BACKGROUND: The success of evidence-based practice depends on clearly and effectively communicating often complex data to stakeholders. In our program of research, Translating Research in Elder Care (TREC), we focus on improving the quality and safety of care delivered to nursing home residents in western Canada. More specifically, we investigate associations among organizational context, the use of best practices and resident outcomes. Our data are complex and we have been challenged with presenting these data in a way that is not only intuitive, but also useful for our stakeholders. AIM: To illustrate a technique of organizing and presenting complex data to nonresearch stakeholders. METHODS: Using observational data previously collected within the TREC study, we used k-means cluster analysis to categorize nursing home resident care units or facilities within our sample into two distinct groups-those with more favorable contexts (work environment) and those with less favorable contexts. We then produced scatter plots to illustrate group differences between context and various quality indicators among resident care units or facilities. RESULTS: Care aides working on units with more favorable context reported higher use of best practices. When aggregated at the nursing home facility level, facilities with low rates of both urinary tract infections and indwelling catheter use are higher in organizational context. When feeding back these results to stakeholders, we identify their units so that they are able to visually assess their units, both relative to each other and relative to all other units and facilities both within and among provinces. LINKING EVIDENCE TO ACTION: Although we have not formally evaluated this method, we have used it extensively as part of the feedback we provide to stakeholders. As we are examining modifiable aspects of context, the stakeholder can then identify areas for improvement and thus implement a focused plan.
Article recommended by Dr. Carole Estabrooks
Regulating Individual Charges for Long-Term Residential Care In Canada
Provinces and territories differ in how publicly regulated long-term residential care is financed. Although the costs of ?care? are funded publicly, all provinces and territories except Nunavut require contributions from individuals to cover so-called accommodation costs. These vary widely. This paper examines trends and variations in long-term residential care fee structures and the implications for equity (within and across jurisdictions), including gender equity.; AbstractProvinces and territories differ in how publicly regulated long-term residential care is financed. Although the costs of ?care? are funded publicly, all provinces and territories except Nunavut require contributions from individuals to cover so-called accommodation costs. These vary widely. This paper examines trends and variations in long-term residential care fee structures and the implications for equity (within and across jurisdictions), including gender equity.
New article by Dr Jo Rycroft-Malone
Implementing best practice in infection prevention and control. A realist evaluation of the role of intermediaries
Non UofA Access
Background Implementing best practice in healthcare is complex. There is evidence to suggest that certain individuals, collectively termed ‘intermediaries,’ can contribute to implementation processes, but understanding exactly what happens and how intermediaries promote best practice is unclear. Objectives The aim of this study was to evaluate the role of intermediaries in promoting infection prevention, and provide an explanation about what works, for whom, how, and under which conditions. Methods Realist methodology was used as the underpinning explanatory framework for the study. From a concept mining of the existing literature, a set of hypothetical statements about the plausible range of context- mechanism – outcome propositions that postulate how intermediaries can contribute to promoting best practice were developed and evaluated. Design Case studies were conducted consecutively to refine and test the propositions. Data included semi-structured interviews (n = 32), non-participant observations (n = 5) and documentation review. Data were analysed by open coding, content and pattern matching. Settings Case studies were undertaken in two hospitals within the United Kingdom. Participants Purposive sampling was used to identify individuals within the organizations who had professional or organizational responsibilities for infection prevention. The inclusion criteria were; employees of the chosen organisations who would consent to take part in the study, participants with infection prevention responsibilities, adults over 18 years with the capacity to consent. The exclusion criteria were; participants outside of the chosen organisation, participants under 18 years of age, and participants who lacked the capacity to consent. Results Four context-mechanism-outcome configurations contribute to advancing our understanding about the potential of intermediaries to promote best practice. Findings showed that the ways in which intermediaries watch over practice (their human surveillance), promoted better adherence with infection control practices. Particular styles and approaches used by intermediaries led to individual staff feeling personally supported. Distinct ways of providing performance feedback for staff together with the policy discourse promoted good habitual behaviours. Practice-based teaching heightened awareness of individuals’ own practice and made learning more real. Conclusions Findings offer a new lens on the role of intermediaries in bridging the evidence to practice gap. As such they could be considered when reviewing or developing new interventions/programmes that use intermediaries to plug the gap between theory and practice. The findings could also be used to guide the design and development of new intermediary models in healthcare, to promote best practice and support the quality of patient care.
New article by Dr Margaret McGregor
Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?
Non UofA Access
Margaret McGregor and colleagues consider Bradford Hill’s framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.
Profile of Long Term Care Residents in Alberta
2014/2015 Alberta Long-Term Care Resident Profile
A frequently discussed value in the provision of long-term care is ensuring that the care provided is person-centred. Alberta’s continuing care system describes the dynamic populations found within the continuing care system in that province annually in their “Long-term Care Resident Profiles” which provide description of demographics, health conditions and care and interventions. The information presented in their report is based on data collected in MDS assessments.
Grants & Awards
The purpose of these awards is to build capacity for the conduct and use of patient-oriented research in Ontario among patients and their families, health care providers, policy makers and managers, and researchers and research trainees.
The Canadian Institutes of Health Research (CIHR) has released a call for Strategy for Patient Oriented Research Primary and Integrated Health Care Innovation Network (SPOR PIHCIN) 2016 Knowledge Synthesis (KS) grants. The purpose of this funding opportunity is to support knowledge syntheses and scoping reviews, which is a cornerstone of knowledge translation. They transform vast libraries of scientific literature into knowledge that is reliable, relevant and readable for knowledge users and may be used as an evidence-based approach to make informed decisions about health policies, programs and/or practices.
Funding Opportunity Pre-announcement: Researchers invited to analyze Canadian Longitudinal Study on Aging (CLSA) data
Canadian researchers from all research areas are invited to submit health research projects that make use of available CLSA data. The data, collected from over 50,000 Canadians, covers various aspects of people’s lives, including biological, medical, psychological, social, lifestyle and economic aspects. The research projects should help us understand how these factors, taken individually and in combination, have an impact in both maintaining health and in the development of disease and disability as people age. This funding opportunity is restricted to the currently available alpha numeric data available from the CLSA. The selected projects will help find ways to improve the health of Canadians by better understanding the aging process and the factors that shape the way we age.
PURPOSE: To explore the evidence around facilitation as an intervention for the successful implementation of new knowledge into clinical practice. ORGANIZING CONSTRUCT: The revised version of the Promoting Action on Research Implementation in Health Services (PARIHS) framework, called the integrated or i-PARIHS framework, is used as the explanatory framework. This framework posits that evidence is a multidimensional construct embedded within innovation and operationalized by clinicians (individuals and within teams), working across multiple layers of context. Facilitation is the active ingredient that promotes successful implementation. FINDINGS: An emerging body of evidence supports facilitation as a mechanism to getting new knowledge into clinical practice. Facilitation roles are divided into beginner, experienced, and expert facilitators. Facilitators can be internal or external to the organization they work in, and their skills and attributes complement other knowledge translation (KT) roles. Complex KT projects require facilitators who are experienced in implementation methods. CONCLUSIONS: Facilitation is positioned as the active ingredient to effectively introduce new knowledge into a clinical setting. Levels of facilitation experience are assessed in relation to the complexity of the KT task. Three core facilitation roles are identified, and structured interventions are established taking into account the nature and novelty of the evidence, the receptiveness of the clinicians, and the context or setting where the new evidence is to be introduced. CLINICAL RELEVANCE: Roles such as novice, experienced, and expert facilitators have important and complementary parts to play in enabling the successful translation of evidence into everyday practice in order to provide effective care for patients.
BACKGROUND: There are wide variations in maternal-newborn care practices and outcomes across Ontario. To help institutions and care providers learn about their own performance, the Better Outcomes Registry & Network (BORN) Ontario has implemented an audit and feedback system, the Maternal-Newborn Dashboard (MND), for all hospitals providing maternal-newborn care. The dashboard provides (1) near real-time feedback, with site-specific and peer comparison data about six key performance indicators; (2) a visual display of evidence-practice gaps related to the indicators; and (3) benchmarks to provide direction for practice change. This study aims to evaluate the effects of the dashboard, dashboard attributes, contextual factors, and facilitation/support needs that influence the use of this audit and feedback system to improve performance. The objectives of this study are to (1) evaluate the effect of implementing the dashboard across Ontario; (2) explore factors that potentially explain differences in the use of the MND among hospitals; (3) measure factors potentially associated with differential effectiveness of the MND; and (4) identify factors that predict differences in hospital performance. METHODS/DESIGN: A mixed methods design includes (1) an interrupted time series analysis to evaluate the effect of the intervention on six indicators, (2) key informant interviews with a purposeful sample of directors/managers from up to 20 maternal-newborn care hospitals to explore factors that influence the use of the dashboard, (3) a provincial survey of obstetrical directors/managers from all maternal-newborn hospitals in the province to measure factors that influence the use of the dashboard, and (4) a multivariable generalized linear mixed effects regression analysis of the indicators at each hospital to quantitatively evaluate the change in practice following implementation of the dashboard and to identify factors most predictive of use. DISCUSSION: Study results will provide essential data to develop knowledge translation strategies for facilitating practice change, which can be further evaluated through a future cluster randomized trial.
BACKGROUND: Intentions play a central role in numerous empirically supported theories of behavior and behavior change and have been identified as a potentially important antecedent to successful evidence-based treatment (EBT) implementation. Despite this, few measures of mental health clinicians’ EBT intentions exist and available measures have not been subject to thorough psychometric evaluation or testing. This paper evaluates the psychometric properties of the evidence-based treatment intentions (EBTI) scale, a new measure of mental health clinicians’ intentions to adopt EBTs. METHODS: The study evaluates the reliability and validity of inferences made with the EBTI using multi-method, multi-informant criterion variables collected over 12 months from a sample of 197 mental health clinicians delivering services in 13 mental health agencies. Structural, predictive, and discriminant validity evidence is assessed. RESULTS: Findings support the EBTI’s factor structure (chi (2) = 3.96, df = 5, p = .556) and internal consistency reliability (alpha = .80). Predictive validity evidence was provided by robust and significant associations between EBTI scores and clinicians’ observer-reported attendance at a voluntary EBT workshop at a 1-month follow-up (OR = 1.92, p < .05), self-reported EBT adoption at a 12-month follow-up (R (2) = .17, p < .001), and self-reported use of EBTs with clients at a 12-month follow-up (R (2) = .25, p < .001). Discriminant validity evidence was provided by small associations with clinicians’ concurrently measured psychological work climate perceptions of functionality (R (2) = .06, p < .05), engagement (R (2) = .06, p < .05), and stress (R (2) = .00, ns). CONCLUSIONS: The EBTI is a practical and theoretically grounded measure of mental health clinicians’ EBT intentions. Scores on the EBTI provide a basis for valid inferences regarding mental health clinicians’ intentions to adopt EBTs. Discussion focuses on research and practice applications.
