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Hughes JM, Zullig LL, Choate AL, Decosimo KP, Wang V, Van Houtven CH, Allen KD, Nicole Hastings S. Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up. THE GERONTOLOGIST 2023; 63:604-613. [PMID: 36029028 PMCID: PMC10461172 DOI: 10.1093/geront/gnac130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multilevel and multistep process to develop and evaluate implementation intensification. Steps included (a) review completed trial data; (b) conduct listening sessions; (c) review literature; (d) draft foundational and enhanced implementation support packages; (e) iteratively refine packages; and (7) devise an evaluation plan. Our model of implementation intensification may be relevant to other health care systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more health care systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.
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Affiliation(s)
- Jaime M Hughes
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley L Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Kasey P Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine , Chapel Hill, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Albasha N, Ahern L, O’Mahony L, McCullagh R, Cornally N, McHugh S, Timmons S. Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review. BMC Geriatr 2023; 23:47. [PMID: 36698065 PMCID: PMC9878796 DOI: 10.1186/s12877-023-03738-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies. METHODS A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001-2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results. RESULTS Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3-17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders' interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8). CONCLUSION This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined. TRIAL REGISTRATION This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.
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Affiliation(s)
- Neah Albasha
- grid.7872.a0000000123318773Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, The Bungalow, Block 13, Douglas Road, Cork City, Ireland ,grid.449346.80000 0004 0501 7602Rehabilitation Department, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Leanne Ahern
- grid.7872.a0000000123318773School of Clinical Therapies, University College Cork, Cork City, Ireland
| | - Lauren O’Mahony
- grid.7872.a0000000123318773Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, The Bungalow, Block 13, Douglas Road, Cork City, Ireland
| | - Ruth McCullagh
- grid.7872.a0000000123318773School of Clinical Therapies, University College Cork, Cork City, Ireland
| | - Nicola Cornally
- grid.7872.a0000000123318773School of Nursing and Midwifery, University College Cork, Cork City, Ireland
| | - Sheena McHugh
- grid.7872.a0000000123318773School of Public Health, University College Cork, Cork City, Ireland
| | - Suzanne Timmons
- grid.7872.a0000000123318773Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, The Bungalow, Block 13, Douglas Road, Cork City, Ireland
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Wang V, D'Adolf J, Decosimo K, Robinson K, Choate A, Bruening R, Sperber N, Mahanna E, Van Houtven CH, Allen KD, Colón-Emeric C, Damush TM, Hastings SN. Adapting to CONNECT: modifying a nursing home-based team-building intervention to improve hospital care team interactions, functioning, and implementation readiness. BMC Health Serv Res 2022; 22:968. [PMID: 35906589 PMCID: PMC9335996 DOI: 10.1186/s12913-022-08270-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/29/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Clinical interventions often need to be adapted from their original design when they are applied to new settings. There is a growing literature describing frameworks and approaches to deploying and documenting adaptations of evidence-based practices in healthcare. Still, intervention modifications are often limited in detail and justification, which may prevent rigorous evaluation of interventions and intervention adaptation effectiveness in new contexts. We describe our approach in a case study, combining two complementary intervention adaptation frameworks to modify CONNECT for Quality, a provider-facing team building and communication intervention designed to facilitate implementation of a new clinical program. METHODS This process of intervention adaptation involved the use of the Planned Adaptation Framework and the Framework for Reporting Adaptations and Modifications, for systematically identifying key drivers, core and non-core components of interventions for documenting planned and unplanned changes to intervention design. RESULTS The CONNECT intervention's original context and setting is first described and then compared with its new application. This lays the groundwork for the intentional modifications to intervention design, which are developed before intervention delivery to participating providers. The unpredictable nature of implementation in real-world practice required unplanned adaptations, which were also considered and documented. Attendance and participation rates were examined and qualitative assessment of reported participant experience supported the feasibility and acceptability of adaptations of the original CONNECT intervention in a new clinical context. CONCLUSION This approach may serve as a useful guide for intervention implementation efforts applied in diverse clinical contexts and subsequent evaluations of intervention effectiveness. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov ( NCT03300336 ) on September 28, 2017.
