repositioning is not a cost-effective use of UK National Health Service resources (compared with 4 hourly repositioning) for this high risk group of patients at a cost-effectiveness threshold of pound20,000 per quality adjusted life years. These results were used to inform the clinical guideline recommendations for those who are at high risk of developing pressure ulcers.

Content validation of the Tilburg Frailty Indicator from the perspective of frail elderly. A qualitative explorative study.
Non UofA Access
J. Andreasen, H. Lund, M. Aadahl, R. J. Gobbens and E. E. Sorensen.
Arch Gerontol Geriatr 2015 Aug 24

The Tilburg Frailty Indicator is a questionnaire with a bio-psycho-social approach, which measures frailty by 15 questions. A questionnaire about frailty should be in alignment with experiences of frail elderly themselves as a target population is an important source of knowledge in content validation. AIM: To validate the Tilburg Frailty Indicator on content in relation to the physical, psychological and social domain by exploring the experience of daily life of community dwelling frail elderly. METHODS: The design was a qualitative content validation study. The participants were acutely admitted frail elderly discharged to home and interviewed one week after discharge. A deductive content analysis, with categories structured in advance, was performed. RESULTS: A total of 422 meaning units were extracted from the transcriptions; 131 units related to the physical domain, 106 units to the psychological domain and 185 units to the social domain. 56 units were not linked into the existing structure of the questionnaire. 14 of 15 questions were confirmed from a target population perspective. The four issues pain, sleep quality, spirituality and meaningful activities that seem to be important elements for frail elderly were not directly covered by the questionnaire. DISCUSSION: It seems likely that the majority of important items related to frailty are covered in the questionnaire. The findings add to the scientific body of knowledge in relation to the validity of the questionnaire. Future research should investigate the importance of the four issues pain, sleep quality, spirituality and meaningful activities in relation to the screening of frailty.

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Events

UofA

Whose Life Is It Anyway? Decision-Making for Those Lacking Capacity
Friday 2 October Lister Conference Centre

Some topics presenters will address are: autonomy and vulnerable trust for individuals lacking capacity, handling disagreements between parents of seriously ill children and health care teams, virtue of physicians as advocates, health care practitioners’ difficult conversations, and relationships in difficult decision-making for the mentally ill.

PaCER (Patient and Community Engagement Research)
Thursday 24 September 08:30–10:00 ECHA L1 230

PaCER is a unique program that works to create the partnerships and infrastructure needed to transform the role of patients and families in health and health culture experience. They bring an authentic patient presence to research planning, projects and knowledge uptake. PaCER will present on their program to engage and include the patient/family voice and participation in health research. They will discuss their methods and answer any questions. Please RSVP to Tanya Barber at 780.492.2409 or tkbarber@ualberta.ca.

Online

A Patient-Centred Approach to Being with Older Adults with Dementia
Wednesday 16 September 10:00-11:00 MT
BrainXchange in partnership with the Alzheimer Society of Canada and the Canadian Consortium of Neurodegeneration in Aging (CCNA)
Presenter: Dr. Katherine S. McGilton

The purpose of this presentation is to introduce the REAP framework, a comprehensive person-centered approach to care that gives health care practitioners practical, specific means and strategies with which to deliver person-centered dementia care. The four pillars of the REAP framework model are relating well, manipulating the environment, recognizing retained abilities, and knowing the person.

KT Canada Rounds: Translating Emergency Knowledge for Kids (TREKK), a knowledge mobilization initiative to improve emergency care for all children in Canada
Thursday 10 September 10:00-11:00 MT

Learning Objectives: Learn how TREKK has:
-Determined the needs of end users
-Designed and created resources
-Connected with stakeholders across the country

Accessing Information on Employment by Individuals with Traumatic Brain Injury: Facebook as a Knowledge Translation Strategy
Wednesday 18 November 12:00 – 12:45 MT

This webcast will cover the findings from a study using Facebook to provide information on employment evidence-based practices to individuals with traumatic brain injury (TBI). Two groups of individuals with TBI participated in the study. One group was randomly assigned to the Facebook intervention and the other group assigned to a “business as usual” group. This group received a monthly e-mail with resources similar to those posted in the Facebook group. The presenters will cover the results of the study and discuss needs for future research on using social media as a knowledge translation strategy.

TVN Webinar: Rehabilitation for the frail elderly: models of care and quality indicators
Wednesday 9 September 10:00 MT

Join Dr. Lora Giangregorio and Caitlin McArthur of the University of Waterloo as they discuss the results of a scoping review describing the types of rehabilitation interventions evaluated in LTC, the outcomes used to evaluate the interventions, and tools or models used to guide allocation of services. The results of an associated consensus process to determine which current quality indicators could be used to evaluate physical rehabilitation in long-term care will also be presented. The results of this project will not only provide clinicians and policy-makers with knowledge on how to evaluate the impact and quality of rehabilitation services in LTC (e.g. what QIs to use), but also identify the gaps in knowledge and identify areas for future research for rehabilitation for the frail elderly.