Background: Although feasible protocols for pain assessment and management in long-term care (LTC) have been developed, these have not been implemented on a large-scale basis. Objective: To implement a program of regular pain assessment in two LTC facilities, using implementation science principles, and to evaluate the process and success of doing so. Methods. The implementation protocol included a pain assessment workshop and the establishment of a nurse Pain Champion. Quality indicators were tracked before and after implementation. Focus groups and interviews with staff were also conducted. Results: The implementation effort was successful in increasing and regularizing pain assessments. This was sustained during the follow-up period. Staff members reported enthusiasm about the protocol at baseline and positive results following its implementation. Despite the success in increasing assessments, we did not identify changes in the percentages of patients reported as having moderate-to-severe pain. Discussion. It is our hope that our feasibility demonstration will encourage more facilities to improve their pain assessment/management practices. Conclusions: It is feasible to implement regular and systematic pain assessment in LTC. Future research should focus on ensuring effective clinical practices in response to assessment results, and determination of longer-term sustainability. Copyright 2016 Thomas Hadjistavropoulos et al.
BACKGROUND: There is a need to understand scientific evidence in light of the context within which it will be used. Deliberative dialogues are a promising strategy that can be used to meet this evidence interpretation challenge. METHODS: We evaluated a deliberative dialogue held by a transnational violence prevention network. The deliberative dialogue included researchers and knowledge user partners of the Preventing Violence Across the Lifespan (PreVAiL) Research Network and was incorporated into a biennial full-team meeting. The dialogue included pre- and post-meeting activities, as well as deliberations embedded within the meeting agenda. The deliberations included a preparatory plenary session, small group sessions and a synthesizing plenary. The challenge addressed through the process was how to mobilize research to orient health and social service systems to prevent family violence and its consequences. The deliberations focused on the challenge, potential solutions for addressing it and implementation factors. Using a mixed-methods approach, data were collected via questionnaires, meeting minutes, dialogue documents and follow-up telephone interviews. RESULTS: Forty-four individuals (all known to each other and from diverse professional roles, settings and countries) participated in the deliberative dialogue. Ten of the 12 features of the deliberative dialogue were rated favourably by all respondents. The mean behavioural intention score was 5.7 on a scale from 1 (strongly disagree) to 7 (strongly agree), suggesting that many participants intended to use what they learned in their future decision-making. Interviews provided further insight into what might be done to facilitate the use of research in the violence prevention arena. CONCLUSION: Findings suggest that participants will use dialogue learnings to influence practice and policy change. Deliberative dialogues may be a viable strategy for collaborative sensemaking of research related to family violence prevention, and other public health topics.
BACKGROUND: Knowledge translation (KT, also known as research utilization, and sometimes referring to implementation science) is a dynamic and iterative process that includes the synthesis, dissemination, exchange, and ethically sound application of knowledge to improve health. A KT intervention is one which facilitates the uptake of research. The long-term sustainability of KT interventions is unclear. We aimed to characterize KT interventions to manage chronic diseases that have been used for healthcare outcomes beyond 1 year or beyond the termination of initial grant funding. METHODS: We conducted a scoping review by searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Campbell from inception until February 2013. We included experimental, quasi-experimental, and observational studies providing information on the sustainability of KT interventions for managing chronic diseases in adults and focusing on end-users including patients, clinicians, public health officials, health service managers, and policy-makers. Articles were screened and abstracted by two reviewers, independently. The data were charted and results described narratively. RESULTS: We included 62 studies reported in 103 publications (total 260,688 patients) plus 41 companion reports after screening 12,328 titles and abstracts and 464 full-text articles. More than half of the studies were randomized controlled trials (RCTs). The duration of the KT intervention ranged from 61 to 522 weeks. Nine chronic conditions were examined across the studies, such as diabetes (34 %), cardiovascular disease (28 %), and hypertension (16 %). Thirteen KT interventions were reported across the studies. Patient education was the most commonly examined (20 %), followed by self-management (17 %). Most studies (61 %) focused on patient-level outcomes (e.g. disease severity), while 31 % included system-level outcomes (e.g. number of eye examinations), and 8 % used both. The interventions were aimed at the patient (58 %), health system (28 %), and healthcare personnel (14 %) levels. CONCLUSIONS: We found few studies focusing on the sustainability of KT interventions. Most of the included studies focused on patient-level outcomes and patient-level KT interventions. A future systematic review can be conducted of the RCTs to examine the impact of sustainable KT interventions on health outcomes.
BACKGROUND: This study determined the perceived barriers to and facilitators of Nepalese nurses in utilizing research in the workplace. Evidence-based nursing practice provides the synergy for high-quality patient care, but it does not seem to be the case in underdeveloped countries, such as Nepal. METHOD: A descriptive, cross-sectional study involving 97 nurses from Nepal was conducted. Data were collected using the BARRIERS Scale and a facilitator questionnaire. RESULTS: The top three barriers to research utilization in Nepalese nurses are (a) research reports and articles are not readily available (80.5%), (b) inadequate facilities for implementation (75.3%), and (c) research reports and articles are not published fast enough (71.6%). The top three facilitators perceived to encourage Nepalese nurses to utilize or participate in research are (a) initiation of nursing research projects (27.4%), (b) educational update on research methods (16.7%), and (c) provision of funding for research (15.5%). CONCLUSION: Findings from this study mirror the barriers to research utilization experienced by nurses in other countries. Macro- and micro-level support are needed to foster a culture of evidence-based practice among Nepalese nurses to empower them in making informed decisions based on research in providing quality patient care.
OBJECTIVE: To explore the factors, including barriers and facilitators, influencing the practice of evidence-based medicine (EBM) across various primary care settings in Malaysia based on the doctors’ views and experiences. RESEARCH DESIGN: The qualitative study was used to answer the research question. 37 primary care physicians participated in six focus group discussions and six individual in-depth interviews. A semistructured topic guide was used to facilitate both the interviews and focus groups, which were audio recorded, transcribed verbatim, checked and analysed using a thematic approach. PARTICIPANTS: 37 primary care doctors including medical officers, family medicine specialists, primary care lecturers and general practitioners with different working experiences and in different settings. SETTING: The study was conducted across three primary care settings-an academic primary care practice, private and public health clinics in Klang Valley, Malaysia. RESULTS: The doctors in this study were aware of the importance of EBM but seldom practised it. Three main factors influenced the implementation of EBM in the doctors’ daily practice. First, there was a lack of knowledge and skills in searching for and applying evidence. Second, workplace culture influenced doctors’ practice of EBM. Third, some doctors considered EBM as a threat to good clinical practice. They were concerned that rigid application of evidence compromised personalised patient care and felt that EBM did not consider the importance of clinical experience. CONCLUSIONS: Despite being aware of and having a positive attitude towards EBM, doctors in this study seldom practised EBM in their routine clinical practice. Besides commonly cited barriers such as having a heavy workload and lack of training, workplace ‘EBM culture’ had an important influence on the doctors’ behaviour. Strategies targeting barriers at the practice level should be considered when implementing EBM in primary care.
With recent growth in the field of dissemination and implementation (D&I) research, multiple training programs have been developed to build capacity, including summer training institutes, graduate courses, degree programs, workshops, and conferences. While opportunities for D&I research training have expanded, course organizers acknowledge that available slots are insufficient to meet demand within the scientific and practitioner community. In addition, individual programs have struggled to best fit various needs of trainees, sometimes splitting coursework between specific D&I content and more introductory grant writing material. This article, stemming from a 2013 NIH workshop, reviews experiences across multiple training programs to align training needs, career stage and role, and availability of programs. We briefly review D&I needs and opportunities by career stage and role, discuss variations among existing training programs in format, mentoring relationships, and other characteristics, identify challenges of mapping needs of trainees to programs, and present recommendations for future D&I research training.
Reporting on three decades of knowledge diffusion and utilization research, this study provides an updated, cross-disciplinary framework for viewing information and communication technologies and development. It examines research streams over time (including that of the author) and concepts from the fields of communication, organizational sociology, public administration, and political science. Attention is paid to key variables (such as interorganizational trust, absorptive capacity at the organizational and interorganizational levels, and social learning) related to the cross-cultural diffusion/utilization/adaptation of knowledge against the backdrop of interconnected public, private, and not-for profit organizations and institutions. Findings also highlight changes in variables studied over these decades within and across the research streams. These include the emergence of cross-cultural co-processes (including co-design of diffusion plans in networked settings) and their roles in successful knowledge diffusion/utilization. In sum, this meta-analysis examining research over three decades possesses implications for understanding diffusion and social change today and makes recommendations for research agendas in the decade ahead.; AbstractReporting on three decades of knowledge diffusion and utilization research, this study provides an updated, cross-disciplinary framework for viewing information and communication technologies and development. It examines research streams over time (including that of the author) and concepts from the fields of communication, organizational sociology, public administration, and political science. Attention is paid to key variables (such as interorganizational trust, absorptive capacity at the organizational and interorganizational levels, and social learning) related to the cross-cultural diffusion/utilization/adaptation of knowledge against the backdrop of interconnected public, private, and not-for profit organizations and institutions. Findings also highlight changes in variables studied over these decades within and across the research streams. These include the emergence of cross-cultural co-processes (including co-design of diffusion plans in networked settings) and their roles in successful knowledge diffusion/utilization. In sum, this meta-analysis examining research over three decades possesses implications for understanding diffusion and social change today and makes recommendations for research agendas in the decade ahead.
OBJECTIVE: To summarise existing systematic reviews that assess the effects of non-pharmacological, pharmacological and alternative therapies on activities of daily living (ADL) function in people with dementia. DESIGN: Overview of systematic reviews. METHODS: A systematic search in the Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE and PsycInfo in April 2015. Systematic reviews of randomised controlled trials conducted in people with Alzheimer’s disease or dementia measuring the impact on ADL function were included. Methodological quality of the systematic reviews was independently assessed by two authors using the AMSTAR tool. The quality of evidence of the primary studies for each intervention was assessed using GRADE. RESULTS: A total of 23 systematic reviews were included in the overview. The quality of the reviews varied; however most (65%) scored 8/11 or more on the AMSTAR tool, indicating high quality. Interventions that were reported to be effective in minimising decline in ADL function were: exercise (6 studies, 289 participants, standardised mean difference (SMD) 0.68, 95% CI 0.08 to 1.27; GRADE: low), dyadic interventions (8 studies, 988 participants, SMD 0.37, 95% CI 0.05 to 0.69; GRADE: low) acetylcholinesterase inhibitors and memantine (12 studies, 4661 participants, donepezil 10 mg SMD 0.18, 95% CI 0.03 to 0.32; GRADE: moderate), selegiline (7 studies, 810 participants, SMD 0.27, 95% CI 0.13 to 0.41; GRADE: low), huperzine A (2 studies, 70 participants, SMD 1.48, 95% CI 0.95 to 2.02; GRADE: very low) and Ginkgo biloba (7 studies, 2530 participants, SMD 0.36, 95% CI 0.28 to 0.44; GRADE: very low). CONCLUSIONS: Healthcare professionals should ensure that people with dementia are encouraged to exercise and that primary carers are trained and supported to provide safe and effective care for the person with dementia. Acetylcholinesterase inhibitors or memantine should be trialled unless contraindicated. TRIAL REGISTRATION NUMBER: CRD42015020179.