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Affiliation(s)
- Virginia Wang
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Joshua D'Adolf
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Kasey Decosimo
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Katina Robinson
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Ashley Choate
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Rebecca Bruening
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Nina Sperber
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth Mahanna
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Courtney H Van Houtven
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kelli D Allen
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cathleen Colón-Emeric
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Teresa M Damush
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, IN, USA
- Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Susan N Hastings
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
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Beynon C, Siegel EO, Supiano K, Edelman LS. Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review. J Gerontol Nurs 2022; 48:27-34. [PMID: 35511065 DOI: 10.3928/00989134-20220405-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].
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Bunn F, Goodman C, Corazzini K, Sharpe R, Handley M, Lynch J, Meyer J, Dening T, Gordon AL. Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E987. [PMID: 32033293 PMCID: PMC7037621 DOI: 10.3390/ijerph17030987] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 11/16/2022]
Abstract
Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | | | - Rachel Sharpe
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Melanie Handley
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Jennifer Lynch
- Centre for Research in Public Health and Community Care, University of Hertfordshire, College Lane, Hatfield, Hertfordshire AL10 9AB, UK; (R.S.); (M.H.)
| | - Julienne Meyer
- Care for Older People, City, University of London, London EC1V OHB, UK;
| | - Tom Dening
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham NG7 2TU, UK;
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby DE22 3NE, UK;
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Van Houtven CH, Hastings SN, Colón-Emeric C. A Path To High-Quality Team-Based Care For People With Serious Illness. Health Aff (Millwood) 2019; 38:934-940. [DOI: 10.1377/hlthaff.2018.05486] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Courtney H. Van Houtven
- Courtney H. Van Houtven is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs (VA) Health Care System, and a professor in the Department of Population Health Sciences at the Duke University School of Medicine, in Durham, North Carolina
| | - S. Nicole Hastings
- S. Nicole Hastings is center director and a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and an associate professor of medicine and population health sciences and a senior fellow in the Center for the Study of Aging and Human Development at the Duke University School of Medicine
| | - Cathleen Colón-Emeric
- Cathleen Colón-Emeric is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and in the Durham VA Geriatrics Research, Education, and Clinical Center; a professor of medicine and chief of the Division of Geriatrics in the Department of Medicine, Duke University; and a senior fellow in the Center for the Study of Aging and Human Development, Duke University School of Medicine
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Cameron ID, Dyer SM, Panagoda CE, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2018; 9:CD005465. [PMID: 30191554 PMCID: PMC6148705 DOI: 10.1002/14651858.cd005465.pub4] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012. OBJECTIVES To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017. SELECTION CRITERIA Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals. DATA COLLECTION AND ANALYSIS One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence. MAIN RESULTS Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.