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News

Website linking personal care homes and clients ready for development in Saskatoon Health Region Canada-flat-icon

The proposed website has three goals – to allow clients and their families an easier time to find a PCH that meets their needs, and provide ways to help them in their search, to build awareness of the resources that are available either locally or provincially, and to allow the care home operators a means of changing and updating information like vacancies and contact information.

Four things we can do to improve healthcare in Canada Canada-flat-icon

As the federal election campaign unfolds, Canadians should be pressing the parties to take a leadership position on healthcare issues.

8 reasons why journals reject manuscripts

You’ve put a great deal of time and effort into your manuscript, so you want to make sure that it stands the best possible chance of getting accepted into the journal of your choice. However, too many manuscripts are rejected because of easy to avoid errors or oversights.

Provinces with more seniors should get more health care cash, doctors say Canada-flat-icon

As Canada hands out federal health money on a per capita basis, provinces with aging populations could be in trouble. During the election debate, the word “health care” is only used a handful of times during the two-hour broadcast. Advocates say health care should be on election radar. The Canadian Medical Association fears this framework could mean those dollars aren’t going to where they’re needed most: Canada’s seniors.

Effective Treatments for Depression in Elderly Care Settings (US)

With roughly 7 million adults 65 and older in the US experiencing some form of depression, according to Treatments for elderly depressionthe Centers for Disease Control and Prevention, finding effective treatment methods is essential. Depression Care Management (DCM) in the home or in a clinical setting, as well as cognitive-behavioral approaches, can help the elderly cope with depression, improve their quality of life and lower the risk of suicide.

New Edmonton hospital unit designed to improve seniors medical care Canada-flat-icon

A recently transformed surgical unit at an Edmonton hospital will help senior patients get home sooner, in better health and with fewer complications after emergency surgery, doctors say.

Dementia stabilized in Europe, studies suggest

Emerging evidence points to ways to lower risk of dementia.

I thought I could fix my Alzheimer’s patients. I learned to help them instead.

My first day in a nursing home was one of the most traumatic events of my life. I’d taken all the classes. I’d done the required clinical internship. I had the knowledge and the firsthand experience. But nothing prepared me for that first day on the floor.

Three in Five Canadians (63%) Aren’t Prepared to Care for Family Members who Require Long-term Care Canada-flat-icon

Three in five Canadians (63%) say their family is not in a good position (financially or otherwise) to care for older family members if they need long term health care, and it worries them greatly. Nearly nine in ten Canadians (89%) agree that whoever wins the election this fall, the next Prime Minister needs to address the health care needs of Canada’s aging population.

Global life expectancy rises, but people remain sicker for longer

World has made great progress in health;challenge is to invest in ways to prevent, treat major illlnesses.

New official administrator appointed to lead Alberta Health Services Canada-flat-icon

Health Minister Sarah Hoffman has named David Carpenter the Official Administrator of Alberta Health Services, while work continues on a long-term governance plan for the organization.

Antipsychotic Use Continues to Decrease Among Long-Stay Nursing Home Residents, CMS Report Shows (US)

According to data compiled by the National Partnership to Improve Dementia Care in Nursing Homes – a public-private coalition under the direction of CMS – 18.7 percent of long-stay nursing home residents were receiving an antipsychotic medication in the first quarter of 2015 compared with 23.9 percent in the fourth quarter of 2011, representing a 21.7 percent decrease.

The costs of dementia in Europe have increased by 25 per cent to $300 billion in 2015

The total estimated worldwide cost of dementia has reached $818 billion (£521 billion) and will become a trillion dollar disease by 2018, finds the World Alzheimer Report 2015.

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Resources

AHRQ Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration

This document is designed as a practical guide to the uses of and methods for conducting rapid-cycle research. It was developed by the Agency for Healthcare Research and Quality (AHRQ) Practice-Based Research Network (PBRN) Resource Center to:
-address a demand of researchers and implementers, including the primary care PBRN community to describe the process of identifying opportunities to pursue rapid-cycle research, and
-provide in-depth exploration of some methodologies of interest.

A Road Less Rocky Making the Road Less Rocky for Carers: A Guide on how to Support Carers of People with Dementia (UK)
Carers Trust

This toolkit is designed around the issues carers face at these points and what will make a positive difference. It has been produced to sit alongside A Road Less Rocky and gives guidance to professionals who come in contact with carers.

CMA: Promise Tracker Canada-flat-icon

Use this resource to keep track of the federal political parties promises on health and seniors care.

BMC Collection on Extending Evidence-Based Medicine

The science of evidence-based medicine (EBM) is more than 20 years old. Unsurprisingly the movement has produced both an established orthodoxy and dissenting voices. This series of papers, whose authors include both ‘orthodox’ and ‘dissenting’ perspectives, considers how EBM might be extended beyond the epidemiological focus of its founding fathers. We invite comments from readers and anticipate that this series will provoke an important contemporary debate on what EBM is and what it should become.

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