BACKGROUND: Local and national governments have implemented sector-specific policies to support economic development through innovation, entrepreneurship and knowledge exchange. Supported by the Welsh Government through the European Regional Development Fund, The Life Science Exchange(R) project was created with the aim to increase interaction between stakeholders, to develop more effective knowledge exchange mechanisms, and to stimulate the formation and maintenance of long-term collaborative relationships within the Welsh life sciences ecosystem. The Life Science Exchange allowed participants to interact with other stakeholder communities (clinical, academic, business, governmental), exchange perspectives and discover new opportunities. METHODS: Six sub-sector focus groups comprising over 200 senior stakeholders from academia, industry, the Welsh Government and National Health Service were established. Over 18 months, each focus group provided input to inform healthcare innovation policy and knowledge mapping exercises of their respective sub-sectors. Collaborative projects identified during the focus groups and stakeholder engagement were further developed through sandpit events and bespoke support. RESULTS: Each sub-sector focus group produced a report outlining the significant strengths and opportunities in their respective areas of focus, made recommendations to overcome any ‘system failures’, and identified the stakeholder groups which needed to take action. A second outcome was a stakeholder-driven knowledge mapping exercise for each area of focus. Finally, the sandpit events and bespoke support resulted in participants generating more than pound1.66 million in grant funding and inward investment. This article outlines four separate outcomes from the Life Science Exchange programme. CONCLUSIONS: The Life Science Exchange process has resulted in a multitude of collaborations, projects, inward investment opportunities and special interest group formations, in addition to securing over ten times its own costs in funding for Wales. The Life Science Exchange model is a simple and straightforward mechanism for a regional or national government to adapt and implement in order to improve innovation, skills, networks and knowledge exchange.
Looking for a tool to apply recommendations from a guidance document to your context? A newly released workbook on “Contextualizing health-systems guidance” outlines how to contextualize policy recommendations in developing local policy recommendations and decisions about health-system arrangements and implementation strategies.
Health Care Administration and Organization
OBJECTIVES: Deceptive practice has been shown to be endemic in long-term care settings. However, little is known about the use of deception in dementia care within general hospitals and staff attitudes towards this practice. This study aimed to develop understanding of the experiences of general hospital staff and explore their decision-making processes when choosing whether to tell the truth or deceive a patient with dementia. METHOD: This qualitative study drew upon a constructivist grounded theory approach to analyse data gathered from semi-structured interviews with a range of hospital staff. A model, grounded in participant experiences, was developed to describe their decision-making processes. FINDINGS: Participants identified particular triggers that set in motion the need for a response. Various mediating factors influenced how staff chose to respond to these triggers. Overall, hospital staff were reluctant to either tell the truth or to lie to patients. Instead, ‘distracting’ or ‘passing the buck’ to another member of staff were preferred strategies. The issue of how truth and deception are defined was identified. CONCLUSION: The study adds to the growing research regarding the use of lies in dementia care by considering the decision-making processes for staff in general hospitals. Various factors influence how staff choose to respond to patients with dementia and whether deception is used. Similarities and differences with long-term dementia care settings are discussed. Clinical and research implications include: opening up the topic for further debate, implementing staff training about communication and evaluating the impact of these processes.
The purpose of this study was to identify structural, market, and administrator factors of nursing homes that are related to the implementation of person-centered care. Administrators of Medicare/Medicaid-certified nursing homes in the Deep South were invited to complete a standardized survey about their facility and their perceptions and attitudes regarding person-centered care practices (PCCPs). Nursing home structural and market factors were obtained from public websites, and these data were matched with administrator data. Consistent with the resource-based theory of competitive advantage, nursing homes with greater resources and more competition were more likely to implement PCCPs. Implementation of person-centered care was also higher in nursing homes with administrators who perceived culture change implementation to be feasible in their facilities. Given that there is a link between resource availability and adoption of person-centered care, future research should investigate the cost of such innovations.
BACKGROUND: Quality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards. METHODS: A questionnaire measuring staff perception of their patient’s end of life experience (SPELE) was developed. Content validity (CVI) was assessed by a panel of experts, and piloting was conducted with dyads of healthcare assistants (n=15) and nurses (n=15). RESULTS: The SPELE captures facets of the quality of the death and dying experience from healthcare staff’s perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain. CONCLUSION: Further testing of the questionnaire is required. However it is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL.
We analyzed qualitative and quantitative data from U.S.-based employees in 30 long-term care facilities. Analysis of semi-structured interviews from 154 managers informed quantitative analyses. Quantitative data include 1214 employees’ scoring of their supervisors and their organizations on family supportiveness (individual scores and aggregated to facility level), and three outcomes: (1), care quality indicators assessed at facility level (n = 30) and collected monthly for six months after employees’ data collection; (2), employees’ dichotomous survey response on having additional off-site jobs; and (3), proportion of employees with additional jobs at each facility. Thematic analyses revealed that managers operate within the constraints of an industry that simultaneously: (a) employs low-wage employees with multiple work-family challenges, and (b) has firmly institutionalized goals of prioritizing quality of care and minimizing labor costs. Managers universally described providing work-family support and prioritizing care quality as antithetical to each other. Concerns surfaced that family-supportiveness encouraged employees to work additional jobs off-site, compromising care quality. Multivariable linear regression analysis of facility-level data revealed that higher family-supportive supervision was associated with significant decreases in residents’ incidence of all pressure ulcers (-2.62%) and other injuries (-9.79%). Higher family-supportive organizational climate was associated with significant decreases in all falls (-17.94%) and falls with injuries (-7.57%). Managers’ concerns about additional jobs were not entirely unwarranted: multivariable logistic regression of employee-level data revealed that among employees with children, having family-supportive supervision was associated with significantly higher likelihood of additional off-site jobs (RR 1.46, 95%CI 1.08-1.99), but family-supportive organizational climate was associated with lower likelihood (RR 0.76, 95%CI 0.59-0.99). However, proportion of workers with additional off-site jobs did not significantly predict care quality at facility levels. Although managers perceived providing work-family support and ensuring high care quality as conflicting goals, results suggest that family-supportiveness is associated with better care quality.
BACKGROUND: A cloud-based mobile electronic prescribing and medication management system (ePMMS), in which prescribers’ orders directly populate residential aged care facility (RACF) medication administration records (MARs) and are communicated electronically to the RACF’s pharmacy, may create efficiencies and improve patient safety when compared to the paper-based and hybrid paper-electronic medication management systems used in most Australian RACFs. Little is known about general-practitioners’ (GPs’), nurses’ and pharmacists’ acceptance of, or experiences with, ePMMS. OBJECTIVES: To explore the uptake of an ePMMS by GPs, and the experiences and perceptions of GPs, nurses and pharmacists, at a 90-bed RACF that tested a beta-version ePMMS. METHODS: Retrospective audit to determine the proportion of medicines ordered by GPs via the ePMMS over a three-month period. Focus groups conducted three-to-four months after implementation: one with GPs (n=5), one with nurses (n=12); in-depth interview/survey of pharmacists (n=2). Qualitative data were analysed thematically. RESULTS: Three of seven GPs used the ePMMS to order medicines; 53/205(25.9%) medicines were ordered via the ePMMS by GPs. Two broad themes were identified: benefits of the ePMMS, and barriers/limitations. Benefits related to patient safety and workforce efficiency, and included GPs’ ability to access and modify residents’ MARs remotely, no need for nurses to fax orders to the pharmacy, and no need for pharmacy transcription of GPs’ handwritten orders to create electronic MARs. Barriers and limitations related to inefficiency, low GP uptake and training/support, and included slower prescribing compared to written orders, the need for GP-signed paper copies of the MAR, lack of integration with GP clinic software, and low GP motivation to use the system, especially GPs with few patients at the RACF. CONCLUSIONS: GPs, nurses and pharmacists felt the ePMMS improved medication-safety and workforce-efficiency, however a number of barriers were identified that contributed to low GP-uptake and limited the benefits.
BACKGROUND: A key message in the World Health Organization’s report on dementia emphasizes the need to improve public and professional attitudes to dementia and its understanding, while acknowledging the fact that the workforce in dementia care is becoming increasingly diverse culturally. OBJECTIVES: To explore possible differences among formal caretakers from varied cultural background in their attitudes toward the autonomy and human dignity of patients with dementia. RESEARCH DESIGN: Semi-structured interviews and content analysis, utilizing two fictional vignettes for eliciting caretakers’ attitudes toward dignity and autonomy of their patients. PARTICIPANTS AND CONTEXT: A total of 20 formal caretakers of patients with dementia from three different cultural groups in Israel (“Sabras,” “Arabs,” and “Russians”), working in nursing homes and a hospital. ETHICAL CONSIDERATION: Approvals of relevant research ethics committees were obtained and followed. FINDINGS: In comparison with the other groups, most Arab caretakers offer markedly richer perceptions of human dignity and autonomy. Their human dignity’s conceptualization emphasizes “person-centered approach,” and their perception of patients’ autonomy includes provision of explanations and preservation and encouragement of independence. DISCUSSION: The differences found in the attitudes toward the meaning of autonomy and human dignity between the Arab caretakers and the other caretakers stand in contrast to previous studies regarding human dignity, emphasizing the common nature of these attitudes. Offering a linkage (theoretical and empirical) between the Arab perceptions of dignity and autonomy, the study strengthen and further the importance attributed in existing literature to person-centered care in enhancing the quality of care for patients with dementia. CONCLUSION: The conceptualization of human dignity may vary among different cultural groups. It may also influence the extent to which the caretaker holds a full-fledged perception of the patients’ autonomy.
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
BACKGROUND: Healthcare professionals perform knowledge-intensive work in very specialized disciplines. Across the professional divide, collaboration becomes increasingly difficult. For effective teamwork and collaboration to occur, it is considered necessary for individuals to believe in their ability to draw on their expertise and provide what others need to perform their job well. To date, however, no instruments exist to measure such a construct. METHODS: A two-study design is used to test the psychometric properties, factor structure and incremental validity of a five-item questionnaire measuring informational role self-efficacy. RESULTS: Based on parallel analysis and exploratory factor analysis, Study 1 shows a robust and reliable one-dimensional construct. Study 2 cross-validates this factor structure using confirmatory factor analysis. Study 2 also shows that informational role self-efficacy predicts proactive teamwork behaviors over and above goal similarity, interdependence, coordination and intra-team trust. CONCLUSIONS: The instrument can be used in research to assess an individual’s capability beliefs in communicating his/her informational characteristics that are pertinent to the task performance of others. The construct is also shown to have value in team-building exercises.
OBJECTIVE: The advantages of empowering direct care workers (DCWs) within nursing homes (NHs) are well documented. Our objective is to identify factors that create DCW empowerment as this has not received adequate attention. METHOD: The data come from a larger study focused on the empowerment of DCWs in NHs. A self-administered instrument was completed by 372 DCWs within 11 NHs in the north Texas region. Cluster analysis and ordinary least squares (OLS) regression were performed. RESULTS: Feedback from nurse management to DCWs was positively associated with shared decision-making (SDM) and ranked highest followed by information exchange, trust in management, and wages linked to performance. DISCUSSION: SDM may be enhanced where nurse management shares relevant information with the DCWs, listens to their ideas, provides explanations when DCW suggestions are not used, and does so in a supportive environment. Organizational characteristics of importance include linking wages to DCW performance and providing an accessible training program.