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Affiliation(s)
- Ian D Cameron
- The University of SydneyJohn Walsh Centre for Rehabilitation Research, Sydney Medical School, Northern Clinical SchoolReserve RoadSt LeonardsNSWAustralia2065
| | - Suzanne M Dyer
- DHATR Consulting120 Robsart StreetParksideSouth AustraliaAustralia5063
| | - Claire E Panagoda
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health DistrictSt LeonardsNSWAustralia2065
| | - Geoffrey R Murray
- Illawarra Shoalhaven Local Health DistrictAged Care, Rehabilitation and Palliative CareWarrawongAustralia
| | - Keith D Hill
- Curtin UniversitySchool of Physiotherapy and Exercise Science, Faculty of Health SciencesGPO Box U1987PerthWestern AustraliaAustralia6845
| | - Robert G Cumming
- Sydney Medical School, University of SydneySchool of Public HealthRoom 306, Edward Ford Building (A27)Fisher RoadSydneyNSWAustralia2006
| | - Ngaire Kerse
- University of AucklandDepartment of General Practice and Primary Health CarePrivate Bag 92019AucklandNew Zealand
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Kadri A, Rapaport P, Livingston G, Cooper C, Robertson S, Higgs P. Care workers, the unacknowledged persons in person-centred care: A secondary qualitative analysis of UK care home staff interviews. PLoS One 2018; 13:e0200031. [PMID: 29985934 PMCID: PMC6037344 DOI: 10.1371/journal.pone.0200031] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/17/2018] [Indexed: 11/30/2022] Open
Abstract
Personhood discourses in dementia care have gained prominence and current care home standards mandate that care should be "person-centred". However, it is unclear how the personhood of staff is construed within the care relationship. This paper aims to explore how the personhood of paid carers of people with dementia can be understood by focussing on the views and experiences of care home staff. We undertook a secondary qualitative analysis of interviews with 25 paid care staff in England, conducted as part of the MARQUE (Managing Agitation and Raising QUality of lifE) study. The authors inductively developed themes around the topic of personhood for staff, contrasting management and care staff perspectives. We found that many care staff are not identified as persons in their own right by their employing institutions, and that there is a general lack of acknowledgment of the moral work of caring that occurs within formal care work. This oversight can reduce the complex relationships of care work to a series of care tasks, challenges care workers' self-worth and self-efficacy, and impede their efforts to deliver person-centred care. We conclude that care staff status as persons in their own right should be explicitly considered in quality standards and supported by employers' policies and practices, not simply for their role in preserving the personhood of people with dementia but for their own sense of valued personhood. Enhancing staff personhood may also result in improved care.
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Affiliation(s)
- Adam Kadri
- UCL Department of Old Age Psychiatry, Division of Psychiatry, University College London, London, United Kingdom
| | - Penny Rapaport
- UCL Department of Old Age Psychiatry, Division of Psychiatry, University College London, London, United Kingdom
| | - Gill Livingston
- UCL Department of Old Age Psychiatry, Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington NHS Foundation trust, London, United Kingdom
| | - Claudia Cooper
- UCL Department of Old Age Psychiatry, Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington NHS Foundation trust, London, United Kingdom
| | - Sarah Robertson
- UCL Department of Old Age Psychiatry, Division of Psychiatry, University College London, London, United Kingdom
| | - Paul Higgs
- UCL Department of Old Age Psychiatry, Division of Psychiatry, University College London, London, United Kingdom
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Wang V, Allen K, Van Houtven CH, Coffman C, Sperber N, Mahanna EP, Colón-Emeric C, Hoenig H, Jackson GL, Damush TM, Price E, Hastings SN. Supporting teams to optimize function and independence in Veterans: a multi-study program and mixed methods protocol. Implement Sci 2018; 13:58. [PMID: 29678137 PMCID: PMC5910600 DOI: 10.1186/s13012-018-0748-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Successful implementation of new clinical programs depends on effectively establishing, reorganizing, or enhancing team structures and processes to coordinate the work of individuals who are interdependent in their tasks, manage relationships, and share responsibility for outcomes. However, a one-size-fits-all approach is rarely effective. In partnership with VA national clinical leaders and local clinical champions, the Optimizing Function and Independence VA Quality Enhancement Research Initiative program (Function QUERI) will evaluate efforts to implement team-based clinical programs for Veterans at risk for functional decline and disability. Methods Function QUERI will implement and evaluate three innovative, evidence-based clinical programs in VA medical centers: (1) a group physical therapy program for knee osteoarthritis (Group PT); (2) assisted early mobility for hospitalized older veterans (STRIDE), a supervised walking program for hospitalized older veterans; and (3) implementation of helping invested family members improve veteran experiences study (iHI-FIVES), a skills