Knowledge of a nursing home resident’s everyday living preferences provides the foundation for ongoing individualized care planning. OBJECTIVE: The purpose of this study is to identify nursing home (NH) staff perceptions of facilitators and barriers to learning about and meeting residents’ preferences and reasons why staff feel residents change their minds about preferences. METHODS: Focus group sessions and interviews were conducted with 36 NH staff members working in a facility that has been actively assessing resident preferences for five years. RESULTS: Thematic codes classifying facilitators, barriers, and dependencies were identified. Staff shared ways they are able to help meet residents’ preferences as well as barriers to fulfilling resident preferences through their own behaviors, facility characteristics, the social environment, and resident characteristics. In addition, staff believe that residents change their minds about important preferences ‘depending on’ several factors including; global environmental characteristics, social environment, resident characteristics, and general staff perceptions. CONCLUSIONS: This work identifies key facilitators and barriers to consider when implementing quality improvement efforts designed to improve the person-centered nature of care in nursing homes and is intended to further inform the culture change movement, which aims to transform NHs by empowering staff and delivering person-centered care.
This article is the first of a two-part series that informs and describes digital skills training using a dedicated console computer provided for staff and residents in a care home setting. This was part of a programme of culture change in a large care home with nursing in Glasgow, Scotland. The literature review shows that over the past decade there has been a gradual increase in the use of digital technology by staff and older people in community settings including care homes. Policy from the European Commission presents a persuasive argument for the advancement of technology-enabled care to counter the future impact of an increased number of people of advanced age on finite health and social care resources. The psychosocial and environmental issues that inhibit or enhance the acquisition of digital skills in care homes are considered and include the identification of exemplar schemes and the support involved.
As the impact of health care reform continues to evolve, the movement of patients from acute to post-acute settings will continue to expand. Currently, the turnover and retention of RNs nationally in long-term care is at an all-time high, with a median turnover rate of 50% for RNs. Workforce instability is a prime contributor to poor patient outcomes, increased costs, and a dissatisfied nursing workforce. Therefore, the New Jersey Action Coalition determined that the Institute of Medicine’s Future of Nursing: Leading Change, Advancing Health recommendation to implement nurse residency programs across settings would be a priority for New Jersey. A 12-month new nurse residency and preceptor program was developed and implemented in long-term care, with 37 new nurses and 37 preceptors. The design and implementation processes are described, as well as lessons learned along the journey.
In Western countries, assistive technology is implemented on a large scale in elder care settings. Only a few studies have attempted to explore the different attitudes to assistive technology among various groups of users. In this study, we investigated and explained the different attitudes among the involved leaders, nursing staff, and older people to a newly-implemented robot bathtub. Qualitative analyses of eight interviews with managers, nursing staff, and the older users revealed that the informants focused on different aspects (process, values, and functionality, respectively), used different implicit quality criteria, and ascribed different symbolic significance to the robot bathtub. Thus, the study demonstrated how attitudes toward the robot bathtub were connected to the informants’ institutional role. The findings challenge the current paradigm, where technology is expected to operate as a passive tool, simply facilitating desired human acts and interactions. Further studies drawing on the epistemological and ontological perceptions of science technology studies are needed in order to understand human rationalities in the assistive technology context and to offer new insights into how technology “works” in organizations.
Health Care Innovation and Quality Assurance
Improving work as part of clinical practice is challenging. Plans for improvement are often made, but not followed through.A recent experience of failure in an ICU led to a change in approach. Members of the multi-professional team committed to meet weekly to learn about quality improvement by working on improvement projects.The group selected four topics they wanted to work on. These were: a bundle for patients admitted with septic shock; early (â‰¤4 hours) sedation vacation after admission to ICU to allow titration of sedation to effect; achieving â‰¥ 20 minutes of mobilisation per day in ventilated patients; and medicines reconciliation.This quality improvement meeting was built into another regular weekly meeting. Initially the meeting ran for 30 minutes; each week some focused quality improvement teaching was provided in addition to talking about each individual project.The team found the meeting useful, they saw the progress they were making but felt the allotted time was too short. After 6 weeks, the initial early results persuaded the team to increase the duration of this meeting to 45 minutes.At the start reliability of each process was low (between 10% and 38%). All four projects achieved their stated process reliability aim. This took between 165 and 334 days for each project. Many tests of change ideas were required to achieve this.We have been able to improve multiple topics in a short period and produce sustainable change. The weekly meeting provided the focus to this improvement work. The teaching and coaching on quality improvement methodology that occurred as part of this meeting helped accelerate our rate of progress.We believe this experience and the learning we have gained will help provide ideas for others who also want to improve healthcare delivery in different settings.
BACKGROUND: Quality improvement (QI) is becoming an important focal point for health systems. There is increasing interest among health system stakeholders to learn from and share experiences on the use of QI methods and approaches in their work. Yet there are few easily accessible, online repositories dedicated to documenting QI activity. METHODS: We conducted a scoping review of publicly available, web-based QI repositories to (i) identify current approaches to sharing information on QI practices; (ii) categorise these approaches based on hosting, scope and size, content acquisition and eligibility, content format and search, and evaluation and engagement characteristics; and (iii) review evaluations of the design, usefulness and impact of their online QI practice repositories. The search strategy consisted of traditional database and grey literature searches, as well as expert consultation, with the ultimate aim of identifying and describing QI repositories of practices undertaken in a healthcare context. RESULTS: We identified 13 QI repositories and found substantial variation across the five categories. The QI repositories used different terminology (eg, practices vs case studies) and approaches to content acquisition, and varied in terms of primary areas of focus. All provided some means for organising content according to categories or themes and most provided at least rudimentary keyword search functionality. Notably, none of the QI repositories included evaluations of their impact. DISCUSSION: With growing interest in sharing and spreading best practices and increasing reliance on QI as a key contributor to health system performance, the role of QI repositories is likely to expand. Designing future QI repositories based on knowledge of the range and type of features available is an important starting point for improving their usefulness and impact.
PURPOSE: To determine the views of nurses and on the feasibility of implementing current evidence-based guidelines for oral care, examining barriers and facilitators to implementation. RESULTS: This mixed-methods study involved an online survey of 35 nurses and residential care workers, verified and expanded upon by one focus group of six residential care workers. Results reflected that nurses and residential care workers (a) have little or no training in recommended oral care techniques, and (b) lack access to the equipment and professional supports needed to provide adequate oral care. Basic oral care might be performed less than once per day in some settings and patients with problematic behaviours, dysphagia, or sensitivities associated with poor oral health might be less likely to receive oral care. While lack of time was highlighted as a barrier in the survey findings, focus group members considered that time should not be a barrier to prioritising oral care practices on a daily basis in residential care settings. CONCLUSION: There are several important discrepancies between the recommendations made in evidence-based guidelines for oral care and the implementation of such practices in residential care settings. Nursing and residential care staff considered adequate oral care to be feasible if access, funding and training barriers are removed and facilitators enhanced.
BACKGROUND: Antibiotics are highly utilized in nursing homes. The aim of the study was to test the effectiveness of a decision-making aid for urinary tract infection management on reducing antibiotic prescriptions for suspected bacteriuria in the urine without symptoms, known as asymptomatic bacteriuria (ASB) in twelve nursing homes in Texas. METHOD: A pre- and post-test with comparison group design was used. The data was collected through retrospective chart review. The study sample included 669 antibiotic prescriptions for suspected urinary tract infections ordered for 547 nursing home residents. The main measurement for the outcome variable was whether an antibiotic was prescribed for suspected urinary tract infections with no symptoms present. RESULTS: Most of the prescriptions for antibiotics UTIs were written without documented symptoms – thus for asymptomatic bacteuria (ASB) (71 % during the pre-intervention period). Exposure to the decision-making aid decreased the number of prescriptions written for ASB (from 78 % to 65 % in the low-intensity homes and from 65 % to 57 % in the high-intensity homes), and decreased odds of a prescription being written for ASB (OR = 0.63, 95 % CI = 0.25 – 1.60 for low-intensity homes; OR = 0.79, 95 % CI = 0.33 – 1.88 for high-intensity homes). The odds of a prescription being written for ASB decreased significantly in homes that succeeded in implementing the decision-making aid (OR = 0.35, 95 % CI = 0.16-0.76), compared to homes with no fidelity. CONCLUSIONS: The decision-making aid improved antibiotic stewardship in nursing homes.
BACKGROUND: Research suggests and common sense indicates that there are relationships between staff variables in residential dementia care and the quality of life (QOL) of residents, with poor care due to staff factors increasing resident suffering. Despite these indications, we do not have a coherent picture of these relationships, which variables are important, and where to intervene in order to minimize suffering for people with dementia. METHODS: This systematic review examined associations between staff variables, quality of care (QOC), and QOL for residents, using published peer-reviewed literature from the last 20 years. A comprehensive search was conducted using an exhaustive list of search terms, leading to the identification of 33,204 unique papers, which was reduced to 35 on-topic papers. RESULTS: In the main, we were able to provide collective evidence to suggest there are relationships between potentially adjustable staff variables and QOC on to QOL. When staff treat and interact empathetically and humanely in care, there is a relationship with better mood for residents, delayed functional dependence and better food intake. Where staff are more skilled and educated, there is less psychotropic medication use. Unlimited empathy about the risk of residents falling or being in pain is not enough; staff need to know about the dangers of restraint. CONCLUSIONS: Confidence in these indicative links is weakened by a lack of high-quality prospective longitudinal studies focusing on potentially adjustable staff variables, with a bias towards cross-sectional studies including only variables that are fixed or unlikely to change. (Review registration no. PROSPERO 2014:CRD42014015224).
OBJECTIVE: To develop a set of explicit criteria for pharmacologically inappropriate medication use in nursing homes. DESIGN: In an expert panel, a three-round Delphi consensus process was conducted via survey software. SETTING: Norway. SUBJECTS: Altogether 80 participants – specialists in geriatrics or clinical pharmacology, physicians in nursing homes and experienced pharmacists – agreed to participate in the survey. Of these, 62 completed the first round, and 49 panellists completed all three rounds (75.4% of those ultimately entering the survey). MAIN OUTCOME MEASURES: The authors developed a list of 27 criteria based on the Norwegian General Practice (NORGEP) criteria, literature, and clinical experience. The main outcome measure was the panellists’ evaluation of the clinical relevance of each suggested criterion on a digital Likert scale from 1 (no clinical relevance) to 10. In the first round panellists could also suggest new criteria to be included in the process. For each criterion, degree of consensus was based on the average Likert score and corresponding standard deviation (SD). RESULTS: A list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed through a three-round web-based Delphi consensus process. Degree of consensus increased with each round. No criterion was voted out. Suggestions from the panel led to the inclusion of seven additional criteria in round two. IMPLICATIONS: The NORGEP-NH list may serve as a tool in the prescribing process and in medication list reviews and may also be used in quality assessment and for research purposes.
INTRODUCTION: Care by Design (CBD) (Canada), a model of coordinated team-based primary care, was implemented in long-term care facilities (LTCFs) in Halifax, Nova Scotia, Canada, to improve access to and continuity of primary care and to reduce high rates of transfers to emergency departments (EDs). METHODS: This was an observational time series before and after the implementation of CBD (Canada). Participants are LTCF residents with 911 Emergency Health Services calls from 10 LTCFs, representing 1424 beds. Data were abstracted from LTCF charts and Emergency Health Services databases. The primary outcome was ambulance transports from LTCFs to EDs. Secondary outcomes included access (primary care physician notes in charts) and continuity (physician numbers and contacts). RESULTS: After implementation of CBD (Canada), transports from LTCFs to EDs were reduced by 36%, from 68 to 44 per month (P = .01). Relational and informational continuity of care improved with resident charts with >/=10 physician notes, increasing 38% before CBD to 55% after CBD (P = .003), and the median number of chart notes increased from 7 to 10 (P = .0026). Physicians contacted before 911 calls and onsite assessment increased from 38% to 54% (P = .01) and 3.7% to 9.2% (P = .03), respectively, before CBD to after CBD. CONCLUSION: A 34% reduction in overall transports from LTCFs to EDs is likely attributable to improved onsite primary care, with consistent physician and team engagement and improvements in continuity of care.
PURPOSE: The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions. QUESTIONS: We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.) NEXT STEPS: Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement.
The objective of this study was to empirically demonstrate the use of a new framework for describing the strategies used to implement quality improvement interventions and provide an example that others may follow. Implementation strategies are the specific approaches, methods, structures, and resources used to introduce and encourage uptake of a given intervention’s components. Such strategies have not been regularly reported in descriptions of interventions’ effectiveness, or in assessments of how proven interventions are implemented in new settings. This lack of reporting may hinder efforts to successfully translate effective interventions into “real-world” practice. A recently published framework was designed to standardize reporting on implementation strategies in the implementation science literature. We applied this framework to describe the strategies used to implement a single intervention in its original commercial care setting, and when implemented in community health centers from September 2010 through May 2015. Per this framework, the target (clinic staff) and outcome (prescribing rates) remained the same across settings; the actor, action, temporality, and dose were adapted to fit local context. The framework proved helpful in articulating which of the implementation strategies were kept constant and which were tailored to fit diverse settings, and simplified our reporting of their effects. Researchers should consider consistently reporting this information, which could be crucial to the success or failure of implementing proven interventions effectively across diverse care settings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02299791.
OBJECTIVE: To describe changes in the health service delivery process experienced by professionals, patients and informal caregivers during implementation of a national programme to improve quality of care of geriatric rehabilitation by improving integration of health service delivery processes. STUDY SETTING: Sixteen skilled nursing facilities. STUDY DESIGN: Prospective study, comparing three consecutive cohorts. DATA COLLECTION: Professionals (elderly care physicians, physiotherapists and nursing staff) rated four domains of health service delivery at admission and at discharge of 1075 patients. In addition, these patients [median age 79 (Interquartile range 71-85) years, 63% females] and their informal caregivers rated their experiences on these domains 4 weeks after discharge. PRINCIPAL FINDINGS: During the three consecutive cohorts, professionals reported improvement on the domain team cooperation, including assessment for intensive treatment and information transfer among professionals. Fewer improvements were reported within the domains alignment with patients’ needs, care coordination and care quality. Between the cohorts, according to patients (n = 521) and informal caregivers (n = 319) there were no changes in the four domains of health service delivery. CONCLUSION: This national programme resulted in small improvements in team cooperation as reported by the professionals. No effects were found on patients’ and informal caregivers’ perceptions of health service delivery.
BACKGROUND: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. METHODS: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. RESULTS: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7-9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between euro10 and euro17.8 million/annum and reduction in ambulance transfers, estimated at euro0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from euro17.7 to euro42.4 million nationally. CONCLUSIONS: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.
PURPOSE: Long-term care facilities have lagged heavily behind other health providers in adopting health information technology (IT). This article examines the facility characteristics that are associated with health IT adoption. DESIGN AND METHODS: This study is a secondary data analysis of information gathered between 2005 and 2011 about nursing facility characteristics contained in the Online Certification & Reporting (OSCAR) files and information about health IT adoption in each nursing home contained in the Healthcare Information and Management Systems Society (HIMSS) Analytics Database. Multivariate regression analysis is conducted. RESULTS: Nursing homes with licensed nursing staff levels above the state average were 20% more likely to adopt computer-provided order entry (CPOE) than homes with licensed nursing staff below average. Resident resources (more Medicare-paid patients and fewer Medicaid patients) were positively correlated to health IT adoption, particularly to a clinical data repository (CDR), clinical decision support systems (CDSS), and an order entry (OE) system. Other characteristics, including chain affiliation, ownership, and market competition, are also related to some health IT adoption within nursing homes. IMPLICATION: Nursing homes with more personnel or resident resources are more likely to adopt health IT. Other factors such as market competition are also important predictors. Future research is needed to examine what factors motivate nursing homes to adopt health IT.
It is now more important than ever for person- and family-centred care (PFCC) to be at the forefront of program and service design and delivery; yet, to date, very little guidance is available to assist home, community and long-term care (LTC) organizations to operationalize this concept and overcome inherent challenges. This article provides a list of practical strategies for healthcare leaders to promote and support a culture shift towards PFCC in their organizations and identifies and addresses five common concerns. The unique opportunities and challenges for practicing PFCC in home, community and LTC settings are also discussed.
Background Public health interventions are mostly composed of several interconnected actions and hence they are popularly referred to as “Complex”. The domain of complexity lacks clarity and the conceptual framework needs to be simplified and strengthened as till date most of the issues/concepts relating to this domain remain unexplored. This paper investigates the perception about complexity among people working in the area of public health. Study design and methodology We adopted a qualitative study design and conducted unstructured interviews/dialogues/focus group discussions among people working in the public health domain on their perception about complexity. The process was audio-recorded and the interpretations were summarised. Responses were consolidated on the basis of five major sources complexity as depicted by Medical Research Council, UK guidance. Results and conclusion This paper provides an outlook of people on how they perceive the complexity in public health interventions. Participants perceived complexity in a diverse manner which was evident from the varying responses obtained. Therefore there is a need for a strong theoretical base to understand complexity and also a concrete methodological framework to tackle it. The external validity of a public health research can be seriously affected in presence of complexity. Therefore it is necessary to adopt effective strategies to tackle complexity to obtain valid results.
INTRODUCTION: As an increasing number of people are living with more than 1 long-term condition, identifying effective interventions for the management of multimorbidity in primary care has become a matter of urgency. Interventions are challenging to evaluate due to intervention complexity and the need for adaptability to different contexts. A process evaluation can provide extra information necessary for interpreting trial results and making decisions about whether the intervention is likely to be successful in a wider context. The 3D (dimensions of health, drugs and depression) study will recruit 32 UK general practices to a cluster randomised controlled trial to evaluate effectiveness of a patient-centred intervention. Practices will be randomised to intervention or usual care. METHODS AND ANALYSIS: The aim of the process evaluation is to understand how and why the intervention was effective or ineffective and the effect of context. As part of the intervention, quantitative data will be collected to provide implementation feedback to all intervention practices and will contribute to evaluation of implementation fidelity, alongside case study data. Data will be collected at the beginning and end of the trial to characterise each practice and how it provides care to patients with multimorbidity. Mixed methods will be used to collect qualitative data from 4 case study practices, purposively sampled from among intervention practices. Qualitative data will be analysed using techniques of constant comparison to develop codes integrated within a flexible framework of themes. Quantitative and qualitative data will be integrated to describe case study sites and develop possible explanations for implementation variation. Analysis will take place prior to knowing trial outcomes. ETHICS AND DISSEMINATION: Study approved by South West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via a final report, peer-reviewed publications and practical guidance to healthcare professionals, commissioners and policymakers. TRIAL REGISTRATION NUMBER: ISRCTN06180958.
Purpose: This paper aims to argue the beneficial effects of communities of practices for organizations. More specifically, given their intrinsic features, communities of practices support individuals and organizations in developing and diffusing the organizational culture, in making sense and guiding individual and collective actions, in defining identities and finally in coping with change and transitions. Design/methodology/approach ? Moving from a constructionist view of organizations, the paper reported the lessons learnt through literature about communities of practices, reviewing the most recent empirical evidences on the topic. Findings ? Boundary objects and boundary interactions are the concrete tools that allow individuals to exchange knowledge and to develop practices, thus becoming a community. This exchange of skills and expertise concretely shapes the practices that give sense to individual and organizational actions. Nonetheless, organizations and communities are open spaces constantly in interaction, both inside and outside the organizational borders. Thus, through contamination, namely, through the encounter with different actors and contexts, practices could be expanded and reformulated as long as they might suit to specific demands. Originality/value ? The paper argued that communities of practices in times of change could become a space for learning and development as long as they allow people to redefine mental models and practices and thus to make sense and to cope with a new cultural scenario.; Purpose ? This paper aims to argue the beneficial effects of communities of practices for organizations. More specifically, given their intrinsic features, communities of practices support individuals and organizations in developing and diffusing the organizational culture, in making sense and guiding individual and collective actions, in defining identities and finally in coping with change and transitions. Design/methodology/approach ? Moving from a constructionist view of organizations, the paper reported the lessons learnt through literature about communities of practices, reviewing the most recent empirical evidences on the topic. Findings ? Boundary objects and boundary interactions are the concrete tools that allow individuals to exchange knowledge and to develop practices, thus becoming a community. This exchange of skills and expertise concretely shapes the practices that give sense to individual and organizational actions. Nonetheless, organizations and communities are open spaces constantly in interaction, both inside and outside the organizational borders. Thus, through contamination, namely, through the encounter with different actors and contexts, practices could be expanded and reformulated as long as they might suit to specific demands. Originality/value ? The paper argued that communities of practices in times of change could become a space for learning and development as long as they allow people to redefine mental models and practices and thus to make sense and to cope with a new cultural scenario.
AIM: To examine the influence of leadership when facilitating change in nursing homes. BACKGROUND: The study is a part of an education intervention for care staff to prevent the use of restraint in nursing home residents with dementia in 24 nursing homes (NHs) in Norway. Leadership is known to be a fundamental factor for success of evidence-based practice (EBP) implementation in health services. However, the type of leadership that strengthens the processes of change remains to be clarified. METHOD: A multi-site comparative ethnography was performed in four nursing homes to investigate how contextual factors influenced the implementation. The analysis was informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and in particular the sub-element of leadership. RESULTS: Different leadership styles to facilitate change were identified. Paradoxically, a strong collective and collaborative leadership style was found to hamper change in one particular home, whereas a remote leadership style combined with almost no cooperation with staff proved successful in another setting. CONCLUSIONS: The study indicates that leadership cannot be understood on a low-high continuum as suggested by the PARIHS framework, but rather as a factor characterised by diversity. IMPLICATION FOR NURSING MANAGEMENT: Our study indicates, as a minimum, that a leader’s presence is necessary to facilitate the internal processes in order more successfully to implement EBP.
Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.