training program for caregivers of disabled Veterans. A common reason for clinical care gaps in these populations is poor communication and coordination among the many interdisciplinary providers involved in their care. To facilitate the implementation of the clinical programs, Function QUERI will evaluate the impact of complexity science-based implementation intervention to promote team readiness (CONNECT), an implementation intervention designed as a bundle of interaction-oriented activities to promote team function and readiness for change, on the implementation of clinical programs across multiple sites. The evaluation will use a mixed methods design. Group PT is a local, single-site quality improvement project where a modified CONNECT intervention will be tested to inform the remaining program implementation projects. For STRIDE and iHI-FIVES projects, we will randomize participating sites to implement the clinical program, with the CONNECT intervention or not, and will use a stepped-wedge cluster randomized trial design. Discussion Function QUERI will translate its findings across its projects to identify the contextual factors and components from CONNECT that improve team processes and function to optimize effective implementation for future rollout of VA clinical programs. Synthesizing findings within and across projects, we will specify dimensions of team characteristics and function that enhance capacity for clinical innovation and uptake of evidence-based programs. Trial registration NCT03300336 Registered September 28, 2017, NCT03474380 Registered March 15, 2018. Electronic supplementary material The online version of this article (10.1186/s13012-018-0748-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Virginia Wang
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA. .,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Kelli Allen
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine and Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney H Van Houtven
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia Coffman
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Nina Sperber
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth P Mahanna
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA
| | - Cathleen Colón-Emeric
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Helen Hoenig
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Physical Medicine and Rehabilitation Service, Durham VA Health Care System, Durham, NC, USA
| | - George L Jackson
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Teresa M Damush
- Health Services Research and Development Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, 1481 W. 10th St., HSRD 11H, Indianapolis, IN, 46202, USA.,Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Erika Price
- San Francisco VA Care System, 94121, 4150 Celement St., Box 111, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Susan N Hastings
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
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10
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Colón-Emeric CS, Corazzini K, McConnell ES, Pan W, Toles M, Hall R, Cary MP, Batchelor-Murphy M, Yap T, Anderson AL, Burd A, Amarasekara S, Anderson RA. Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern Med 2017; 177:1634-1641. [PMID: 28973516 PMCID: PMC5710274 DOI: 10.1001/jamainternmed.2017.5073] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. OBJECTIVE To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. INTERVENTIONS CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program. MAIN OUTCOMES AND MEASURES Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. RESULTS Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. CONCLUSIONS AND RELEVANCE An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00636675.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Eleanor S McConnell
- Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina.,Duke University School of Nursing, Durham, North Carolina
| | - Wei Pan
- Duke University School of Nursing, Durham, North Carolina
| | - Mark Toles
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill
| | - Rasheeda Hall
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Michael P Cary
- Duke University School of Nursing, Durham, North Carolina
| | | | - Tracey Yap
- Duke University School of Nursing, Durham, North Carolina
| | | | - Andrew Burd
- Duke University School of Nursing, Durham, North Carolina
| | | | - Ruth A Anderson
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill
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11
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Toles M, Colón-Emeric C, Naylor MD, Asafu-Adjei J, Hanson LC. Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers. J Am Geriatr Soc 2017; 65:2322-2328. [PMID: 28815552 DOI: 10.1111/jgs.15015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood. OBJECTIVE To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads. DESIGN A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers. SETTING Three SNFs in the Southeastern United States. PARTICIPANTS Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. INTERVENTION The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads. MEASUREMENTS Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15). RESULTS The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24). CONCLUSION Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.