Research Practice and Methodology
PRISMA-Children (C) and PRISMA-Protocol for Children (P-C) Extensions: a study protocol for the development of guidelines for the conduct and reporting of systematic reviews and meta-analyses of newborn and child health research
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INTRODUCTION: Paediatric systematic reviews differ from adult systematic reviews in several key aspects such as considerations of child tailored interventions, justifiable comparators, valid outcomes and child sensitive search strategies. Available guidelines, including PRISMA-P (2015) and PRISMA (2009), do not cover all the complexities associated with reporting systematic reviews in the paediatric population. Using a collaborative, multidisciplinary structure, we aim to develop evidence-based and consensus-based PRISMA-P-C (Protocol for Children) and PRISMA-C (Children) Extensions to guide paediatric systematic review protocol and completed review reporting. METHODS AND ANALYSIS: This project’s methodology follows published recommendations for developing reporting guidelines and involves the following six phases; (1) establishment of a steering committee representing key stakeholder groups; (2) a scoping review to identify potential Extension items; (3) three types of consensus activities including meetings of the steering committee to achieve high-level decisions on the content and methodology of the Extensions, a survey of key stakeholders to generate a list of possible items to include in the Extensions and a formal consensus meeting to select the reporting items to add to, or modify for, the Extension; (4) the preliminary checklist items generated in phase III will be evaluated against the existing evidence and reporting practices in paediatric systematic reviews; (5) extension statements and explanation and elaboration documents will provide detailed advice for each item and examples of good reporting; (6) development and implementation of effective knowledge translation of the extension checklist, and an evaluation of the Extensions by key stakeholders. ETHICS AND DISSEMINATION: This protocol was considered a quality improvement project by the Hospital for Sick Children’s Ethics Committee and did not require ethical review. The resultant checklists, jointly developed with all relevant stakeholders, will be disseminated through peer-reviewed journals as well as national and international conference presentations. Endorsement of the checklist will be sought simultaneously in multiple journals.
Scholars often do not describe in detail the complex process of conducting focus groups, including what happens when they take unexpected turns. A critical incident lens provides a framework for better analyzing and understanding what actually happens during focus group sessions. Using a critical incident approach, we examine our experiences of carrying out focus groups about the human papillomavirus (HPV) vaccine with vaccine-eligible adolescent girls and parents/caregivers of vaccine-eligible adolescent girls in New Mexico. The critical incident lens allowed us to productively explore the context and interactional dynamics of our focus groups and ultimately pushed us to talk through the challenges of conducting and analyzing them. We hope this serves as a call to qualitative researchers to be attentive to the critical incidents in your own research to enrich your analysis and contribute to a broader discussion of the realities of focus group conduct.
Scientific collaboration networks are a hallmark of contemporary academic research. Researchers are no longer independent players, but members of teams that bring together complementary skills and multidisciplinary approaches around common goals. Social network analysis and co-authorship networks are increasingly used as powerful tools to assess collaboration trends and to identify leading scientists and organizations. The analysis reveals the social structure of the networks by identifying actors and their connections. This article reviews the method and potential applications of co-authorship network analysis in health. The basic steps for conducting co-authorship studies in health research are described and common network metrics are presented. The application of the method is exemplified by an overview of the global research network for Chikungunya virus vaccines.
BACKGROUND: Complexity has been linked to health interventions in two ways: first as a property of the intervention, and secondly as a property of the system into which the intervention is implemented. The former recognizes that interventions may consist of multiple components that act both independently and interdependently, making it difficult to identify the components or combinations of components (and their contexts) that are important mechanisms of change. The latter recognizes that interventions are implemented in complex adaptive systems comprised of intelligent agents who modify their behaviour (including any actions required to implement the intervention) in an effort to improve outcomes relative to their own perspective and objectives. Although an intervention may be intended to take a particular form, its implementation and impact within the system may deviate from its original intentions as a result of adaptation. Complexity highlights the challenge in developing interventions as effective health solutions. The UK Medical Research Council provides guidelines on the development and evaluation of complex interventions. While mathematical modelling is included in the guidelines, there is potential for mathematical modeling to play a greater role. DISCUSSION: The dynamic non-linear nature of complex adaptive systems makes mathematical modelling crucial. However, the tendency is for models of interventions to limit focus on the ecology of the system – the ‘real-time’ operation of the system and impacts of the intervention. These models are deficient by not modelling the way the system reacts to the intervention via agent adaptation. Complex intervention modelling needs to capture the consequences of adaptation through the inclusion of an evolutionary dynamic to describe the long-term emergent outcomes that result as agents respond to the ecological changes introduced by intervention in an effort to produce better outcomes for themselves. Mathematical approaches such as those found in economics in evolutionary game theory and mechanism design can inform the design and evaluation of health interventions. As an illustration, the introduction of a central screening clinic is modeled as an example of a health services delivery intervention. Complexity necessitates a greater role for mathematical models, especially those that capture the dynamics of human actions and interactions.
BACKGROUND: Many medical research projects encounter difficulties. The objective of this study was to assess the self-reported frequency of difficulties encountered by medical researchers while conducting research and to identify factors associated with their occurrence. METHODS: The authors conducted a cross-sectional survey in 2010 among principal investigators of 996 study protocols approved by the Research Ethics Committee in Geneva, Switzerland, between 2001 and 2005. The authors asked principal investigators to rate the level of difficulty (1: none, to 5: very great) encountered across the research process. RESULTS: 588 questionnaires were sent back (participation rate 59.0 %). 391 (66.5 %) studies were completed at the time of the survey. Investigators reported that the most frequent difficulties were related to patient enrollment (44.3 %), data collection (26.7 %), data analysis and interpretation (21.5 %), collaboration with caregivers (21.0 %), study design (20.4 %), publication in peer-reviewed journal (20.2 %), hiring of competent study personnel (20.2 %), and getting funding (19.2 %). On average, investigators reported 2.8 difficulties per project (SD 2.8, range 0 to 12). In multivariable analysis, the number of difficulties was higher for studies initiated by public sponsors (vs. private), single center studies (vs. multicenter), and studies about treatment, diagnosis or prognosis (i.e., clinical vs. other studies). CONCLUSIONS: Medical researchers reported substantial logistical difficulties in conducting clinical research.
BACKGROUND: With the current funding climate and need for advancements in implementation science, there is a growing demand for grantsmanship workshops to increase the quality and rigor of proposals. A group-based implementation science-focused grantsmanship workshop, the Implementation Development Workshop (IDW), is one methodology to address this need. This manuscript provides an overview of the IDW structure, format, and findings regarding its utility. RESULTS: The IDW methodology allows researchers to vet projects in the proposal stage in a structured format with a facilitator and two types of expert participants: presenters and attendees. The presenter uses a one-page handout and verbal presentation to present their proposal and questions. The facilitator elicits feedback from attendees using a format designed to maximize the number of unique points made. After each IDW, participants completed an anonymous survey assessing perceptions of the IDW. Presenters completed a funding survey measuring grant submission and funding success. Qualitative interviews were conducted with a subset of participants who participated in both delivery formats. Mixed method analyses were performed to evaluate the effectiveness and acceptability of the IDW and compare the delivery formats. Of those who participated in an IDW (N = 72), 40 participated in face-to-face only, 16 in virtual only, and 16 in both formats. Thirty-eight (face-to-face n = 12, 35 % response rate; virtual n = 26, 66.7 % response rate) responded to the surveys and seven (15.3 % response rate), who had attended both formats, completed an interview. Of 36 total presenters, 17 (face-to-face n = 12, 42.9 % response rate; virtual n = 5, 62.9 % response rate) responded to the funding survey. Mixed method analyses indicated that the IDW was effective for collaboration and growth, effective for enhancing success in obtaining grants, and acceptable. A third (35.3 %) of presenters ultimately received funding for their proposal, and more than 80 % of those who presented indicated they would present again in the future. The IDW structure and facilitation process were found to be acceptable, with both formats rated as equally strong. CONCLUSIONS: The IDW presents an acceptable and successful methodology for increasing competitiveness of implementation science grant proposals.
BACKGROUND: Residents living in long-term care facilities are a vulnerable population. For many residents, a nursing home is their place of death. Palliative care and end-of-life decisions are important components of their care provision. AIM: To study the views of cognitively able residents and relatives on advance care planning, end-of-life care, and decision-making in nursing homes. DESIGN: A qualitative study with in-depth interviews with nursing home residents and focus group interviews with relatives of nursing home residents. Analysis is based on interpretive description. SETTING/PARTICIPANTS: In total, 43 informants from nine nursing homes participated in the study (25 nursing home residents and 18 relatives). All included residents had capacity to provide informed consent and lived in long-term care. RESULTS: The main findings of this study were the differing views about decision-making and advance care planning of residents and relatives. Residents do trust relatives and staff to make important decisions for them. The relatives are in contrast insecure about the residents’ wishes and experience decision-making as a burden. The majority of the residents had not participated in advance care planning. None of the residents stated challenges connected to end-of-life care or mentioned the wish for euthanasia. CONCLUSION: Although most residents seem to be satisfied with decision-making and end-of life care, there is a need for systematic advance care planning. Advance care planning could help to explore future wishes for care and ease decision-making for the relatives, physicians, and staff and should be offered to all cognitively able nursing homes residents.
Aim To describe what characterizes residents with higher levels compared with those with lower levels of thriving in nursing homes using the Thriving of Older People Assessment Scale. Background Thriving is conceptualized as people’s experiences of well-being in relation to the environment where they live. Thriving has the potential to emphasize health-promotion and positive experiences in nursing home residents in addition to current focus on illness and symptoms. Design Cross-sectional design. Methods Data from a total sample of 191 residents in a large Swedish nursing home facility were separated into two groups; rated as having high and low thriving based on a median split of thriving total score for each participating resident. The characteristics of residents with higher and lower levels of thriving were compared using bivariate analyses to investigate differences. Data were collected in 2013. Results Residents with higher levels of thriving had shorter length of stay at the facility, higher functioning in Activities of Daily Living and less cognitive impairment, lower frequency of behavioural and psychological symptoms and higher assessed quality of life. The ability to walk and possibilities to spend time outdoors were higher among those with higher levels of thriving. Conclusion Nursing home residents who experience thriving have a higher level of functioning in activities of daily living, a higher quality of life and are less physically and cognitively impaired.
OBJECTIVE: Moral distress is increasingly being recognized as a concern for health care professionals. The purpose of this study was to explore the nature and prevalence of moral distress among nursing staff who care for people living with dementia. METHODS: This study was focused on nursing staff caring for people with dementia in long-term care and assisted living sites. The Moral Distress in Dementia Care Survey instrument was distributed to 23 sites and nursing staff rated the frequency and severity of situations that were identified as potentially causing moral distress. RESULTS: Moral distress is prevalent in the nursing staff who provide dementia care. Nursing staff reported experiencing moral distress at least daily or weekly. Both frequency and severity of moral distress increased with proximity to (amount of time spent at) the bedside. Moral distress had negative psychological and physiological effects on nursing staff, and affected intention to quit.
BACKGROUND: The aim of this study is to identify the barriers and facilitators in dementia care with respect to information provision, communication, and collaboration from the perspectives of the person with dementia, family caregivers, and health care professionals over the course of the illness. METHODS: A qualitative study using Focus-Group methodology was carried out in people with dementia, family caregivers, and health care providers. RESULTS: The categories that emerged from the analysis were insufficient information provided, specific dementia care needs, and acceptance of long-term care institutionalization from the people with dementia and caregivers’ groups and insufficient communication between health care providers, differential information according to disease stage, and home care coordination from the health care providers’ groups. CONCLUSION: The family is a key element in successful care coordination during dementia care provision. New effective strategies including self-management and emergent roles, such as case managers, could bring great benefits to people with dementia, caregivers, and health care providers.