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Affiliation(s)
- Mark Toles
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Mary D Naylor
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Laura C Hanson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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12
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Vlaeyen E, Stas J, Leysens G, Van der Elst E, Janssens E, Dejaeger E, Dobbels F, Milisen K. Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. Int J Nurs Stud 2017; 70:110-121. [PMID: 28242505 DOI: 10.1016/j.ijnurstu.2017.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/28/2017] [Accepted: 02/01/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify the barriers and facilitators for fall prevention implementation in residential care facilities. DESIGN Systematic review. Review registration number on PROSPERO: CRD42013004655. DATA SOURCES Two independent reviewers systematically searched five databases (i.e. MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science) and the reference lists of relevant articles. REVIEW METHODS This systematic review was conducted in line with the Center for Reviews and Dissemination Handbook and reported according to the PRISMA guideline. Only original research focusing on determinants of fall prevention implementation in residential care facilities was included. We used the Mixed Method Appraisal Tool for quality appraisal. Thematic analysis was performed for qualitative data; quantitative data were analyzed descriptively. To synthesize the results, we used the framework of Grol and colleagues that describes six healthcare levels wherein implementation barriers and facilitators can be identified. RESULTS We found eight relevant studies, identifying 44 determinants that influence implementation. Of these, 17 were facilitators and 27 were barriers. Results indicated that the social and organizational levels have the greatest number of influencing factors (9 and 14, respectively), whereas resident and economical/political levels have the least (3 and 4, respectively). The most cited facilitators were good communication and facility equipment availability, while staff feeling overwhelmed, helpless, frustrated and concerned about their ability to control fall management, staffing issues, limited knowledge and skills (i.e., general clinical skill deficiencies, poor fall management skills or lack of computer skills); and poor communication were the most cited barriers. CONCLUSION Successful implementation of fall prevention depends on many factors across different healthcare levels. The focus of implementation interventions, however, should be on modifiable barriers and facilitators such as communication, knowledge, and skills. Effective fall prevention must consist of multifactorial interventions that target each resident's fall risk profile, and should be tailored to overcome context-specific barriers and put into action the identified facilitators.
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Affiliation(s)
- Ellen Vlaeyen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.
| | - Joke Stas
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Greet Leysens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Elisa Van der Elst
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Elise Janssens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Eddy Dejaeger
- Department of Internal Medicine, Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium; Department of Internal Medicine, Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
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13
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Verloo H, Desmedt M, Morin D. Beliefs and implementation of evidence-based practice among nurses and allied healthcare providers in the Valais hospital, Switzerland. J Eval Clin Pract 2017; 23:139-148. [PMID: 27687154 DOI: 10.1111/jep.12653] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE Evidence-based practice (EBP) is upheld as a means for patients to receive the most efficient care in a given context. Despite the available evidence and positive beliefs about it, implementing EBP as standard daily practice still faces many obstacles. AIMS AND OBJECTIVES This study investigated the beliefs about and implementation of EBP among nurses and allied healthcare providers (AHP) in 9 acute care hospitals in the canton of Valais, Switzerland. MATERIALS AND METHODS A cross-sectional descriptive survey was conducted. The target population was composed of 1899 nurses and 126 AHPs. Beliefs about and implementation of EBP were measured using EBP-Beliefs and EBP-Implementation scales of Melnyk et al. RESULTS The initial sample consisted in 491 participants (overall response rate 24.2%): 421 nurses (22.4% response rate) and 78 AHPs (61.9% response rate). The final sample, composed only of those who declared previous exposure to EBP, included 391 participants (329 nurses and 62 AHPs). Overall, participants had positive attitudes towards EBP and were willing to increase their knowledge to guide practice. However, they acknowledged poor implementation of EBP in daily practice. A significantly higher level of EBP implementation was declared by those formally trained in it (P = 0.006) and by those occupying more senior professional functions (P = 0.004). EBP-Belief scores predicted 13% of the variance in the EBP-Implementation scores (R2 = 0.13). DISCUSSION EBP is poorly implemented despite positive beliefs about it. Continuing education and support on EBP would help to ensure that patients receive the best available care based on high-quality evidence, patient needs, clinical expertise, and a fair distribution of healthcare resources. CONCLUSION This study's results will be used to guide institutional strategy to increase the use of EBP in daily practice.
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Affiliation(s)
- Henk Verloo
- University of Applied Sciences and Arts Western Switzerland, 5, Chemin de l'Agasse, CH, -1950, Sion, Switzerland.,Department of Nursing Sciences, Valais Hospital, 86, Avenue de Grand-Champsec, CH, -1951, Sion, Switzerland
| | - Mario Desmedt
- Valais Hospital, Directorate General, 86, Avenue de Grand-Champsec, CH, -1951, Sion, Switzerland
| | - Diane Morin
- Institut Universitaire de Formation et Recherche en Soins (IUFRS), Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital, 10, Route de la Corniche, CH, -1010, Lausanne, Switzerland.,Faculty of Nursing Sciences, Université Laval, Québec, Canada
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14
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Toles M, Colón-Emeric C, Naylor MD, Barroso J, Anderson RA. Transitional care in skilled nursing facilities: a multiple case study. BMC Health Serv Res 2016; 16:186. [PMID: 27184902 PMCID: PMC4869313 DOI: 10.1186/s12913-016-1427-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. METHODS In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. RESULTS Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. CONCLUSIONS Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
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Affiliation(s)
- Mark Toles
- University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA.
| | - Cathleen Colón-Emeric
- School of Medicine and the Geriatric Research, Education and Clinical Center (GRECC), Durham Veterans Affairs Medical Center, Duke University, DUMC 3469, Durham, NC, 27710, USA
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Room 341 Fagin Hall, 418 Curie Blvd., Philadelphia, PA, 19104-4217, USA
| | - Julie Barroso
- Medical University of South CarolinaCollege of Nursing, Room 508 99 Jonathan Lucas St., Charleston, SC, 29425-1600, USA
| | - Ruth A Anderson
- University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA
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15
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The feasibility of a train-the-trainer approach to end of life care training in care homes: an evaluation. BMC Palliat Care 2016; 15:11. [PMID: 26801232 PMCID: PMC4724146 DOI: 10.1186/s12904-016-0081-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 01/12/2016] [Indexed: 11/12/2022] Open
Abstract
Background The ABC End of Life Education Programme trained approximately 3000 care home staff in End of Life (EoL) care. An evaluation that compared this programme with the Gold Standards Framework found that it achieved equivalent outcomes at a lower cost with higher levels of staff satisfaction. To consolidate this learning, a facilitated peer education model that used the ABC materials was piloted. The goal was to create a critical mass of trained staff, mitigate the impact of staff turnover and embed EoL care training within the organisations. The aim of the study was to evaluate the feasibility of using a train the trainer (TTT) model to support EoL care in care homes. Methods A mixed method design involved 18 care homes with and without on-site nursing across the East of England. Data collection included a review of care home residents’ characteristics and service use (n = 274), decedents’ notes n = 150), staff interviews (n = 49), focus groups (n = 3), audio diaries (n = 28) and observations of workshops (n = 3). Results Seventeen care homes participated. At the end of the TTT programme 28 trainers and 114 learners (56 % of the targeted number of learners) had been trained (median per home 6, range 0–13). Three care homes achieved or exceeded the set target of training 12 learners. Trainers ranged from senior care staff to support workers and administrative staff. Results showed a positive association between care home stability, in terms of leadership and staff turnover, and uptake of the programme. Care home ownership, type of care home, size of care home, previous training in EoL care and resident characteristics were not associated with programme completion. Working with facilitators was important to trainers, but insufficient to compensate for organisational turbulence. Variability of uptake was also linked to management support, programme fit with the trainers’ roles and responsibilities and their opportunities to work with staff on a daily basis. Conclusion When there is organisational stability, peer to peer approaches to skills training in end of life care can, with expert facilitation, cascade and sustain learning in care homes.
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16
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Chodosh J, Price RM, Cadogan MP, Damron-Rodriguez J, Osterweil D, Czerwinski A, Tan ZS, Merkin SS, Gans D, Frank JC. A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care-Preliminary Data. J Am Geriatr Soc 2015; 63:2395-9. [PMID: 26503548 DOI: 10.1111/jgs.13775] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.