BACKGROUND: It is widely acknowledged that mental health disorders are common in older adults and that depression is one of the most serious threats to the mental health of older adults. Although best practice guidelines point out that moderate to severe depression should be approached with pharmacotherapy together with complementary therapies, the use of antidepressant drugs in older adults has various disadvantages, such as long response time, side effects, potential risk of dependency and tolerance, poor compliance rates and high probability of drug interactions. In addition, qualitative studies of depressed people with a chronic illness have indicated that both patients and healthcare professionals prefer a psychosocial treatment for depression over a pharmacological one. OBJECTIVE: This review aimed to identify and synthesize the best available evidence related to the effectiveness of non-pharmacological interventions for older adults with depressive disorders. DESIGN: Systematic review of studies with any experimental design considering non-pharmacological interventions for older adults with depressive disorders. DATA SOURCES: An initial search of MEDLINE and CINAHL was undertaken, followed by a second search for published and unpublished studies, from January 2000 to March 2012, of major healthcare-related electronic databases. Studies in English, Spanish and Portuguese were included in the review. REVIEW METHODS: This review considered studies that included adult patients, aged over 65 years with any type of depressive disorder, regardless of comorbidities and any previous treatments, but excluded those with manic or psychotic episodes/symptoms. All studies that met the inclusion criteria were assessed for methodological quality by two independent reviewers using a standardized critical appraisal checklist for randomized and quasi-randomized controlled studies from the Joanna Briggs Institute. Data extraction was also conducted by two independent reviewers based on the Joanna Briggs Institute data extraction form for experimental studies. RESULTS: Twenty-three studies met the inclusion criteria. Of those, seventeen were excluded after critical appraisal of methodological quality and six were included in this review. These studies included 520 participants and described cognitive behavior therapy, competitive memory training, reminiscence group therapy, problem-adaptation therapy, and problem-solving therapy in home care. Evidence suggests that all these interventions reduce depressive symptoms. CONCLUSIONS: According to evidence, non-pharmacological interventions had positive effects on improving patients’ depression and may be useful in practice. However, due to the diversity of interventions and the low number of studies per intervention included in this systematic review, evidence is not strong enough to produce a best practice guideline.
BACKGROUND & AIMS: Old persons are more likely to suffer from malnutrition, which may result in higher dependency in activities of daily living. We aimed to provide a quantitative synthesis of prevalence data on malnutrition and its risk as assessed by the Mini Nutritional Assessment across different healthcare settings. The association between nutritional status and setting-related level of dependence was also investigated. METHODS: Non-interventional studies published as full-text articles in English up to 31th December 2014 were searched for in PubMed and by reviewing references of eligible articles. Meta-analysis and meta-regression of potential sources of heterogeneity were conducted. RESULTS: A total of 240 studies/795 citations – providing 258 setting-specific prevalence estimates (113,967 subjects) – fulfilled inclusion criteria for meta-analysis. Prevalence of malnutrition differed significantly across the healthcare settings considered: community, 4.0% (95%CI, 2.7-5.4); outpatients, 4.9% (95%CI, 3.4-6.5); home-care services, 9.9% (95%CI, 5.7-14.0); hospital, 22.3% (95%CI, 18.2-26.5); nursing homes, 15.2% (95%CI, 10.9-19.4); long-term care, 30.0% (95%CI, 20.9-39.0); rehabilitation/sub-acute care, 32.5% (95%CI, 22.5-42.5). For every setting significant heterogeneity in individual study results was observed (I2 >/=80%, P < 0.001) and meta-regression showed that study quality was the most important determinant. Finally, meta-regression of all the studies included showed that both malnutrition and its risk were directly associated with the setting-related level of dependence (P < 0.001). However, despite multiple adjustments, residual heterogeneity remained high. CONCLUSION: We provided updated estimates of malnutrition and its risk in different healthcare settings. Although the level of dependence appears to be an important determinant, heterogeneity in individual study results remained substantially unexplained. The cause-effect relationship between nutritional status and level of dependence deserves further investigation.
BACKGROUND: Social engagement is known to be an important factor that affects the quality of life and the psychological well-being of residents in long-term care settings. Few studies have examined social engagement in long-term care facilities in non-Western countries. PURPOSE: This study aimed to evaluate the validity and reliability of the revised index for social engagement (RISE), which was derived from the Korean version of the interRAI Long Term Care Facilities instrument. METHODS: Three hundred fourteen older adults from 10 nursing homes in Korea were included in the study. Convergent and discriminant validities were tested using correlation analysis and t tests, respectively. Factor analysis was adopted to examine the factor structure. The reliability of the RISE was tested using Cronbach’s alpha values for internal consistency, and interrater reliability was tested using item kappa values and intraclass correlation coefficients. RESULTS: The RISE showed excellent convergent validity with the average time involved in activities (r = .58). The known-group comparison showed a significant difference in the means of RISE between the group with cognitive impairment and the group without cognitive impairment, indicating satisfactory discriminant validity. Factor analysis showed a good model fit for two factors in the RISE: group involvement and interaction with others. The RISE showed satisfactory internal consistency (alpha >/= .70) and adequate interrater reliability (>/=.40). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The RISE is a valid and reliable tool for measuring the social engagement of nursing home residents in Korea. Furthermore, this tool may be a useful instrument for assessing older ethnic Korean residents who reside in nursing homes that are located outside Korea.
OBJECTIVE: To discuss models of care for frail seniors provided in primary care settings and those developed by Canadian FPs. SOURCES OF INFORMATION: Ovid MEDLINE and the Cochrane database were searched from 2010 to January 2014 using the terms models of care, family medicine, elderly, and geriatrics. MAIN MESSAGE: New models of funding for primary care have opened opportunities for ways of caring for complex frail older patients. Severity of frailty is an important factor, and more severe frailty should prompt consideration of using an alternate model of care for a senior. In Canada, models in use include integrated care systems, shared care models, home-based care models, and family medicine specialty clinics. No one model should take precedence but FPs should be involved in developing and implementing strategies that meet the needs of individual patients and communities. Organizational and remunerative supports will need to be put in place to achieve widespread uptake of such models. CONCLUSION: Given the increased numbers of frail seniors and the decrease in access to hospital beds, prioritized care models should include ones focused on optimizing health, decreasing frailty, and helping to avoid hospitalization of frail and well seniors alike. The Health Care of the Elderly Program Committee at the College of Family Physicians of Canada is hosting a repository for models of care used by FPs and is asking physicians to submit their ideas for how to best care for frail seniors.
Nursing homes have been criticised for not providing a home for their residents. This article aims to provide insight into (1) the features of home and institution as experienced by residents and caregivers of a secured ward in a nursing home, and (2) how interventions implemented on the ward can contribute to a more home-like environment. For this purpose, a participatory intervention study, involving both caregivers and residents, was carried out. We collected data through qualitative research methods: observations, in-depth interviews and diaries to evaluate the interventions over time. We adopted an informed grounded theory approach, and used conceptualisations of total institutions and home as a theoretical lens. We found that the studied ward had strong characteristics of a total institution, such as batch living, block treatment and limited privacy. To increase the sense of home, interventions were formulated and implemented by the caregivers to increase the residents’ autonomy, control and privacy. In this process, caregivers’ perceptions and attitudes towards the provision of care shifted from task-oriented to person-centred care. We conclude that it is possible to increase the home-like character of a secured ward by introducing core values of home by means of interventions involving both caregivers and residents.
OBJECTIVES: To systematically review longitudinal studies examining the association between oral health and cognitive decline. DESIGN: Studies published between January 1993 and March 2013 were identified by search of English language publications in PubMed/Medline using relevant Medical Subject Heading terms and title and abstract keywords and from CINAHL using relevant subject headings. After applying eligibility criteria and adding four studies identified from article references, 56 of the 1,412 articles identified remained; 40 were cross-sectional, and 16 were longitudinal; 11 of the latter examined the effect of oral health on change in cognitive health or dementia incidence, five examined the reverse. SETTING: Sources of information included administrative data, subject evaluations in parent studies, medical and dental records, self-reports, and in-person evaluations. PARTICIPANTS: Older adults. MEASUREMENTS: Most studies used subjects whose oral or cognitive status was known, using standard approaches to impute for missing information. The oral health information most frequently studied included number of teeth, periodontal and caries problems, and denture use. Cognition was most frequently evaluated using the Mini-Mental State Examination or according to a diagnosis of dementia. RESULTS: Some studies found that oral health measures such as number of teeth and periodontal disease were associated with risk of cognitive decline or incident dementia, whereas others did not find an association. Similarly, cognitive decline was not consistently associated with greater loss of teeth or number of decayed teeth. It is likely that methodological limitations play a major role in explaining the inconsistent findings. CONCLUSION: It is unclear how or whether oral health and cognitive status are related. Additional research is needed in which there is greater agreement on how oral health and cognitive states are assessed to better examine the linkages between these two health outcomes.
To assess the efficacy, comparative effectiveness, and adverse effects of nonpharmacologic interventions for agitation and aggression in individuals with dementia. Ovid MEDLINE(R), Ovid Embase(R), and the Cochrane Central Register of Controlled Trials bibliographic databases; hand searches of references of relevant studies. Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials evaluating nonpharmacologic interventions to manage agitation/aggression in individuals with dementia in nursing home, assisted living, or community settings. We analyzed outcomes of agitation/aggression, general behavior, patient quality of life, admission to long-term care, and staff and caregiver outcomes related to patient behavior and care burden. We assessed risk of bias, extracted data, and evaluated strength of evidence for each comparison and outcome. We analyzed pooled estimates to assess efficacy and comparative effectiveness. We conducted a qualitative analysis when data could not be pooled. We identified 126 unique randomized controlled trials as of July 2015. Patient-level interventions involving music, aromatherapy with lavender, and bright light were similar to usual treatment or attention control at managing agitation/aggression in people with dementia (low-strength evidence); interventions tailored to recipients’ skills, interests, or both were similar to usual care in managing agitation/aggression in people with dementia (low-strength evidence). Care delivery-level interventions (dementia care mapping and person-centered care) were similar to usual care in managing agitation/aggression in people with dementia (low-strength evidence). Evidence was insufficient to draw conclusions on the effectiveness of most caregiver-level interventions in managing agitation/aggression in people with dementia; caregiver interventions targeting caregiver skills and behavior were similar to attention control in managing agitation/aggression (low-strength evidence). However, these interventions show benefits in caregiver confidence in caregiving and caregiver distress. Adverse effects were rarely reported. Although many trials have been conducted to determine effective nonpharmacologic interventions for agitation/aggression in dementia, which is a critical topic, the evidence base is weak because of the variety of comparisons, measurement issues, and other methodological limitations. When evidence was sufficient to draw conclusions about effectiveness for a group of interventions, agitation/aggression outcomes were typically similar to those of control groups. Future research is needed to guide providers and informal caregivers toward effective interventions for agitation/aggression in dementia.
BACKGROUND: There is increasing emphasis on promoting “homelike” residential care models enabling care-dependent people to continue living in a self-determined manner. Yet, little is known about the outcomes of homelike residential care models. PURPOSE: We aimed to (1) identify homelike residential care models for older care-dependent people with and without dementia, and (2) explore the impact of these models on resident-, family-, and staff-related outcomes. DESIGN AND METHODS: We applied a scoping review method and conducted a comprehensive literature search in PubMed, Embase, and CINAHL in May 2015. RESULTS: We included 14 studies, reported in 21 articles. Studies were conducted between 1994 and 2014, most using a quasi-experimental design and comparing the Eden Alternative (n = 5), nondementia-specific small houses (eg Green House homes) (n = 2), and dementia-specific small houses (n = 7) with usual care in traditional nursing homes. The studies revealed evidence of benefit related to physical functioning of residents living in dementia-specific small houses and satisfaction with care of residents living in nondementia-specific small houses compared with those living in traditional nursing homes. We did not find other significant benefits related to physical and psychosocial outcomes of residents, or in family- and staff-related outcomes. IMPLICATIONS: The current evidence on homelike residential care models is limited. Comparative-effectiveness research building on a clear theoretical framework and/or logic model and including a standardized set of resident-, family-, and staff-related outcomes, as well as cost evaluation, is needed to provide a stronger evidence base to justify the uptake of more homelike residential care models.
BACKGROUND: Risks and prevalence of malnutrition and dehydration are high in older people but even higher in older people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions aiming to improve, maintain or facilitate food/drink intake indirectly, through food service or dining environment modification, education, exercise or behavioural interventions in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). METHODS: We comprehensively searched Medline and twelve further databases, plus bibliographies, for intervention studies with >/=3 cognitively impaired adult participants (any type/stage). The review was conducted with service user input in accordance with Cochrane Collaboration’s guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data. Meta-analysis (statistical pooling) was not appropriate so data were tabulated and synthesised narratively. RESULTS: We included 56 interventions (reported in 51 studies). Studies were small and there were no clearly effective, or clearly ineffective, interventions. Promising interventions included: eating meals with care-givers, family style meals, soothing mealtime music, constantly accessible snacks and longer mealtimes, education and support for formal and informal care-givers, spaced retrieval and Montessori activities, facilitated breakfast clubs, multisensory exercise and multicomponent interventions. CONCLUSIONS: We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. A variety of promising indirect interventions need to be tested in large, high-quality RCTs, and may be approaches that people with dementia and their formal or informal care-givers would wish to try. TRIAL REGISTRATION: The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007611).
Cognitive stimulation therapy (CST), reminiscence therapy (RT), and aroma-massage therapy (AT) are believed to be beneficial for people with dementia (PwD). However, the comparing effects of these interventions have not been reported in previous studies. The purpose of this research was thus to compare the effects of these 3 interventions on alleviating agitation and depressive mood in PwD.; PurposeCognitive stimulation therapy (CST), reminiscence therapy (RT), and aroma-massage therapy (AT) are believed to be beneficial for people with dementia (PwD). However, the comparing effects of these interventions have not been reported in previous studies. The purpose of this research was thus to compare the effects of these 3 interventions on alleviating agitation and depressive mood in PwD.
Efforts to improve the quality of life of persons with dementia in long-term care through the implementation of various approaches to person-centered care have been underway for the past two decades. Studies have yielded conflicting reports evaluating the evidence for these approaches. The purpose of this article is to outline the findings of several systematic reviews of this literature, highlighting the areas of improvement needs, and to describe a new person-centered care model, DementiAbility Methods: The Montessori Way. This model focuses on the abilities, needs, interests, and strengths of the person and creating worthwhile and meaningful roles, routines, and activities for the person within a supportive physical environment. This is accomplished through gaining the commitment of the facility’s leaders, training staff, and monitoring program implementation. The potential for a culture change in long-term care environments is dependent on the development and rigorous evaluation of person-centered care approaches.
OBJECTIVE: Little is known about how and to what extent people with dementia live positively with their condition. This study aimed to review and carry out a synthesis of qualitative studies where accounts of the subjective experiences of people with dementia contained evidence of positive states, experiences or attributes. METHODS: A meta-synthesis was undertaken to generate an integrated and interpretive account of the ability of people with dementia to have positive experiences. A methodological quality assessment was undertaken to maximize the reliability and validity of this synthesis and to contextualize the findings with regard to methodological constraints and epistemological concepts. FINDINGS: Twenty-seven papers were included. Three super-ordinate themes relating to positive experiences and attributes were identified, each with varying and complementing sub-themes. The first super-ordinate theme related to the experience of engaging with life in ageing rather than explicitly to living with dementia. The second theme related to engaging with dementia itself and comprised the strengths that people can utilize in facing and fighting the condition. The third theme captured how people with dementia might transcend the condition and seek ways to maintain identity and even achieve personal growth. CONCLUSIONS: This review provides a first step towards understanding what conceptual domains might be important in defining positive outcomes for people who live with dementia. Highlighting the potential for people to have positive experiences in spite of or even because of their dementia has important implications for de-stigmatizing dementia and will enhance person-centred approaches to care.
Research Excellence Series: Leading Real Multi-Disciplinary Teams
Presenter Dr. Jason Dyck.
1. Learn about the burden of multiple chronic diseases affecting older
2. Understand the potential impact of current KT tools targeting multiple
chronic conditions through a systematic review
3. Discuss findings in the context of informing a KT tool aimed at
integrating the care of top high-burden chronic conditions affecting
The majority of direct care partners and interdisciplinary team members do not receive evidence-based and practical knowledge on the prevalent, concerning but under-recognized public health problem of distressing and harmful resident-to-resident interactions in dementia in long-term care homes. Based on an extensive review of practice and research literature and an observational study conducted by Dr. Caspi, this introductory presentation will identify:
-Consequences of these behavioral expressions;
-Common contributing factors, causes, and situational triggers;
-Key psychosocial prevention and de-escalation strategies.
Join Dr. Gill Westhorp for this exciting Realist Summer School. Each day will include an advanced skills workshop in the morning with topics selected in response to a needs analysis of participants, and working sessions in the afternoons. Working sessions will provide participants with opportunities to work on their own projects with support from facilitators; opportunities to workshop specific issues or difficulties with other participants; and opportunities to present aspects of work in progress and receive feedback from others. Projects can be of any type – realist evaluation, realist reviews, research funding applications, or other realist research projects – and at any stage of development, from conception through design to data collection, analysis or write-up. The summer school will provide a real opportunity to consolidate knowledge, develop expertise, strengthen teams and build a network of realist practitioners.
Fundamentals of Implementation Science in Global Health is a one to two-week intensive course – with an intensive didactic week, and an optional second week of mentored protocol development – that provides course participants with an introduction to the emerging field of Implementation Science. The course outlines and explores an inter-disciplinary framework of methods (including applied engineering, management tools, health systems, and policy research) applied to improving implementation and scale-up of health programs, paired with experiential case studies from global health leaders.
What is knowledge translation? Scientific study of methods to promote the uptake of research findings into routine healthcare Who is this course for? This course is open to students and researchers interested in drawing upon cognitive and behaviour change theories to promote changing practice to improve healthcare delivery (no prior experience required). Priority spaces for University of Ottawa graduate students. Spaces are limited – we encourage registering early Format Three consecutive full day sessions (9am-5pm) involving interactive lectures, student presentations, small group work, case studies and 1-1 faculty meetings. Core reading to be completed prior to the course.
The Online Certificate Program is a one-year, part-time program consisting of a series of six online courses focused on theories and methods relevant to the design of strategies to facilitate uptake of health-related interventions. Scholars can choose to take individual courses instead of completing all six courses required for the Certificate. The Online Courses and Certificate program are designed for people from a broad range of professional settings who are currently engaged in the development, implementation, and evaluation of strategies to promote and improve health and health care quality, including clinical and public health researchers, quality improvement officers, community-based clinic staff, public health and public policy practitioners, and clinicians. We welcome trainees who work in clinical and public health settings outside the U.S.
You may have just produced a great wadge of material through free writing. Or perhaps you have a very messy draft of a paper, or a draft thesis chapter. Where to start to try to sort out the useful writing from the rest? What is gold and what is dross? How to get to a more refined next draft?
The prevalence of dementia in the UK may not be increasing as fast as has been feared, say researchers after reporting a 20% drop in the numbers of new cases diagnosed between 1989 and 2011 in a study published online in Nature Communications.
Steven Lewis says seniors falling through cracks of health care system.
The chair of the search committee has now made it clear that they are prepared to offer you a faculty position in their department and would like to begin negotiating the details of your appointment. Along with this offer you will typically be invited back for a second interview where you are expected to meet with additional members of the department to get a feel for what you will need to launch a successful research lab.
I fear the day when I put my fingers on the keyboard and don’t know how to write anymore.
The NHS is providing a second-class service to many of the 280,000 people with dementia who live in care homes in England.
Many older people who need long-term (LTC) care prefer to remain in their own home for as long as possible, and most OECD countries aim to support them to do so. Over the last decade, nearly all countries for which we have data have seen an increase in the proportion of LTC users living at home, with particularly large shifts in France, Sweden and Korea. The only exception to this trend is Finland, but this reflects an increase in the use of specially adapted “service housing” where 24-hour care is available, rather than traditional care institutions.
We’ve all heard stories of backlogs caused by people turning up at the emergency room with conditions could be treated elsewhere. Now new research reveals that nursing home residents make up a surprising number of those unnecessary visits.
The ability to choose what to eat and when to do so is hugely important for seniors’ quality of life.
A withered person with a scrambled mind, memories sealed away: That is the familiar face of Alzheimer’s. But there is also the waiting period, which Geri Taylor has been navigating with prudence, grace and hope.
Ever found yourself at the end of a paper but not sure what you were writing about? Lots of words but not sure what it all means? Ever got feedback on a paper which said there were too many ideas going on? Or that there was lots of material but the reader wasn’t sure of where it was going? Ever wanted to help a writer who had written a lot but hadn’t got their point across?
The Directory aims to profile, promote and encourage research into the health needs of people aged over 50 to enable the use of evidence for policy. This evidence will be crucial in enabling countries undergoing rapid demographic and epidemiological transitions to develop appropriate policy responses to monitor the implementation and impact of policies.
Sea Hero Quest follows the story of a young man who sails the ocean recovering his father’s lost memories. Rather than being given points on a map to follow, players must navigate the world themselves using methods that test their memory and orientations skills. Understanding how people navigate 3D environments is important because the skill is often one of the first lost by people who have dementia.
Age UK has made available an online interactive map depicting the regional prevalence of loneliness and social isolation in the English local authorities.
Measure: Dementia-percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period (US)
This measure is used to assess the percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.
The term wicked problems is increasingly used to describe a particularly complex type of problem that is difficult, persistent, and resistant to resolution. Frequently encountered in both public health and public policy, wicked problems present a high level of difficulty because, among other things, they are often intertwined with other complex problems. This presentation provides an overview of wicked problems and how they differ from tame ones. Future web presentations will focus on strategies for dealing with wicked problems.
This senior post-doctoral fellowship offers a unique leadership development programme with three years’ funding for original, applied research dedicated to improving health care in the UK. We are looking for up to five fellows who will receive:
-a tailored leadership development programme including facilitated action learning sets and individual coaching
-funding for full salary and research costs
-the opportunity to work with international experts in improvement science.
Applicants must demonstrate leadership skills and significant research or improvement in practice experience, with a PhD, professional doctorate or MD. We encourage applications from clinicians who wish to combine research with continuing clinical practice.
The Institute for Health, Health Care Policy and Aging Research, a unit of Rutgers Biomedical and Health Sciences (RBHS), is developing a program in Dissemination and Implementation Science and seeks tenured/tenure track faculty with a research focus in this area. Funding is anticipated to be available for two positions, one at the Full or Associate Professor level and one at the Assistant Professor level. Initial emphasis of this search is on recruiting an outstanding individual at the senior level; outstanding junior candidates will also be considered.