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Affiliation(s)
- Joshua Chodosh
- Veterans Affairs Greater Los Angeles Health System, Los Angeles, California.,University of California at Los Angeles, Los Angeles, California.,Division of Geriatric Medicine and Palliative Care, School of Medicine, New York University, New York, New York
| | - Rachel M Price
- University of California at Los Angeles, Los Angeles, California
| | - Mary P Cadogan
- University of California at Los Angeles, Los Angeles, California
| | | | - Dan Osterweil
- University of California at Los Angeles, Los Angeles, California.,California Association of Long Term Care Medicine, Los Angeles, California
| | | | - Zaldy S Tan
- University of California at Los Angeles, Los Angeles, California
| | - Sharon S Merkin
- University of California at Los Angeles, Los Angeles, California
| | - Daphna Gans
- University of California at Los Angeles, Los Angeles, California
| | - Janet C Frank
- University of California at Los Angeles, Los Angeles, California
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17
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Corazzini KN, McConnell ES, Day L, Anderson RA, Mueller C, Vogelsmeier A, Kennerly S, Walker B, Flanagan JT, Haske-Palomino M. Differentiating Scopes of Practice in Nursing Homes: Collaborating for Care. JOURNAL OF NURSING REGULATION 2015. [DOI: 10.1016/s2155-8256(15)30009-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Bonner A, Tappen R, Herndon L, Ouslander J. The INTERACT Institute: Observations on Dissemination of the INTERACT Quality Improvement Program Using Certified INTERACT Trainers. THE GERONTOLOGIST 2014; 55:1050-7. [PMID: 25378465 DOI: 10.1093/geront/gnu103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 09/30/2014] [Indexed: 11/13/2022] Open
Abstract
Unnecessary hospitalizations of vulnerable nursing home (NH) residents can lead to hospital-acquired conditions, morbidity, mortality, and excess health care expenditures. Previous research has shown that a substantial percentage of these hospitalizations are preventable. Interventions to reduce acute care transfers (INTERACT) is a quality improvement program that has been adopted by many NHs throughout the United States. The original INTERACT toolkit was first created in a project supported by the Centers for Medicare and Medicaid Services. The toolkit was further refined and tested in a collaborative quality improvement project involving 30 NHs in 3 states, which resulted in a 17% reduction in all-cause hospitalizations. This study was limited because it was not randomized or controlled. Nevertheless, the data provide evidence that the program, even in the absence of strong regulatory oversight or financial incentives, is feasible to implement and that more active program engagement is associated with higher reductions in hospitalization. This paper describes dissemination of the INTERACT program using a pragmatic and relatively low cost model to prepare certified INTERACT Trainers in collaboration with several professional organizations.
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Affiliation(s)
- Alice Bonner
- Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts.
| | - Ruth Tappen
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Laurie Herndon
- Massachusetts Senior Care Foundation, Newton Lower Falls, Massachusetts
| | - Joseph Ouslander
- Charles E. Schmidt College of Medicine, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
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19
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Participation in decision making as a property of complex adaptive systems: developing and testing a measure. Nurs Res Pract 2013; 2013:706842. [PMID: 24349771 PMCID: PMC3857844 DOI: 10.1155/2013/706842] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/27/2013] [Indexed: 11/17/2022] Open
Abstract
Objectives. To (1) describe participation in decision-making as a systems-level property of complex adaptive systems and (2) present empirical evidence of reliability and validity of a corresponding measure. Method. Study 1 was a mail survey of a single respondent (administrators or directors of nursing) in each of 197 nursing homes. Study 2 was a field study using random, proportionally stratified sampling procedure that included 195 organizations with 3,968 respondents. Analysis. In Study 1, we analyzed the data to reduce the number of scale items and establish initial reliability and validity. In Study 2, we strengthened the psychometric test using a large sample. Results. Results demonstrated validity and reliability of the participation in decision-making instrument (PDMI) while measuring participation of workers in two distinct job categories (RNs and CNAs). We established reliability at the organizational level aggregated items scores. We established validity of the multidimensional properties using convergent and discriminant validity and confirmatory factor analysis. Conclusions. Participation in decision making, when modeled as a systems-level property of organization, has multiple dimensions and is more complex than is being traditionally measured. Managers can use this model to form decision teams that maximize the depth and breadth of expertise needed and to foster connection among them.
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